Behavioral Health: Chemical Dependency/Substance Abuse Inpatient Treatment

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1 UTILIZATION MANAGEMENT GUIDELINE COVERAGE GUIDELINE CODING RELATED POLICIES SCOPE ADDITIONAL INFORMATION HISTORY Behavioral Health: Chemical Dependency/Substance Abuse Inpatient Treatment Number Effective Date January 1, 2015 Revision Date(s) N/A Replaces N/A Coverage Guideline Inpatient chemical dependency/substance abuse treatment may be considered medically necessary when treatment is provided in a stand-alone chemical dependency/substance abuse facility that is licensed as a hospital, in a chemical dependency/substance abuse unit within a licensed hospital or licensed psychiatric hospital, or in a chemical dependency/substance abuse program or track within a licensed psychiatric hospital or psychiatric unit of a licensed hospital, and the criteria listed below are met. Criteria Severity of Illness Criteria for Inpatient Admission All of the following must be present: I. Chemical dependency or substance abuse (a DSM-5 Substance Use Disorder) other than for tobacco/nicotine, not in remission. II. Chemical dependency/substance abuse is out of control, including immediately prior to admission (i.e. no significant period of abstinence prior to admission), to the extent that the patient is unable to initiate or maintain abstinence, and prevent continued use or relapse, without a 24/7 contained, structured, supportive treatment setting. If transferring directly from another inpatient setting (detoxification, psychiatric, eating disorders, or medical), a sub-acute or residential detoxification setting, a crisis treatment center, psychiatric or eating disorders residential treatment, a wilderness or adventure or camping program or expedition, or from incarceration, this criterion was present immediately prior to admission to that setting, and would rapidly recur with discharge or release to a home or community setting. III. Imminent probability of harm to self or others (physical, medical, severe functional) without cessation of use, or serious pervasive deterioration in functioning and/or self-care due to use. If transferring directly from another inpatient setting (detoxification, psychiatric, eating disorders, or medical), a sub-acute or residential detoxification setting, a crisis treatment center, psychiatric or eating disorders residential treatment, a wilderness or adventure or camping program or expedition, or from incarceration, this criterion was present immediately prior to admission to that setting, and would rapidly recur with discharge or release to a home or community setting. IV. At least one of the following must be present a. Poor or no awareness of, or outright denial of, her or his chemical dependency/substance abuse, the negative consequences of her or his chemical dependency/substance abuse, and/or the need to cease substance use and be abstinent, and/or the need for chemical dependency/substance abuse treatment. b. Significant difficulty cooperating with, or resistance or overt opposition to, chemical dependency/substance abuse treatment.

2 c. Poor or no recognition or utilization of the skills needed to prevent continued use or relapse. d. Active ongoing drug craving coupled with inability to delay immediate gratification. e. Poor or no recognition of relapse triggers, or inadequate skills to be able to prevent or interrupt the relapse process, and unable to use peer or community supports to prevent or stop relapse. f. Living environment and/or social network do not support abstinence, or actively undermine or sabotage abstinence, or are dysfunctional or toxic to the extent that initiation and maintenance of abstinence are not feasible. g. Unable to cease use or maintain abstinence despite treatment in accessible less restrictive/intensive level(s) of care (residential, partial hospitalization, intensive outpatient treatment, outpatient treatment). V. At least one of the following must be present a. An unstable co-morbid medical condition for which 24/7 medical management and nursing monitoring and care is required in order for the patient to participate in and utilize chemical dependency/substance abuse treatment. If transferring directly from chemical dependency/substance abuse residential treatment, the unstable co-morbid medical condition became evident or developed during residential treatment. b. An unstable co-morbid psychiatric condition for which 24/7 psychiatric management and nursing monitoring and care is required in order for the patient to participate in and utilize chemical dependency/substance abuse treatment, and which is too unstable to be controlled and managed in the residential treatment setting. If transferring directly from chemical dependency/substance abuse residential treatment, the unstable co-morbid psychiatric condition became evident or developed during residential treatment. And the patient is medically stable to the extent that inpatient detoxification is not needed. Alternately, inpatient chemical dependency/substance abuse treatment admission may be appropriate in lieu of residential treatment when criteria (I) through (IV) above are met (i.e. chemical dependency/substance abuse residential treatment is medically necessary), criterion (V) is not met, at least one of the following circumstances is present, and the plan is for a brief or short-term stay (generally a maximum of 21 days): A. The patient does not have a chemical dependency/substance abuse residential treatment benefit; B. There are no available chemical dependency/substance abuse residential treatment facilities within reasonable driving distance for the patient, the patient cannot afford the cost of air travel to available chemical dependency/substance abuse residential treatment facilities, and inpatient chemical dependency/substance abuse treatment is available in the patent s local geographic area or nearby; C. For an adolescent patient or a young adult patient who resides with parents, there are no available chemical dependency/substance abuse residential treatment facilities in the patent s local geographic area or nearby, inpatient chemical dependency/substance abuse treatment is available in the patent s local geographic area or nearby, and inpatient treatment will include significantly greater parent/family participation than would occur with more distant residential treatment. Additional Criteria for Inpatient Admission Either a or b, and all of c through g, must be met: a. The purpose of the inpatient admission is to achieve sufficient control and stabilization of the comorbid medical or psychiatric condition in the context of a brief or short-term stay (generally a maximum of 14 days) to allow the patient to adequately participate in and utilize chemical dependency/substance abuse treatment; plus one of the following: 1. Initiation of participation in and utilization of chemical dependency/substance abuse treatment that will continue in residential treatment. 2. If discharge to residential treatment is not feasible, development of sufficient coping skills and relapse prevention skills to be able to transfer to partial hospitalization, intensive outpatient treatment, or outpatient treatment without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others (physical, medical, severe functional) or imminent probability of serious pervasive deterioration in functioning and/or self-care. b. If inpatient chemical dependency/substance abuse treatment is being utilized in lieu of residential chemical dependency/substance abuse treatment per the admission criteria above, the purpose of the inpatient admission is development of sufficient coping skills and relapse prevention skills to

3 be able to transfer to partial hospitalization, intensive outpatient treatment, or outpatient treatment without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others (physical, medical, severe functional) or imminent probability of serious pervasive deterioration in functioning and/or self-care (generally within a maximum of 21 days). c. Inpatient admission is not primarily due to involuntarily commitment, forensic evaluation, or other court-ordered stay in the absence of criteria (I) through (V) above, or the alternate criteria for inpatient treatment in lieu of residential treatment. d. The patient has sufficient cognitive capacity to participate in, utilize, and benefit from chemical dependency/substance abuse treatment, or is expected to have sufficient cognitive capacity after sufficient control and stabilization of the co-morbid medical or psychiatric condition has been achieved. e. If there have been multiple previous episodes of inpatient and/or residential chemical dependency/substance abuse treatment, an explanation is provided of why previous treatment episodes failed to be effective, or why improvement during previous treatment episodes was not able to be maintained (i.e. why relapses occurred), and what is going to be different about another episode of chemical dependency/substance abuse treatment (inpatient this time) such that it is expected to result in improvement during treatment, and if discharging directly to partial hospitalization, intensive outpatient treatment, or outpatient treatment, sustained maintenance of improvement and abstinence following discharge. f. Inpatient treatment is not being utilized as an alternative to respite for family or community. g. Inpatient treatment is not being utilized as an alternative to incarceration. Severity of Illness Criteria for Continued Stay At least one of the following must be present: a. Admission criterion (V) must still be present. However, if the stay exceeds seven days, there is improvement in control and stabilization of the co-morbid medical or psychiatric condition, and improved participation in and utilization of chemical dependency/substance abuse treatment, every three to four days. b. If inpatient chemical dependency/substance abuse treatment is being utilized in lieu of residential chemical dependency/substance abuse treatment per the admission criteria above, one or more of admission criteria (IV a) through (IV f) above must still be present in conjunction with insufficient development of coping skills and relapse prevention skills to be able to transfer to a less restrictive/intensive level of care (partial hospitalization, intensive outpatient treatment, outpatient treatment) without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others (physical, medical, severe functional) or imminent probability of serious pervasive deterioration in functioning and/or self-care. However, clinical progress must also be evident. If the stay exceeds seven days, then beginning improvement must be evident within an additional three to four days, followed by observable clinical progress every three to four days in the specific components of admission criterion (IV) that are preventing transfer to a less restrictive/intensive level of care. c. The co-morbid medical or psychiatric condition has been stabilized to the point where of chemical dependency/substance abuse treatment can continue in a less restrictive/intensive level of care (residential, partial hospitalization, intensive outpatient treatment, or outpatient), but a very brief additional period (one to three days) of hospitalization is indicated (1) to ensure that stabilization can be maintained without significant decompensation, (2) to secure placement in a chemical dependency/substance abuse residential treatment facility for a patient who will rapidly decompensate and be re-hospitalized if not discharged directly to such placement, or (3) to secure an appropriate living placement for a patient who will rapidly decompensate and be re-hospitalized if not discharged directly to such placement. d. If inpatient chemical dependency/substance abuse treatment is being utilized in lieu of residential chemical dependency/substance abuse treatment per the admission criteria above, sufficient improvement for partial hospitalization, intensive outpatient treatment, or outpatient treatment has occurred, but a very brief additional period (one to three days) of hospitalization is indicated (1) to ensure that improvement can be maintained without significant decompensation, or (2) to secure an appropriate living placement for a patient who will rapidly decompensate and be re-admitted if not discharged directly to such placement. e. Maximum likely improvement has been achieved, there is little likelihood of further clinical

4 improvement with continued inpatient treatment, but a very brief additional period (one to three days) of hospitalization is needed to secure an appropriate placement for a patient who will rapidly decompensate and be re-admitted if not discharged directly to such placement. f. Little or no improvement has been achieved, there is little likelihood of clinical improvement with continued inpatient treatment, but a very brief additional period (one to three days) of hospitalization is needed to secure an appropriate placement for a patient who will rapidly be readmitted if not discharged directly to such placement. g. If inpatient chemical dependency/substance abuse treatment is being utilized in lieu of residential chemical dependency/substance abuse treatment per the admission criteria above, sufficient improvement for partial hospitalization or intensive outpatient treatment has occurred, but the patient resides in or will be discharging to a location without reasonable geographic access to chemical dependency/substance abuse partial hospitalization or intensive outpatient treatment. In this case, a brief additional period of continued inpatient is appropriate to stabilize the patient sufficiently for discharge to outpatient treatment. Additional Criteria for Continued Stay Either h or i, and all of j through kk, must be met: a. The purpose of inpatient treatment continues to be sufficient control and stabilization of the comorbid medical or psychiatric condition in the context of a brief or short-term stay (generally a maximum of 14 days) to allow the patient to adequately participate in and utilize chemical dependency/substance abuse treatment; plus one of the following: 1. Initiation of participation in and utilization of chemical dependency/substance abuse treatment that will continue in residential treatment. 2. If discharge to residential treatment is not feasible, development of sufficient coping skills and relapse prevention skills to be able to transfer to partial hospitalization, intensive outpatient treatment, or outpatient treatment without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others (physical, medical, severe functional) or imminent probability of serious pervasive deterioration in functioning and/or self-care. b. If inpatient chemical dependency/substance abuse treatment is being utilized in lieu of residential chemical dependency/substance abuse treatment per the admission criteria above, the purpose of the inpatient treatment continues to be development of sufficient coping skills and relapse prevention skills to be able to transfer to partial hospitalization, intensive outpatient treatment, or outpatient treatment without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others (physical, medical, severe functional) or imminent probability of serious pervasive deterioration in functioning and/or self-care (generally within a maximum of 21 days). c. There must be reasonable likelihood, based on clinical information, that continued inpatient treatment has the potential to result in (further) clinical improvement. Continued inability to improve will generally be considered as evidence that this is no longer the case (except for continued stay criteria (e) and (f) above). d. To the extent possible based on any limitations due to a co-morbid medical or psychiatric condition, the patient is compliant with program rules and treatment recommendations, is attending most or all treatment activities, is demonstrating recognition of her or his chemical dependency/substance abuse, is demonstrating commitment to treatment and to abstinence, is demonstrating motivation to improve, is actively participating in treatment and attempting to utilize treatment to achieve clinical progress, and is actively participating in discharge planning. If inpatient chemical dependency/substance abuse treatment is being utilized in lieu of residential chemical dependency/substance abuse treatment per the admission criteria above and admission criteria (IV a) and/or (IV b) are present and therefore impeding compliance, engagement and participation, commitment to abstinence, and/or utilization of treatment, some degree of improvement in these areas must be evident no later than 14 days after admission, with progressive improvement for the remainder of the stay. e. If inpatient chemical dependency/substance abuse treatment is being utilized in lieu of residential chemical dependency/substance abuse treatment per the admission criteria above, the residential treatment facility/program must be able to (1) describe clinical evidence of the risk of relapse outside of the inpatient treatment setting, (2) identify the specific coping skills and relapse prevention skills that the patient lacks or has not yet adequately developed, or the specific

5 elements of a relapse prevention plan that need to be completed, and (3) explain what specifically is being done to help the patient develop those skills or complete those missing elements. f. Continued inpatient stay is not primarily for containment or to prevent regression because there has been minimal or no improvement after a reasonable period of time (generally 14 days) and there is little likelihood of improvement with continued inpatient treatment (except for continued stay criterion (f) above). g. Continued inpatient stay is not primarily for containment or to prevent regression because clinical progress has stalled, or a new or chronic baseline has been reached, or maximum likely improvement has been achieved, and there is little likelihood of further improvement with continued residential treatment (except for continued stay criterion (e) above). h. Continued inpatient treatment is not primarily due to a pre-determined fixed length of stay, a requirement that patients complete a pre-determined program, or a requirement that patients reach a certain level in a level program. Lengths of stay, treatment plans, and treatment goals must be individualized for each patient. i. Continued inpatient treatment is not primarily to complete certain steps or reach a certain step of the Twelve Steps. The Twelve Steps were not developed as goals or indicators of progress for inpatient treatment. j. Continued inpatient treatment is not primarily due to the presence of risk of relapse. Most patients will be at some degree of risk of relapse on an ongoing basis regardless of the treatment setting or living setting. The appropriate level of treatment is determined by ability to manage the risk of relapse, not by the mere the presence of risk of relapse. k. Continued inpatient stay is not primarily due to lack of adequate family, living environment, peer, community, or other external supports when the patient has otherwise improved sufficiently for partial hospitalization, intensive outpatient treatment, or outpatient treatment. Inadequate family, living environment, peer, community, or other external supports, including when admission criteria (IV f) is present, should be identified early in the inpatient stay and actively worked-on throughout the stay such that, by the time the patient has improved sufficiently for partial hospitalization, intensive outpatient treatment, or outpatient treatment, family/living environment/ peer/community/other external supports are not impediments to discharge, or, alternative placement has been sought and secured, or will be sought and secured within one to three days as per continued stay criteria (c), (d), or (e) above. l. Continued inpatient stay is not primarily due to lack of a place for the patient to reside (except for continued stay criteria (c), (d), (e), or (f) above). m. Continued inpatient stay is not primarily due to waiting for a placement to be identified or secured (except for continued stay criteria (c), (d), (e), or (f) above). n. Continued inpatient stay is not primarily due to waiting for funding for a placement (except for continued stay criteria (c), (d), (e), or (f) above). o. Continued inpatient stay is not primarily due to waiting for application to, acceptance by, bed availability at, funding for, or transfer to a halfway house or other sober living residence (except for continued stay criteria (c), (d), (e), or (f) above). p. Continued inpatient stay is not primarily due to waiting for acceptance by, bed availability at, funding for, or transfer to another treatment setting, e.g. a psychiatric or eating disorders RTC, (except for continued stay criteria (c), (d), (e), or (f) above). q. Continued inpatient stay is not primarily due to waiting for the date of enrollment or starting in a school, vocational, treatment, or other program. r. Continued inpatient stay is not primarily due to an involuntary commitment, forensic evaluation, or other court-ordered stay in the absence of one of continued stay criteria (a) through (f) above. s. Continued inpatient stay is not primarily due to waiting for a discharge plan to be determined or worked-on or completed. t. Continued inpatient stay is not primarily due to waiting for a court-order or approval in order to be released. u. Continued inpatient stay is not primarily due to unavailability or refusal of family, friends, or other persons to pick-up the patient. v. Continued inpatient stay is not primarily due to unavailability of, or difficulties or delays in arranging for, transportation to home/community, another treatment facility, a placement, or other discharge location. w. Continued inpatient stay is not primarily because of a pending change in or uncertainty about family structure, e.g. a pending or possible separation or divorce, or for children and adolescent patients, a pending change in or uncertainty about custody or guardianship. x. Continued inpatient stay is not primarily for respite for family or community. y. Continued inpatient stay is not primarily as an alternative to incarceration.

6 z. Continued inpatient stay is not primarily due to patient or family non-compliance with treatment orders, treatment recommendations, or treatment activities, inadequate or non-participation in treatment, or inadequate/absent participation in discharge planning. aa. Continued inpatient stay is not primarily because of post-acute withdrawal syndrome (PAWS) symptoms. PAWS can last for up to 20 months (well beyond reasonable lengths of stay for residential treatment), and is manageable on an outpatient basis. If PAWS is a significant problem for a patient, the residential treatment program is expected to provide adequate education regarding the recognition and self/outpatient-management of PAWS. bb. Continued inpatient stay is not primarily to work on long-term goals, or for intensive work on longstanding or long-term issues. Although long-standing or long-term issues may be contributory to a patient s Substance Use Disorder, and long-term goals may be relevant in the treatment of a Substance Use Disorder, inpatient treatment is not intended to be a long-term process, and much of the work will need to continue post-inpatient treatment. cc. Continued inpatient stay is not primarily for psychotherapeutic work that has the potential to cause a worsening of symptoms (e.g. some forms of trauma work, even if past trauma is believed to be contributory to the patient s Substance Use Disorder). dd. Continued inpatient stay is not primarily to ensure that a certain level of improvement can be maintained for an extended period of time prior to discharge. One to three days of a level of improvement that can be managed at a less restrictive level of care is considered to be sufficient for discharge from inpatient treatment, as per continued stay criteria (c) or (d) above. ee. For inpatient treatment in lieu of residential treatment per the admission criteria above, the stay must continue to be brief or short-term (generally a maximum of 21 days). Stays that exceed brief or short-term necessitate transfer to residential treatment regardless of the initial barriers to residential treatment. Intensity of Service Criteria for Inpatient Admission and Continued Stay All of the following must be present: a. There must be an attending psychiatrist, addiction medicine physician, or psychiatric nurse practitioner who is in charge of treatment. b. A thorough chemical dependency/substance abuse, psychiatric, and medical admission evaluation and initial treatment plan by the attending psychiatrist, addiction medicine physician, or psychiatric nurse practitioner must be completed within 24 hours of admission. c. A thorough physical exam must be completed by the attending psychiatrist, addiction medicine physician, psychiatric nurse practitioner, or by a physician, nurse practitioner, or physician assistant designated by the attending psychiatrist, addiction medicine physician, or psychiatric nurse practitioner, within 24 hours of admission. In addition, appropriate laboratory, radiologic, and other evaluations must be obtained in a timely manner when indicated. d. A comprehensive, individualized, realistic multi-disciplinary treatment plan must be completed within 72 hours of admission, with primary focus on (1) acute stabilization of the unstable comorbid medical or psychiatric condition; (2) initial work on coping skills and relapse prevention skills; (3) if the patient is not transferring to residential treatment, development of sufficient coping skills and relapse prevention skills to be able to transfer to partial hospitalization, intensive outpatient treatment, or outpatient treatment without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others (physical, medical, severe functional), and addressing any psychosocial or environmental factors that are preventing or impeding the development of appropriate coping skills and relapse prevention skills. e. The attending psychiatrist, addiction medicine physician, or psychiatric nurse practitioner must assess the patient's condition, progress, and continued treatment needs in-person, one-on-one, at least once daily (including if inpatient treatment is in lieu of residential treatment). f. For adolescent patients, and for patients 18 and older who are residing with a parent or parents, there must be active family involvement as follows: a minimum of one family therapy session or equivalent professionally-facilitated family treatment activity on-site at least once weekly, with a greater intensity (e.g. two to three times weekly) when clinically indicated, unless it can be clearly demonstrated that an unstable medical or psychiatric disorder precludes adequate patient participation in family therapy or that family therapy/treatment involvement would adversely impact clinical outcome. Telephonic or video sessions may be utilized in lieu of on-site sessions if the family resides more than a three hour one-way drive from the hospital. Multi-family groups are not acceptable for meeting this requirement.

7 g. Unless medically contraindicated or there is a valid clinical reason for a delay, non-addictive psychotropic medication must be rapidly initiated for conditions or symptom constellations known to be potentially medication-responsive. h. The primary foci of treatment and treatment interventions at all times are (1) control and stabilization of the unstable co-morbid medical or psychiatric disorder, and (2) treatment of the patient s Substance Use Disorder to the extent that patient participation and utilization of treatment is not impaired by a co-morbid medical or psychiatric disorder. For inpatient treatment in lieu of residential treatment per the admission criteria above, the primary foci of treatment and treatment interventions at all times are (1) specific coping skills and relapse prevention skills that the patient lacks or has not yet adequately developed that are preventing discharge to a less restrictive/intensive level of treatment, and (2) any ancillary factors (psychosocial, environmental, psychiatric, medical) that are preventing or impeding the development of those skills or otherwise preventing discharge to a less restrictive/intensive level of treatment. i. Concurrent medical or surgical problems must be evaluated and treated in a timely fashion. Failure to access consultative medical-surgical resources in a timely fashion is not by itself adequate grounds for extending length of stay. j. If ongoing cravings for alcohol or opioids are impeding discharge to a less restrictive/intensive level of treatment, then there must be an evaluation by the attending psychiatrist, addiction medicine physician, or psychiatric nurse practitioner for the potential usefulness of anti-craving medication. If such evaluation results in a strong recommendation for anti-craving medication, then such medication must be initiated without delay unless there are medical contraindications, and must be continued for the remainder of the stay unless intolerable adverse effects or medical contraindications develop. k. An initial discharge plan must be formulated within 24 hours of admission. Subsequent to that, active, appropriate, realistic, comprehensive discharge planning must be initiated in a timely fashion and must continue throughout the residential stay until completed. Discharge planning may not be delayed until the patient is clinically ready for discharge. Discharge planning must include early identification of the level of care and/or services, provider types, and other resources that will be needed post-discharge, including family and community supports and resources as appropriate. There must be evidence of ongoing activity to locate and secure post-discharge treatment resources. Appropriate follow-up or post post-discharge facility treatment must be scheduled or arranged and must be timely. If discharge to home/family is not an option, then alternative placement options must be rapidly identified, and there must be active efforts to locate and secure placement. The facility must take primary responsibility for carrying-out and completing discharge planning, and may not expect the patient or family/ guardians to seek and secure follow-up arrangements or placement beyond what the patient or family/guardians are realistically capable of doing and willing to do in a timely manner. The discharge plan may be modified if necessitated by a significant change in the patient s clinical condition or by failure to improve to the extent that had been anticipated. l. Failure to improve within clinically expected timeframes must lead to a reassessment of the treatment plan and an appropriate revision of the treatment plan. m. If chemical dependency/substance abuse developed due to prescribed, non-prescribed, or illicit medication or drug use secondary to chronic pain, then treatment must include development or substitution of alternative pain management or pain tolerance techniques and strategies, or postdischarge plans must include treatment or a treatment program that will incorporate development or substitution of alternative pain management or pain tolerance techniques and strategies. n. Therapeutic passes may be appropriate, when discharge is imminent i.e. within a few days and the discharge plan is for discharge to home or other community setting (1) for evaluating patients' readiness for discharge by assessing their ability to function at home and in the community, (2) for providing a less-abrupt transition back to home and community, or (3) for attending one or two offsite AA, NA, or similar meetings that the patient intends to continue with post-discharge. For adolescent patients, passes must be with a parent, guardian, custodian, or other responsible adult. A maximum of one or two successful short passes is sufficient to assess readiness for discharge or to assist with transition back to home and community, and discharge is then expected within 24 hours of completion. Passes which exceed these parameters, a single pass that results in missing most of a day's treatment activities, or any overnight passes, will be considered to be conclusive evidence that inpatient treatment is no longer medically necessary.

8 Coding CPT Number Description Interactive complexity (List separately in addition to the code for primary procedure) Psychiatric diagnostic evaluation Psychiatric diagnostic evaluation with medical services Psychotherapy, 30 minutes with patient and/or family member Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Psychotherapy, 45 minutes with patient and/or family member Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Psychotherapy, 60 minutes with patient and/or family member Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Family psychotherapy (without the patient present) Family psychotherapy (conjoint psychotherapy) (with patient present) Multiple-family group psychotherapy Group psychotherapy (other than of a multiple-family group) Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI), administered by a computer, with qualified health care professional interpretation and report Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report Related Guidelines / Policies Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification Behavioral Health: Chemical Dependency/Substance Abuse Residential Treatment Behavioral Health: Inpatient/Residential Detoxification

9 Scope Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage. Additional Information References 1. D Mee-Lee et al, The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co- Occurring Conditions, Third Edition. The Change Companies, R Ries et al. The ASAM Principles of Addiction Medicine, Fifth Edition. Wolters Kluwer, American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing, History Date Reason 02/10/15 New UM Guideline, add to Mental Health section. Inpatient psychiatric treatment is considered medically necessary when all criteria are met. This policy is retro-active with an effective date of January 1, Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA) Premera All Rights Reserved.

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