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2 Table f Cntents I. II. Frewrd... 3 Cre Principles... 4 Mental Health Treatment fr Adults... 6 Acute Inpatient Mental Health Treatment fr Adults... 7 Residential Mental Health Treatment fr Adults Partial Hspitalizatin Mental Health Treatment fr Adults Intensive Outpatient Mental Health Treatment fr Adults Mental Health Treatment fr Children and Adlescents Acute Inpatient Mental Health Treatment fr Children and Adlescents Residential Mental Health Treatment fr Children and Adlescents Partial Hspitalizatin Mental Health Treatment fr Children and Adlescents Intensive Outpatient Mental Health Treatment fr Children and Adlescents III. Outpatient Treatment Outpatient Behaviral Health Treatment Halfway Huse fr Behaviral Health & Substance Use Disrders IV. Substance Use Disrders Treatment V. Acute Inpatient Drug and Alchl Detxificatin Ambulatry Drug and Alchl Detxificatin Acute Inpatient Treatment fr Substance Use Disrders Residential Substance Use Disrders Treatment Partial Hspitalizatin fr Substance Use Disrders Intensive Outpatient Treatment fr Substance Use Disrders Eating Disrders Treatment Acute Inpatient Treatment fr Eating Disrders Residential Treatment fr Eating Disrders Partial Hspitalizatin fr Eating Disrders Intensive Outpatient Treatment fr Eating Disrders VI. Behaviral Health Assessment and Treatment Prcedures Crisis Stabilizatin Electrcnvulsive Therapy (ECT) Psychlgical/Neurpsychlgical Testing Autism Behaviral Interventin Therapies (ABIT) Medicatin Assisted Treatment (MAT) fr Opiid Dependence References Editrial Bard Page 2 f 111

3 Frewrd Over the last few years, with the passage f The Federal Mental Health Parity and Addictin Equity Act in 2008 and The Patient Prtectin and Affrdable Care Act in 2010, the health care industry has evlved and increased in cmplexity. There is increased benefit cverage fr peple with mental health and substance use cnditins, and these new laws have changed the way health care cverage is managed. This has addressed sme f the barriers that individuals have faced in btaining the prper diagnsis and essential treatment fr their cnditin; hwever, we cntinue t be faced with a shrtage f mental health services and clinicians in many areas f the cuntry. And despite Americans having a mre sphisticated understanding f mental illness, alng with an increased awareness thrugh expsure n televisin and in the media, studies cntinue t shw that there is persistent scial stigma attached t peple with mental illness and substance use disrders. With ver 150 millin Americans cntinuing t be cvered under emplyer-based insurance, and millins mre nw being cvered thrugh the state-based and federal exchanges, it is essential that we wrk tgether t renew ur fcus and take advantage f the advances brught by these new regulatins. We als need t turn ur remaining challenges int pprtunities. Ultimately, we all share the desire t see every individual get the best care that can be prvided. In ding s, we have the respnsibility t cllabrate with each ther t leverage each individual s health care benefits and t deliver the mst effective care in the mst apprpriate setting at the right time. Several key fcus areas are necessary t cnsider as we engage in a cperative and inclusive dialgue. They include variatins in standards f care acrss the cuntry and health care disparities fr peple with mental health diagnses. There are still significant gaps in service between mental health clinicians and general medical clinicians. This is imprtant nt nly as we attempt t prvide an integrated and hlistic health care experience fr individuals, but especially since the majrity f peple with mental health symptms are currently nly treated by primary care physicians. With all f the cmplexity in health care, we supprt practitiners in exercising their prfessinal judgment t make infrmed decisins and ffer quality care. We als supprt a cnsistent applicatin f evidencebased guidelines t enhance clinical judgment and t ensure that treatment includes cnsideratin f the practices that have been shwn t be mst effective fr each individual s cnditin. In keeping with this cmmitment, we have develped ur Standards and Guidelines - Medical Necessity Criteria fr Treatment f Behaviral Health and Substance Use Disrders. These Criteria are intended t be a wrking dcument t help set expectatins and facilitate a shared respnsibility. These Criteria d nt replace clinical judgment, and we recgnize that these Criteria require adaptatin t the unique situatins f each individual patient. We hpe this dcument will prve t be a wrthwhile resurce, and we thank ur practitiners fr the utstanding wrk they d in helping individuals t live healthier, mre balanced lives. At Cigna, we supprt pen dialgue with ur clinician cmmunity and all f ur custmers. We als always welcme nging feedback t find ways that we can all wrk tgether t better serve yu. Duglas Nemecek, M.D., M.B.A. Chief Medical Officer Behaviral Health Page 3 f 111

4 Cre Principles General Overview Cigna is cmmitted t helping the peple we serve imprve their health, well-being, and sense f security. That is ur missin. We realize that this is nt pssible withut the understanding that mental health is equally imprtant t physical health. There is a grwing awareness acrss the United States f the influence f mental health and substance use cnditins and the burden they place n individuals, families, and sciety. We believe that effective treatment fr any illness must address mental health and physical health tgether. In fact, effective mental health and substance use disrder treatment is a crnerstne t driving hlistic health and well-being. Taking this hlistic view, with ur fcus n mental health and substance use issues, helps the peple we serve be mre prductive at wrk, and mre imprtantly, mre prductive at hme with their families and in their cmmunities. At Cigna, we strngly believe that the cre principle that guides behaviral health care is that access t high quality care shuld be assured fr everyne. This is true regardless f the diagnsis, treatment setting, type f clinician, gegraphic lcatin, r the gender, ethnicity, r sciecnmic backgrund f the individual seeking care. Accrding t the 2005 Institute f Medicine reprt, Imprving the Quality f Health Care fr Mental and Substance-Use Cnditins, there are six dimensins that need t be addressed in achieving high quality care fr patients. 1 Quality mental health care needs t be: safe, effective, patient-centered, timely, efficient, and equitable. Acceptance f these six dimensins f care is essential t delivering the mst effective and mst apprpriate care t every patient. This Institute f Medicine reprt als identifies the imprtance f patient care being crdinated ver time and acrss peple, functins, activities, and treatment settings s that each patient receives the maximum benefit frm their treatment services. It is frm this cre principle that Cigna has develped ur Standards and Guidelines - Medical Necessity Criteria fr Treatment f Behaviral Health and Substance Use Disrders. Medical Necessity Criteria Cigna begins with evidence-based guidelines as the basic platfrm t define established standards f effective care. Scientific evidence is the vital element in the develpment f an infrmed decisin-making prcess fr patients and their clinicians. Over the last 10 years, the Surgen General 2, the President s New Freedm Cmmissin n Mental Health 3, and the Institute f Medicine 1 have all prduced reprts that highlight the imprtance f imprving the disseminatin and adptin f evidence-based practices. Effective treatment is ultimately linked t the cnsistent use f these evidence-based clinical practices and the ability f mental health clinicians t effectively execute these therapies. Cigna has adpted natinally develped and published guidelines f the American Psychiatric Assciatin, the American Assciatin f Pediatrics and the Natinal Institute n Alchl Abuse and Alchlism due t their acceptance as the best f evidence-based practice fr mental health and substance use disrders. Our Criteria then serve as a decisin supprt tl t help define the mst apprpriate treatment setting and help assure cnsistency f care fr each individual. We have chsen nt t adpt private, prprietary level f care guidelines frm cmpanies such as McKessn Health Slutins r MCG, but t develp and implement ur wn. This decisin strngly reflects ur philsphy that Cigna s Criteria shuld reflect the mutual cnsensus f all f ur stakehlders, be transparent and available t everyne, and be flexible enugh t cntinuusly adapt t the changes in mental health and substance use disrder treatment systems. In the develpment f ur Medical Necessity Criteria fr Treatment f Behaviral Health and Substance Use Disrders, Cigna has listened t the messages and feedback frm patients, advcacy grups (MHA and NAMI), prfessinal assciatins (American Psychiatric Assciatin, American Academy f Child and Adlescent Psychiatrists, American Psychlgical Assciatin, Assciatin fr Ambulatry Behaviral Healthcare,, and the American Sciety f Addictin Medicine), psychiatrists, psychlgists, and therapists acrss the cuntry. We have attempted t incrprate the strngest, evidence-based pints int ur Criteria. These Criteria then becme a wrking dcument t help set expectatins and t facilitate a jint wrking relatinship and shared respnsibility between Cigna and mental health and substance use disrder clinicians. Cigna is prud t keep the develpment prcess f ur Criteria pen and transparent t the public. We appreciate the active and meaningful rle that patients, clinicians, and advcates have in determining hw the scientific evidence is applied in ur Criteria. In additin t listening t their input, we have als wrked t write ur Criteria in wrds that everyne can understand. Our Criteria are nly f value when Page 4 f 111

5 we can have pen, clear, and cmplete discussins, and when bth individuals and their clinicians can understand and use the Criteria in their behaviral healthcare decisin making. Cigna believes that all treatment decisins that are made in alignment with these Criteria must be first and fremst clinically based. Care must be patient-centered and take int accunt the individuals needs, clinical and envirnmental factrs, and persnal values. These Criteria d nt replace clinical judgment, and every treatment decisin must allw fr the cnsideratin f the unique situatin f the individual. In this way, the Criteria prmte advcacy fr the patient and enhance the cllabratin between Cigna and clinicians t achieve ptimal, patient-centered utcmes. They als prmte cnsistent cmmunicatin and crdinatin f care frm ne treatment setting t the next. Prviding every individual with access t quality, evidence-based, patient-centered care is the cre tenet f ur philsphy at Cigna. It is frm this philsphy that ur Standards and Guidelines - Medical Necessity Criteria fr Treatment f Behaviral Health and Substance Use Disrders help drive imprvements in hlistic health care and ensure cnsistent, meaningful utcmes fr everyne. Duglas Nemecek, M.D., M.B.A. Chief Medical Officer Behaviral Health 1 Imprving the Quality f Health Care fr Mental and Substance Use Cnditins. Institute f Medicine, Cmmittee n Crssing the Quality Chasm: Adaptatin t Mental Health and Addictive Disrders, Bard f Health Care Services. Washingtn DC: Natinal Academies Press, Mental Health: A Reprt f the Surgen General. Office f the Surgen General. Public Health Service, Department f Health and Human Services. Washingtn DC, Achieving the Prmise: Transfrming Mental Health Care in America. The President s New Freedm Cmmissin n Mental Health, Department Page 5 f 111

6 I. Mental Health Treatment fr Adults Sectin 1 Page 6 f 111

7 Acute Inpatient Mental Health Treatment fr Adults Standards and Guidelines Basic Elements f Medical Necessity - In cnsidering the apprpriateness f any level f care, all basic elements f the Medical Necessity definitin shuld be met: Except where state law r regulatin requires a different definitin, Medically Necessary r Medical Necessity shall mean health care services that a Prvider, exercising prudent clinical judgment, wuld prvide t a patient fr the purpse f evaluating, diagnsing r treating an illness, injury, disease r its symptms, and that are: a) Required t meet the essential health needs f the patient; b) Cnsistent with the diagnsis f the cnditin fr which they are required; c) Cnsistent in type, frequency and duratin f treatment with scientifically-based guidelines as determined by medical research; d) Required fr purpses ther than the cnvenience f the prvider r the cmfrt f the patient; e) Rendered in the least intensive setting that is apprpriate fr the delivery f health care. Descriptin - Acute Psychiatric Hspitalizatin fr Adults is utilized when the fllwing services are needed: Arund-the-clck intensive, psychiatric/medical, and nursing care including cntinuus bservatin and mnitring Acute management t prevent harm r significant deteriratin f functining and t ensure the safety f the individual and/r thers, Daily mnitring f psychiatric medicatin effects and side effects, and A cntained envirnment fr specific treatments that culd nt be safely dne in a nn-mnitred setting. Admissin Cnsideratins fr Acute Psychiatric Hspitalizatin fr Adults: Prir t admissin, there has been a face-t-face individual assessment by a licensed behaviral health clinician, with training and experience in the assessment and treatment f acute psychiatric disrders, t determine if this level f care is medically necessary and clinically apprpriate. Alternative less restrictive levels f care are cnsidered and referrals are attempted as apprpriate. Expectatins fr Acute Psychiatric Hspitalizatin fr Adults: A thrugh Psychiatric Evaluatin is cmpleted within 24 hurs f admissin. Daily active, cmprehensive care by a treatment team that wrks under the directin f a Bard eligible/bard certified psychiatrist. Psychiatric fllw-up ccurs daily r mre frequently as needed. A medical evaluatin is cmpleted as needed r apprpriate. All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant cmrbid cnditins. Within 48 hurs f admissin, there is utreach with existing prviders and family members, t btain needed histry and ther clinical infrmatin. The facility will rapidly assess and address any urgent behaviral and/r physical issues. Family Invlvement Prmpt, timely family invlvement is expected at every level f treatment plan develpment, unless ding s is clinically cntraindicated r wuld nt be in cmpliance with existing federal r state laws. Family invlvement is imprtant in the fllwing cntexts: Assessment The family is needed t prvide detailed initial histry t clarify and understand the current and past events leading up t the admissin. Page 7 f 111

8 Family therapy is relevant t the treatment plan and will ccur as frequently as needed t achieve the treatment gals, but n less than nce weekly, unless clinically cntraindicated, and shuld be n a face-t-face basis. Hwever, if the family lives mre than 3 hurs frm the facility, telephne cntact fr family therapy must be cnducted at least weekly alng with face-t-face family sessins as frequently as pssible. Telephnic sessins are nt t be seen as an equivalent substitute fr face-t-face sessins r based primarily n the cnvenience f the prvider r family, r fr the cmfrt f the patient. Discharge planning. An Individualized Treatment Plan is cmpleted within 24 hurs f admissin. This plan includes: A fcus n the issues leading t the admissin. If this is a readmissin, clarity n what will be dne differently during this admissin that will likely lead t imprvement that has nt been achieved previusly. Assessment f psychiatric and behaviral issues, substance abuse, medical illness(s), persnality traits, scial supprts, educatin, living situatin. The treatment plan results in interventins utilizing medicatin management, scial wrk invlvement, individual, grup, marital and family therapies as apprpriate. The gal is t imprve symptms, develp apprpriate discharge criteria and a plan that invlves crdinatin with cmmunity resurces t allw a smth transitin back t utpatient services, family integratin, and cntinuatin f the recvery prcess. Fr individuals with a histry f multiple re-admissins and treatment episdes, the treatment plan needs t include clear interventins t identify and address the reasns fr previus nnadherence/pr respnse and clear interventins fr the reductin f future risks. A Discharge Plan that starts at the time f admissin and includes: Crdinatin with family, utpatient prviders, and cmmunity resurces t allw a smth transitin t less restrictive levels f care. Timely and clinically apprpriate aftercare appintments A prescriptin fr any prescribed medicatins sufficient t bridge the time between discharge and the scheduled fllw-up psychiatric appintment. Medical Necessity Criteria - Acute Psychiatric Hspitalizatin fr Adults Criteria fr Admissin All f the fllwing must be met: 1. All basic elements f medical necessity must be met. 2. One r mre f the fllwing criteria must be met: A. It is very likely that the individual has a plan and intent t cause serius bdily harm t him/herself r smene else due t a psychiatric illness, (nt due t intentinal criminal behavir), as evidenced by: i) A recent and serius suicide attempt r threat t thers invlving deadly intent r plan, OR ii) A current expressin f suicidal intent r hmicidal intent (r a plan fr bdily harm that has a high pssibility f becming deadly r causing serius injury), OR iii) Recent, serius and intentinal self-injury alng with an inability t develp a reasnable plan fr safety s that 24 hur bservatin, safety measures, and treatment are needed in a secure setting, OR Page 8 f 111

9 OR iv) Recent vilent, impulsive, and unpredictable behavir that is likely t result in harm t the individual r smene else withut 24-hur bservatin and treatment, including the pssible use f seclusin and/r restraints in a secured setting. B. It is very likely that serius harm will cme t the individual due t a psychiatric illness, and that harm cannt be prevented at a lwer level f care as evidenced by: OR i) The individual is unable t care fr self (nutritin, shelter, and ther essential activities f daily living) due t his/her psychiatric cnditin s that life-threatening deteriratin is expected, OR ii) The individual has irratinal r bizarre thinking, and/r severe slwness r agitatin in mvements alng with interference with activities f daily living f such severity as t require 24-hur skilled psychiatric/medical, nursing and scial service interventins C. The individual has a secndary cnditin such that treatment cannt be prvided at a less restrictive level f care as evidenced by: OR i) A life threatening cmplicatin f an eating disrder, OR ii) An active general medical cnditin (i.e.; cardiac disease, pregnancy, diabetes, etc.) which requires that psychiatric interventins be mnitred in a 24-hur psychiatric/medical setting, OR iii) The individual requires Electrcnvulsive Therapy (ECT) and the initial trial requires a 24- hur psychiatric/medical setting. D. Apprpriate less restrictive levels f care are unavailable fr safe and effective treatment. Criteria fr Cntinued Stay All f the fllwing must be met: 1. The individual cntinues t meet all basic elements f medical necessity. 2. One r mre f the fllwing criteria must be met: A. The treatment prvided is leading t measurable clinical imprvements in acute symptms and a prgressin twards discharge frm the present level f care, but the individual is nt sufficiently stabilized s that he/she can be safely and effectively treated at a less restrictive level f care, OR B. If the treatment plan implemented is nt leading t measurable clinical imprvements in acute symptms and a prgressin twards discharge frm the present level f care, there must be nging reassessment and mdificatin t the treatment plan identifying and addressing specific barriers t achieving that imprvement when clinically indicated, OR C. The individual has develped new symptms and/r behavirs that require this intensity f service fr safe and effective treatment. 3. All f the fllwing must be met: A. The individual and family are invlved t the best f their ability in the treatment and discharge planning prcess. B. Cntinued stay is nt primarily fr the purpse f prviding a safe and structured envirnment. C. Cntinued stay is nt primarily due t a lack f external supprts. Page 9 f 111

10 Residential Mental Health Treatment fr Adults Standards and Guidelines Basic Elements f Medical Necessity - In cnsidering the apprpriateness f any level f care, all basic elements f the medical necessity definitin shuld be met: Except where state law r regulatin requires a different definitin, Medically Necessary r Medical Necessity shall mean health care services that a Prvider, exercising prudent clinical judgment, wuld prvide t a patient fr the purpse f evaluating, diagnsing r treating an illness, injury, disease r its symptms, and that are: a) Required t meet the essential health needs f the patient; b) Cnsistent with the diagnsis f the cnditin fr which they are required; c) Cnsistent in type, frequency and duratin f treatment with scientifically-based guidelines as determined by medical research; d) Required fr purpses ther than the cnvenience f the prvider r the cmfrt f the patient; e) Rendered in the least intensive setting that is apprpriate fr the delivery f health care. Descriptin Psychiatric Residential Treatment fr Adults: A Psychiatric Residential Treatment Facility (PTRF) fr Adults is either a stand-alne mental health facility r a physically and prgrammatically-distinct unit within a facility licensed fr this specific purpse and that includes 7-day a week, 24-hur supervisin and mnitring. Treatment facility units and sleeping areas are generally nt lcked, althugh they may ccasinally be lcked when necessary in respnse t the clinical r medical needs f a particular patient. Psychiatric Residential Treatment Facilities are staffed by a multidisciplinary treatment team under the leadership f a Bard Certified/Bard Eligible Psychiatrist wh cnducts a face-t-face interview with each individual within 48 hurs f admissin and as frequently as clinically indicated thrughut the duratin f the admissin, but n less than nce weekly. The prgram prvides fr the mental health and physical health needs f the individual. A nurse is n-site and a psychiatrist is available 24 hurs per day, 7 days per week t assist with crisis interventin and assess and treat medical and psychiatric issues, and administer medicatins as clinically indicated. Treatment is fcused n stabilizatin and imprvement f functining and reintegratin with family r significant thers. Residential treatment is transitinal in nature fr the purpse f returning the individual t the cmmunity with cntinued ambulatry treatment services as needed. Treatment at this level f care is nt primarily fr the purpse f maintaining lng-term gains made in an earlier prgram. Residential treatment cverage is nt based n a preset number f days. The length f a standardized prgram such as a 30-Day Treatment Prgram is nt cnsidered as a medically necessary reasn fr admissin and/r cntinued stay at this level f care. Residential treatment is nt a substitute fr a lack f available supprtive living envirnment(s) in the cmmunity. Exclusins: There are a wide variety f nn-psychiatric prgrams that prvide residential services but are nt licensed as Psychiatric Residential Treatment Facilities (PRTF), r the equivalent, and that d nt meet the abve criteria. A few examples fllw: Page 10 f 111

11 Therapeutic Grup Hmes: These are prfessinally-directed living facilities with psychiatric cnsultatin available as needed. Grup hmes serve brad and varied patient ppulatins with significant individual and/r family dysfunctins. Wilderness Prgrams, Bt Camps, and/r Outward Bund Prgrams: These prgrams may prvide therapeutic alternatives fr trubled and struggling yuth, teens and adults, ffering experiential learning and persnal grwth thrugh utdr and adventure-based prgramming. Hwever, they d nt utilize a multidisciplinary team that includes psychlgists, psychiatrists, and licensed therapists wh are cnsistently invlved in the care f the individual. These prgrams nearly universally d nt meet standards fr certificatin as psychiatric residential treatment prgrams r the quality f care standards fr medically supervised care prvided by licensed mental health prfessinals. (11) Cmmunity Alternatives: The admissin is being used fr purpses f cnvenience r as an alternative t incarceratin r simply as respite r husing. Envirnmental Admissins: Admissin and/r cntinued stay at this level f care is nt justified when primarily fr the purpse f prviding a safe and structured envirnment, due t a lack f external supprts, r because alternative living situatins are nt immediately available. Admissin Cnsideratins fr Psychiatric Residential Treatment fr Adults: Within 72 hurs prir t admissin, there has been a face-t-face assessment with the individual and family by a licensed behaviral health prfessinal. This assessment includes a clinically-based recmmendatin fr the need fr this level f care. The admissins prcess shuld als include: A dcumented diagnsis f a psychiatric disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders, and evidence f significant distress/impairment. Evaluatin by a Bard Certified/Bard Eligible Psychiatrist within 48 hurs f admissin wh als reviews and apprves the apprpriateness fr this level f care and cnsideratin f alternative less restrictive levels f care and wh sees the individual as frequently as clinically indicated thrughut the duratin f the admissin, but n less than nce weekly. A medical assessment and physical examinatin within the first 24 hurs f admissin, unless a physician determines that an examinatin within the week prir t admissin t the facility was sufficient. Identificatin f family and/r cmmunity resurces and family participatin in treatment, unless clinically cntraindicated r ding s wuld nt be in cmpliance with existing federal r state laws. Discharge planning. Expectatins fr Psychiatric Residential Treatment: Residential treatment shuld ccur as clse as pssible t the hme and cmmunity t which the individual will be discharged If ut-f-area placement is unavidable, there must be cnsistent family invlvement with the individual, and regular family therapy and discharge planning sessins, unless clinically cntraindicated, Within 72 hurs f admissin, there is utreach with existing prviders and family members t btain needed histry and ther clinical infrmatin Family Invlvement Prmpt, timely family invlvement f family/significant thers is expected at every level f treatment plan develpment, unless ding s is clinically cntraindicated r wuld nt be in cmpliance with existing federal r state laws. Family invlvement is imprtant in the fllwing cntexts: Assessment - The family/significant thers are needed t prvide detailed initial histry t clarify and understand the current and past events leading up t the admissin. Family therapy shuld ccur at least weekly, unless clinically cntraindicated, and shuld be n a face-t-face basis. Page 11 f 111

12 Hwever, if the family lives mre than 3 hurs frm the facility, telephne cntact fr family therapy must be cnducted at least weekly alng with face-t-face family sessins as frequently as pssible. Telephnic sessins are nt t be seen as an equivalent substitute fr face-t-face sessins r based primarily n the cnvenience f the prvider r family, r fr the cmfrt f the patient. Discharge planning that starts at the time f admissin. A Preliminary Treatment Plan is cmpleted within 48 hurs f admissin and a Cmprehensive Treatment Plan is t be cmpleted within 5 days that includes: A clear fcus n the issues leading t the admissin and n the symptms that needs t imprve t allw treatment t cntinue at a less restrictive level f care. Multidisciplinary assessments f psychiatric and behaviral issues, substance abuse, medical illness(s), persnality traits, scial supprts, educatin, and the living situatin. All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant c-mrbid cnditins. The family/significant thers in at least weekly therapy r, if the family lives greater than 3 hurs frm the facility, weekly telephne cntact fr family therapy must be cnducted with face-tface family therapy sessins as frequently as pssible. Realistic, specific, measurable, and achievable gals. This plan shuld: Be develped jintly with the individual and family/significant thers. Include multidisciplinary assessments. Establish measurable gals and bjectives. Include treatment mdalities that are apprpriate t the clinical needs f the child. Fr individuals with a histry f multiple re-admissins and treatment episdes, the treatment plan needs t include clear interventins t identify and address the reasns fr previus nnadherence/pr respnse and clear interventins fr the reductin f future risks. Nte: The Treatment Plan is nt based n a pre-established prgrammed plan r time frames. Discharge planning will start at the time f admissin and include: Crdinatin with cmmunity resurces t facilitate a smth transitin back t hme, family, wrk r schl, and apprpriate utpatient treatment services. Timely and clinically apprpriate aftercare appintments, with at least ne appintment within 7 days f discharge. Prescriptins fr any necessary medicatins, in a quantity sufficient t bridge any gap between discharge and the first scheduled fllw-up psychiatric appintment. Medical Necessity Criteria - Psychiatric Residential Treatment fr Adults Criteria fr Admissin All f the fllwing must be met: 1. All basic elements f medical necessity must be met. 2. One r mre f the fllwing criteria must be met: A. The individual has been diagnsed with a severe psychiatric disrder that is pervasive and significantly impairs functining. This impairment in functin is seen acrss multiple settings such as wrk, hme, and in the cmmunity, and clearly demnstrates a need fr 24-hur supervisin and active treatment, OR Page 12 f 111

13 B. Immediate prir treatment in a mre intensive level f care (such as mental health inpatient) has resulted in an acceptable degree f stability. Hwever, the individual cntinues t display behavirs due t a treatable psychiatric disrder that require arund-the-clck supervisin and interventins in a structured setting t return the individual t an acceptable baseline where the safety f the individual and thers is assured. 3. All f the fllwing criteria must be met: A. The individual demnstrates chrnic dysfunctin, which is likely t respnd t multiple therapeutic and family treatment interventins, and the individual and family cmmit t active regular treatment participatin B. The individual is able t functin with sme independence, participate in structured activities in a grup envirnment, and is capable f develping the skills necessary fr functining utside f the residential prgram. C. Less restrictive r intensive levels f treatment are nt apprpriate t meet the individual s needs. Criteria fr Cntinued Stay All f the fllwing must be met: 1. The individual cntinues t meet all basic elements f medical necessity. 2. One r mre f the fllwing criteria must be met: A. The treatment prvided is leading t measurable clinical imprvements in acute symptms and a prgressin twards discharge frm the present level f care, but the individual is nt sufficiently stabilized s that he/she can be safely and effectively treated at a less restrictive level f care, OR B. If the treatment plan implemented is nt leading t measurable clinical imprvements in acute symptms and a prgressin twards discharge frm the present level f care, there must be nging reassessment and, mdificatin t the treatment plan, when clinically indicated, OR C. The individual has develped new symptms and/r behavirs that require this intensity f service fr safe and effective treatment. 3. All f the fllwing must be met: A. The individual and family are invlved t the best f their ability in the treatment and discharge planning prcess. B. Cntinued stay is nt primarily fr the purpse f prviding a safe and structured envirnment. C. Cntinued stay is nt primarily due t a lack f external supprts. Page 13 f 111

14 Partial Hspitalizatin Mental Health Treatment fr Adults Standards and Guidelines Basic Elements f Medical Necessity - In cnsidering the apprpriateness f any level f care, all basic elements f the Medical Necessity definitin shuld be met: Except where state law r regulatin requires a different definitin, Medically Necessary r Medical Necessity shall mean health care services that a Prvider, exercising prudent clinical judgment, wuld prvide t a patient fr the purpse f evaluating, diagnsing r treating an illness, injury, disease r its symptms, and that are: a) Required t meet the essential health needs f the patient; b) Cnsistent with the diagnsis f the cnditin fr which they are required; c) Cnsistent in type, frequency and duratin f treatment with scientifically-based guidelines as determined by medical research; d) Required fr purpses ther than the cnvenience f the prvider r the cmfrt f the patient; e) Rendered in the least intensive setting that is apprpriate fr the delivery f health care. Descriptin Psychiatric Partial Hspitalizatin fr Adults Prvides crdinated, intense, ambulatry, multi-disciplinary and time limited treatment fr individuals wh can maintain persnal safety w/ supprt systems in the cmmunity. Treatment prvided in this setting is similar in nature and intensity as that prvided in an inpatient hspital setting. As such, the rle f this level f care is t respnd t acute situatins, which withut this level f care, culd ptentially result in life-threatening emergencies. Cigna agrees with the fllwing principles, as stated by the Assciatin fr Ambulatry Behaviral Healthcare (AABH): Partial hspitalizatin prgrams (PHP s) are active, time-limited, ambulatry behaviral health treatment prgrams that ffer therapeutically intensive, structured, and crdinated clinical services within a stable therapeutic milieu. (7) PHP s may pursue ne r bth f the fllwing majr functins: 1) Acute Crisis Stabilizatin 2) Acute Symptm Reductin. Partial hspitalizatin prgrams may be free-standing, part f a behaviral health rganizatin, r a department within a general medical healthcare system An Individual in Psychiatric Partial Hspitalizatin fr Adults: Is nt apprpriate fr PHP service level if he/she is imminently at risk f suicide r hmicide and withut sufficient impulse/behaviral cntrl and/r minimum necessary scial supprt. Is having acute psychiatric symptms that are cmprmising daily functining with wrk, schl, and/r with ther activities f daily living Has the ability: T make basic decisins fr him/herself AND T accept respnsibility fr his/her wn actins Admissin Cnsideratins fr Psychiatric Partial Hspitalizatin fr Adults: Within 72 hurs prir t admissin, there has been a face-t-face assessment by a licensed behaviral health prfessinal. This assessment includes a clinically-based recmmendatin fr the need fr this level f care. Page 14 f 111

15 The admissins prcess shuld als include: A dcumented current diagnsis f a psychiatric disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders, and evidence f significant distress/impairment. Evaluatin by a Bard Certified/Bard Eligible Psychiatrist within 48 hurs f admissin wh als reviews and apprves the apprpriateness fr this level f care and cnsideratin f alternative less restrictive levels f care wh als reviews and apprves the apprpriateness fr this level f care and cnsideratin f alternative less restrictive levels f care and wh sees the individual as frequently as clinically indicated thrughut the duratin f the admissin, but n less than nce weekly. A medical assessment and physical examinatin within the first 72 hurs f admissin, unless a physician determines that a recent examinatin prir t admissin t the facility was sufficient. Identificatin f family and/r cmmunity resurces and family participatin in treatment when indicated. Discharge planning. Expectatins fr Psychiatric Partial Hspitalizatin fr Adults: Individuals wh are at this level f care: Are typically in a structured treatment prgram 5 days per week. At a minimum, 20 hurs f scheduled prgramming extended ver at least five (5) days per week are t be prvided. Will have the pprtunity t be expsed t circumstances/stressrs that may have cntributed t the admissin and practice their cping skills. Live in the cmmunity withut the restrictins f a 24-hur supervised setting during nnprgram hurs. Are capable f safely cntrlling their behavir and seeking prfessinal assistance r ther supprt as needed. Cigna des nt cver barding fr Partial Hspitalizatin prgrams, as this is an ambulatry service. Hwever, during nn-prgram hurs, an individual wh is barding at r near a facility must have the freedm t interact with the cmmunity independently, withut being accmpanied by staff r thers. The attending psychiatrist is expected t assess individuals weekly r mre frequently as needed. During prgram hurs, there is daily active, cmprehensive care by a treatment team that wrks under the directin f a Bard eligible/bard certified psychiatrist Family Invlvement - Prmpt family invlvement is expected at every level f treatment plan develpment, unless ding s is clinically cntraindicated r wuld nt be in cmpliance with existing federal r state laws. Family invlvement is imprtant in the fllwing cntexts: Assessment - The family is needed t prvide detailed initial histry t clarify and understand the current and past events leading up t the admissin. Family therapy is relevant t the treatment plan and will ccur at a level f frequency and intensity needed t achieve the treatment gals. Family therapy will ccur in a face-t-face setting (Nte: Telephnic cnferences are nt cnsidered a substitute. Exceptins must be reviewed and a decisin t apprve telephnic cnference(s) shuld be made n a clinical basis.) Discharge planning. An Individualized Treatment Plan is cmpleted within 24 hurs f admissin. This plan includes: A fcus n the issues leading t the admissin. Assessment f psychiatric and behaviral issues, substance abuse, medical illness(s), persnality traits, scial supprts, educatin, living situatin. Page 15 f 111

16 All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant c-mrbid cnditins. The treatment plan results in interventins utilizing medicatin management, individual, grup, marital and family therapies as apprpriate. Gals that are clear and achievable with limited timeframes and a fcus n reductin f the symptms that led t the admissin, Clear, bjective and bservable discharge criteria. A discharge plan that includes crdinatin with cmmunity resurces t allw a smth transitin back t utpatient services, family integratin, and cntinuatin f the recvery prcess. Fr individuals with a histry f multiple re-admissins and treatment episdes, the treatment plan needs t include clear interventins t identify and address the reasns fr previus nnadherence/pr respnse and clear interventins fr the reductin f future risks. Nte: The Treatment Plan is nt based n a pre-established prgrammed plan r time frames. The Discharge Plan starts at the time f admissin and includes: Crdinatin with family, utpatient prviders, and cmmunity resurces t allw a smth transitin t less restrictive levels f care. Timely and clinically apprpriate aftercare appintments within 7 days f discharge date. A prescriptin fr any prescribed medicatins sufficient t bridge the time between discharge and the scheduled fllw-up psychiatric appintment. Nte: This level shuld nt be cnfused with sub-acute Day Prgrams where the fcus is n the lng-term scial rehabilitatin and maintenance f individuals with severe and persistent mental illness. Medical Necessity Criteria - Psychiatric Partial Hspitalizatin fr Adults Criteria fr Admissin All f the fllwing must be met: 1. All basic elements f Medical Necessity must be met. 2. The individual has a dcumented primary diagnsis f a psychiatric disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders. 3. One r mre f the fllwing must be met: A. The individual is demnstrating significant impairments in functining secndary t a psychiatric disrder, as evidenced by bth f the fllwing: i) The individual is nt able t cmplete rutine daily scial, family, schl, and/r wrk activities, AND ii) The individual is nt able t emply the necessary cping skills t cmpensate fr this. B. The individual has recently demnstrated actins f r made serius threats f self-harm r harm t thers, but des nt require a 24-hur mnitring envirnment, OR C. The individual requires a structured prgram t avid cmplicatins f a c-existing medical cnditin (e.g., pregnancy, uncntrlled diabetes) 4. The individual is mentally and emtinally capable t actively engage in the treatment prgram \ 5. The individual is able t live in the cmmunity withut the restrictins f a 24-hur supervised setting. 6. The individual is expressing willingness t engage in treatment. 7. The individual is able t develp a safety plan with the prvider that includes being able t access emergency services s that a mre intensive level f care is nt required. Page 16 f 111

17 8. The individual has a supprt system that includes family r significant thers wh are able t actively participate in treatment OR- If the individual has n primary supprt system, the individual has the skills t develp supprts and/r becme invlved in a self-help supprt system. 9. If there are medical Issues, they can be safely managed in a partial hspital level f care. Criteria fr Cntinued Stay All f the fllwing must be met: 1. The individual cntinues t meet all basic elements f medical necessity. 2. One r mre f the fllwing criteria must be met: A. The treatment prvided is leading t measurable clinical imprvements in acute symptms and a prgressin twards discharge frm the present level f care, but the individual is nt sufficiently stabilized s that he/she can be safely and effectively treated at a less restrictive level f care, OR B. If the treatment plan implemented is nt leading t measurable clinical imprvements in acute symptms and a prgressin twards discharge frm the present level f care, there must be nging reassessment and, mdificatin t the treatment plan, when clinically indicated, OR C. The individual has develped new symptms and/r behavirs that require this intensity f service fr safe and effective treatment. 3. All f the fllwing must be met: A. The individual and family are invlved t the best f their ability in the treatment and discharge planning prcess. B. Cntinued stay is nt primarily fr the purpse f prviding a safe and structured envirnment. C. Cntinued stay is nt primarily due t a lack f external supprts. Page 17 f 111

18 Intensive Outpatient Mental Health Treatment fr Adults Standards and Guidelines Basic Elements f Medical Necessity - In cnsidering the apprpriateness f any level f care, all basic elements f the medical necessity definitin shuld be met: Except where state law r regulatin requires a different definitin, Medically Necessary r Medical Necessity shall mean health care services that a Prvider, exercising prudent clinical judgment, wuld prvide t a patient fr the purpse f evaluating, diagnsing r treating an illness, injury, disease r its symptms, and that are: a) Required t meet the essential health needs f the patient; b) Cnsistent with the diagnsis f the cnditin fr which they are required; c) Cnsistent in type, frequency and duratin f treatment with scientifically-based guidelines as determined by medical research; d) Required fr purpses ther than the cnvenience f the prvider r the cmfrt f the patient; e) Rendered in the least intensive setting that is apprpriate fr the delivery f health care. Descriptin - Psychiatric Intensive Outpatient Treatment fr Adults prvides a crdinated, intense, ambulatry, multi-disciplinary and time limited treatment fr individuals wh can maintain persnal safety w/ supprt systems in the cmmunity and wh can maintain sme ability t fulfill family, student, r wrk activities. Intensive Outpatient prgrams may be free-standing, part f a behaviral health rganizatin, r a department within a general medical healthcare system. An Individual in Psychiatric Intensive Outpatient Treatment fr Adults: Has the ability: T make basic decisins fr him/herself AND T accept respnsibility fr his/her wn actins and behavir, Is experiencing psychscial stressrs and/r cmplex family dysfunctin, such that a multidisciplinary treatment team is needed t stabilize the individual. The individual is nt at imminent risk fr serius bdily harm tward self r thers. Clinical interventins may include individual, cuple, family, and grup psychtherapies alng with medicatin management. This level f care can be the first level f care authrized t generate new cping skills, r can fllw a mre intensive level f care t reinfrce acquired skills that might be lst if the participant immediately returned t a less structured utpatient setting. Admissin Cnsideratins fr Psychiatric Intensive Outpatient Treatment fr Adults: Prir t admissin, there has been a face-t-face individual assessment by a licensed behaviral health clinician, t determine if this is a level f care that is medically necessary and clinically apprpriate. Alternative less restrictive levels f care are cnsidered and referrals are attempted as apprpriate. Expectatins fr Psychiatric Intensive Outpatient Treatment fr Adults: Individuals wh are at this level f care: Are typically in a structured treatment prgram 3-4 hurs per day, 3-5 days per week. Page 18 f 111

19 Will have the pprtunity t be expsed t circumstances/stressrs that may have cntributed t the admissin and practice their cping skills Live in the cmmunity withut the restrictins f a 24-hur supervised setting during nnprgram hurs. Are capable f safely cntrlling their behavir and seeking prfessinal assistance r ther supprt as needed. Cigna des nt cver barding fr Intensive Outpatient prgrams as this is an ambulatry service. Hwever, during nn-prgram hurs, an individual wh is barding at r near a facility must have the freedm t interact with the cmmunity independently, withut being accmpanied by staff r thers. The facility prvides a structured prgram, which is staffed by prfessinals wh are trained and experienced in the treatment f mental disrders. A psychiatrist is available fr cnsultatin, as needed. An Individualized Treatment Plan is cmpleted within 24 hurs f admissin. This plan includes: A fcus n the issues leading t the admissin. Assessment f psychiatric and behaviral issues, substance abuse, medical illness(s), persnality traits, scial supprts, educatin, and living situatin. All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant c-mrbid cnditins. The treatment plan results in interventins utilizing medicatin management, individual, grup, marital and family therapies as apprpriate. Gals that are clear and achievable with limited timeframes and a fcus n reductin f the symptms that led t the admissin, Clear, bjective and bservable discharge criteria. A discharge plan that includes crdinatin with family and cmmunity resurces t allw a smth transitin back t utpatient services, family integratin, and cntinuatin f the recvery prcess. Fr individuals with a histry f multiple re-admissins and treatment episdes, the treatment plan needs t include clear interventins t identify and address the reasns fr previus nnadherence/pr respnse and clear interventins fr the reductin f future risks. Nte: The Treatment Plan is nt based n a pre-established prgrammed plan r time frames. Family Invlvement - Prmpt family invlvement is expected at every level f treatment plan develpment, unless ding s is clinically cntraindicated r wuld nt be in cmpliance with existing federal r state laws. Family invlvement is imprtant in the fllwing cntexts: Assessment - The family is needed t prvide detailed initial histry t clarify and understand the current and past events leading up t the admissin. Family therapy is relevant t the treatment plan and will ccur at a level f frequency and intensity needed t achieve the treatment gals. Family therapy will ccur in a face-t-face setting (Nte: Telephnic cnferences are nt cnsidered a substitute. Exceptins must be reviewed and a decisin t apprve telephnic cnference(s) shuld be made n a clinical basis.) Planning fr Discharge A Discharge Plan that starts at the time f admissin and includes: Crdinatin with family, utpatient prviders, and cmmunity resurces t allw a smth transitin t less restrictive levels f care. Timely and clinically apprpriate aftercare appintments Page 19 f 111

20 A prescriptin fr any prescribed medicatins sufficient t bridge the time between discharge and the scheduled fllw-up psychiatric appintment. Medical Necessity Criteria - Psychiatric Intensive Outpatient Treatment fr Adults Criteria fr Admissin All f the fllwing must be met 1. All basic elements f Medical Necessity must be met. 2. The individual has a dcumented primary diagnsis f a psychiatric disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders. 3. The individual is demnstrating difficulties in functining secndary t a psychiatric disrder as evidenced by: A. The individual is mildly t mderately impaired in his/her ability t cmplete rutine daily scial, family, schl, and/r wrk activities, AND B. The individual is able t emply the necessary cping skills t cntinue with mst rutine daily activities. 4. The individual is mentally and emtinally capable t actively engage in the treatment prgram 5. The individual is able t live in the cmmunity withut the restrictins f a 24-hur supervised setting. 6. The individual is expressing willingness t engage in treatment. 7. The individual is able t develp a safety plan with the prvider that includes being able t access emergency services s that a mre intensive level f care is nt required. 8. The individual has a supprt system that includes family r significant thers wh are able t actively participate in treatment OR- If the individual has n primary supprt system, the individual has the skills t develp supprts and/r becme invlved in a self-help supprt system. Criteria fr Cntinued Stay All f the fllwing must be met: 1. The individual cntinues t meet all basic elements f medical necessity. 2. One r mre f the fllwing criteria must be met: A. The treatment prvided is leading t measurable clinical imprvements in acute symptms and a prgressin twards discharge frm the present level f care, but the individual is nt sufficiently stabilized s that he/she can be safely and effectively treated at a less restrictive level f care, OR B. If the treatment plan implemented is nt leading t measurable clinical imprvements in acute symptms and a prgressin twards discharge frm the present level f care, there must be nging reassessment and, mdificatin t the treatment plan, when clinically indicated, OR C. The individual has develped new symptms and/r behavirs that require this intensity f service fr safe and effective treatment. 3. All f the fllwing must be met: A. The individual and family are invlved t the best f their ability in the treatment and discharge planning prcess. B. Cntinued stay is nt primarily fr the purpse f prviding a safe and structured envirnment. C. Cntinued stay is nt primarily due t a lack f external supprts. Page 20 f 111

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