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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

21 II. Mental Health Treatment fr Children and Adlescents Sectin 2 Page 21 f 111

22 Acute Inpatient Mental Health Treatment fr Children and Adlescents 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 Children and Adlescents is utilized when the fllwing care 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 insure 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 Children and Adlescents: Prir t admissin, there has been a face-t-face assessment by a licensed behaviral health clinician, with training and experience in the assessment and treatment f acute psychiatric disrders in children and adlescents, 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 Children and Adlescents: 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 Child Psychiatrist. Psychiatric fllw-up ccurs daily r mre frequently as needed. A medical evaluatin is cmpleted within 24 hurs f admissin. All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant cmrbid cnditins. Within 48 hurs f admissin, utreach will be dne with existing prviders and family members t btain any relevant histry and clinical infrmatin. Yung children (12 years and yunger) will be admitted t a unit exclusively fr children. Page 22 f 111

23 Onging academic schling is prvided t facilitate a transitin back t the child s previus schl setting. The facility will rapidly assess and address any urgent behaviral and/r physical issues. Family Invlvement - The treatment shuld be family-centered with bth the patient and the family included in all aspects f care. Therefre, 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. 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, and living situatin. The treatment plan results in interventins utilizing medicatin management, scial wrk invlvement, individual, grup, and family therapies as apprpriate. The gal is t imprve symptms, develp apprpriate discharge criteria and planning invlving 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 nn-adherence/pr respnse and clear interventins fr the reductin f future risks. A Discharge Plan that starts at the time f admissin and include: Crdinatin with family, utpatient prviders, and cmmunity resurces t facilitate a smth transitin back t hme, family, wrk r schl, and apprpriate less restrictive 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 - Acute Psychiatric Hspitalizatin fr Children and Adlescents Criteria fr Admissin All f the fllwing must be met: 1. All basic elements f medical necessity must be met. Page 23 f 111

24 2. The child/adlescent has a dcumented 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 criteria must be met: A. It is very likely that the child/adlescent is abut t cause serius bdily harm t him/herself r smene else due t a psychiatric illness, and 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 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 child/adlescent due t a psychiatric illness, and that harm cannt be prevented at a lwer level f care as evidenced by: i) The child/adlescent 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 child/adlescent 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 child/adlescent has a secndary cnditin such that treatment cannt be prvided at a less restrictive level f care as evidenced by: i) Serius medical cmplicatins f an eating disrder, 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 child/adlescent requires Electrcnvulsive Therapy (ECT) and the initial trial requires a 24-hur psychiatric/medical setting, OR 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, 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: Page 24 f 111

25 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 25 f 111

26 Residential Mental Health Treatment fr Children and Adlescents 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 Children and Adlescents: Cigna agrees with the fllwing principles, as stated by the American Academy f Child and Adlescent Psychiatry(11): The best place fr children and adlescents is at hme with their families. A child r adlescent with mental illness shuld be treated in the safest and least restrictive envirnment, and needed services shuld be wrapped-arund t prvide mre intensive hme r cmmunity-based services. Hwever, due t the severity f an individual s psychiatric illness, there are times when a patient s needs cannt be met in a cmmunity-based setting. When less restrictive resurces are either unavailable r nt apprpriate fr the patient s needs, it might be necessary fr a child r adlescent t receive treatment in a psychiatric residential treatment center (RTC). A Psychiatric Residential Treatment Facility (PRTF) fr Children and Adlescents is either a standalne mental health facility r a physically and prgrammatically-distinct unit within a facility licensed fr this specific purpse with 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 fr Children and Adlescents are staffed by a multidisciplinary treatment team under the leadership f a Bard Certified/Bard Eligible Psychiatrist with training and experience cnsistent with the age and prblems f children and adlescents 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 child s develpmental, emtinal, physical and educatinal needs, including intensive mental health care, physical health care, and access t n-ging educatin at the apprpriate develpmental level. 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.. Page 26 f 111

27 Treatment is fcused n stabilizatin and imprvement f functining and reintegratin with parents/relatives r guardians, 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 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 all f the abve criteria. A few examples fllw: 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. Therapeutic (Barding) Schls: The primary purpse f these facilities is t prvide specialized educatinal prgrams that may als be supplemented by psychlgical and psychiatric services. These facilities may serve varied ppulatins f students, many f which als have difficulties in scial and academic areas. These prgrams generally d nt have specialized nurses n site and/r a psychiatrist available at all times t assist with medical issues/crisis interventin and medicatin administratin as needed. 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, pediatricians, and licensed therapists wh are cnsistently invlved in the care f the child r adlescent. 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 within the juvenile justice r prtective services system, r as an alternative t specialized schling (which shuld be prvided by the lcal schl system) 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 Children and Adlescents: Prir t the time f admissin, there has been a face-t-face assessment with the child/adlescent and family by a licensed behaviral health prfessinal with training and experience cnsistent with the age and prblems f children and adlescents. This assessment includes a clinically-based recmmendatin fr the need fr this level f care. 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. Page 27 f 111

28 Evaluatin by a Bard Certified/Bard Eligible Psychiatrist with training and experience cnsistent with the age and prblems f children and adlescents 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 fr Children and Adlescents: 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 The treatment shuld be family-centered with bth the patient and the family included in all aspects f care. Therefre, 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. Family therapy shuld ccur at least 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. Therapeutic passes may ccur, when clinically indicated, t allw pprtunity t practice therapeutic skills/gains with the family. Discharge planning that starts at the time f admissin. Onging academic schling is prvided t facilitate a transitin back t the child s previus schl setting. Yung children (12 years and yunger) will be admitted t a unit exclusively fr children. 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. Page 28 f 111

29 All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant c-mrbid cnditins. The family 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-t-face family therapy sessins as frequently as pssible. Realistic, specific, measurable, and achievable gals. This plan shuld: Be develped jintly with the family and the child/adlescent. 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 - Residential Mental Health Treatment fr Children and Adlescents: 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 child/adlescent has been diagnsed with a severe psychiatric disrder that is pervasive and significantly impairs develpmentally apprpriate functining. This impairment in functin is seen acrss multiple settings such as; schl, hme, wrk, and in the cmmunity, and clearly demnstrates a need fr 24-hur supervisin and active treatment, OR 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 child/adlescent cntinues t display behavirs that require arund-the-clck supervisin in a structured setting in rder t maintain the safety f the child/adlescent and thers. 3. All f the fllwing criteria must be met: A. The child /adlescent and/r family demnstrate chrnic dysfunctin, which is likely t respnd t multiple therapeutic and family treatment interventins, and all parties cmmit t active regular treatment participatin. B. The child/adlescent is able t functin with age-apprpriate 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 child/adlescent s needs r have been tried and were unsuccessful. Page 29 f 111

30 Criteria fr Cntinued Stay All f the fllwing must be met: 1. The individual cntinues t meet all basic elements f medical necessity. 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. All f the fllwing must be met: D. The individual and family are invlved t the best f their ability in the treatment and discharge planning prcess. E. Cntinued stay is nt primarily fr the purpse f prviding a safe and structured envirnment. Page 30 f 111

31 Partial Hspitalizatin Mental Health Treatment fr Children and Adlescents 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 Children and Adlescents 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 Children and Adlescents: Children/adlescents are nt apprpriate fr PHP service level if they are 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 schl, wrk, and/r with ther activities f daily living Has the ability: T make age-apprpriate basic decisins fr him/herself AND T accept respnsibility fr his/her wn actins Page 31 f 111

32 Admissin Cnsideratins fr Partial Hspitalizatin Mental Health Treatment fr Children and Adlescents: 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 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 with training and experience cnsistent with the age and prblems f children and adlescents 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 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, unless clinically cntraindicated r ding s wuld nt be in cmpliance with existing federal r state laws. Discharge planning. Expectatins fr Psychiatric Partial Hspitalizatin fr Children and Adlescents: 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, ther than age apprpriate limitatins fr children and adlescents. 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, except as age-apprpriate fr children and adlescents. 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 Eligible Psychiatrist with training and experience cnsistent with the age and prblems f children and adlescents. 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. Page 32 f 111

33 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. Onging academic schling is prvided t facilitate a transitin back t the child s previus schl setting. Yung children (12 years and yunger) will be admitted t a unit exclusively fr children. 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. 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 nn-adherence/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. 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 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 lngterm scial rehabilitatin and maintenance f individuals with severe and persistent mental illness. Medical Necessity Criteria - Psychiatric Partial Hspitalizatin fr Children and Adlescents Criteria fr Admissin All f the fllwing must be met 1. All basic elements f Medical Necessity must be met. 2. The child/adlescent individual has a dcumented 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 child/adlescent is demnstrating significant impairments in functining secndary t a psychiatric disrder, as evidenced by bth f the fllwing: i) The child/adlescent is nt able t cmplete rutine daily scial, family, schl, and/r wrk activities, AND Page 33 f 111

34 ii) The child/adlescent is nt able t emply the necessary cping skills t cmpensate fr this. B. The child/adlescent 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 child/adlescent requires a structured prgram t avid cmplicatins f a c-existing medical cnditin (e.g., pregnancy, uncntrlled diabetes). 4. The child/adlescent is mentally and emtinally capable t actively engage in the treatment prgram 5. The child/adlescent is able t live in the cmmunity withut the restrictins f a 24-hur supervised setting, except as age-apprpriate fr children and adlescents. 6. The child/adlescent is expressing willingness t engage in treatment. 7. The child/adlescent and the family are 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 child/adlescent has a supprt system that includes family r guardians wh are able t actively participate in treatment 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 34 f 111

35 Intensive Outpatient Mental Health Treatment fr Children and Adlescents 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 Children and Adlescents prvides a crdinated, ambulatry, multi-disciplinary, 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 Intensive Outpatient Treatment fr Children and Adlescents: Is experiencing psychscial stressrs and/r cmplex family dysfunctin, such that a multidisciplinary treatment team is needed t stabilize the individual. Has the ability: a) T make age-apprpriate basic decisins fr him/herself AND b) T accept age-apprpriate respnsibility fr his/her wn actins Is nt at imminent risk fr serius bdily harm tward self r thers. The duratin f treatment and frequency f attendance are re-evaluated and adjusted accrding t the individual s severity f signs and symptms. Clinical interventins may include individual, 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. Nte: Lw Intensity Outpatient Prgrams and Aftercare Services are smetimes ffered by facilities that prvide an intermediate step between Intensive Outpatient Treatment and rutine Outpatient care. These prgrams are reviewed as grup therapy, utilizing the guidelines fr Outpatient Treatment. Admissin Cnsideratins fr Intensive Outpatient Treatment fr Children and Adlescents: Within 72 hurs prir t admissin, there has been a face-t-face assessment with the child/adlescent and family by a licensed behaviral health prfessinal with training and experience cnsistent with the age and prblems f children and adlescents. This assessment includes a clinically-based recmmendatin fr the need fr this level f care. Page 35 f 111

36 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. 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. Alternative less restrictive levels f care are cnsidered and referrals are attempted as apprpriate. Expectatins fr Intensive Outpatient Treatment fr Children and Adlescents: 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. 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, ther than age-apprpriate limitatins fr children and adlescents. 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, if an individual is barding at r near a facility, the individual has the freedm t interact with the cmmunity independently, withut being accmpanied by staff r thers, except as age-apprpriate fr children and adlescents. The facility prvides a structured prgram, which is staffed by prfessinals wh are trained and experienced in the treatment and prblems f children and adlescents. 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, 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. The Treatment Plan is nt based n a pre-established prgrammed plan r time frames. Page 36 f 111

37 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 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 Prgram fr Children and Adlescents Criteria fr Admissin All f the fllwing must be met 1. All basic elements f Medical Necessity must be met. 2. The child/adlescent 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 child/adlescent is demnstrating difficulties in functining secndary t a psychiatric disrder t the extent that: A. The child/adlescent is mildly t mderately impaired in his/her ability t cmplete rutine daily scial, family, schl, and/r wrk activities, AND B. The child/adlescent is able t emply the necessary cping skills t cntinue with mst rutine daily activities. 4. The child/adlescent is mentally and emtinally capable t actively engage in the treatment prgram 5. The child/adlescent is able t live in the cmmunity withut the restrictins f a 24-hur supervised setting, except as age-apprpriate fr children and adlescents. 6. The child/adlescent is expressing willingness t engage in treatment. 7. The child/adlescent and the family are 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 child/adlescent has a supprt system that includes family r guardians wh are able t actively participate in treatment. Criteria fr Cntinued Stay All f the fllwing must be met: 1. The individual cntinues t meet all basic elements f medical necessity. 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 Page 37 f 111

38 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. All f the fllwing must be met: D. The individual and family are invlved t the best f their ability in the treatment and discharge planning prcess. E. Cntinued stay is nt primarily fr the purpse f prviding a safe and structured envirnment. F. Cntinued stay is nt primarily due t a lack f external supprts. Page 38 f 111

39 III. Outpatient Treatment Sectin 3 Page 39 f 111

40 Outpatient Behaviral Health Treatment 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 - Outpatient Behaviral Health Treatment has the fllwing fcus and gals: Reduce r alleviate the individual s symptms Return individual t baseline r imprve the level f functining and/r Prevent imminent deteriratin that wuld lead t a need fr admissin t a mre intensive level f care. Outpatient Treatment may cnsist f Individual Therapy, Grup Therapy, r Family Therapy, Medicatin Management, r any cmbinatin f these fur types f treatment. Individual Therapy This is a prcess in which an individual is invlved in a therapeutic setting with a mental health r substance abuse clinician n an individual basis. Individual therapy shuld be cnsidered when: The individual is experiencing symptms r impairments that are impacting their day t day functining, relatinships, wrk r schl perfrmance. The individual has been unable t alleviate their symptms n their wn and/r is in need f additinal assistance t relieve their symptms. Grup Therapy This is a prcess in which a number f peple are invlved in a therapeutic setting at the same time under the guidance f a mental health r substance abuse clinician. Grups fcus n an individual within the cntext f a grup, n interactins that ccur amng individuals in the grup, r n the grup as a whle. Grup therapy may be cnsidered when: Prblems are best treated in a scial cntext, Peer grup interactin will enhance the effectiveness f prblem slving, Creating bnds r learning abut the impact ne has n thers is imprtant fr symptm reslutin and grwth, r Useful slutins may be better heard frm peers. Family Therapy The identified patient in family therapy may be a child, adlescent r adult. Family therapy shuld be cnsidered when: Page 40 f 111

41 The family is affected by either the individual s cnditin r the individual s treatment. The individual s symptms r lack f functining is reflective f family prblems. The family is cmprmising the individual s prgress. The treatment bjectives can mst efficiently be achieved by wrking with the family. The individual has failed t make expected prgress, and family interventins wuld be expected t imprve treatment prgress indicatrs include medicatin nncmpliance, failure t maintain abstinence frm substance abuse r ther self-harming behavirs, recurrent hspitalizatins. The identified individual is a child/adlescent r a yung adult still living at hme and/r requires parental resurces fr apprpriate functining. Medicatin Management: There are a few bilgically-based psychiatric cnditins that require lng-term, cntinuus medicatin management and fllw-up t prevent r minimize the frequency and severity f acute symptm relapse that culd require higher levels f care; All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant cmrbid cnditins. The need fr nging medicatin management des nt necessarily indicate that cntinued utpatient therapy is medically necessary. Expectatins fr Outpatient Behaviral Health Treatment: The therapist and individual will cllabrate t establish clearly defined treatment bjectives and t identify ways t measure imprvement. Frm time t time, individuals may ccasinally have ther unreslved prblems, but their level f functining has been restred t baseline. The presence f unreslved issues des nt necessarily indicate that cntinued utpatient therapy is medically necessary. The type and degree f functinal impairment will be reflected in the treatment plan. Treatment will be slutin-fcused and highly interactive, In mst cases, there is an expectatin that therapy will terminate nce the bjectives f the treatment episde have been met. Extended therapy visits (i.e., sessins lasting mre than 50 minutes) and multiple visits per week are nt cnsidered medically necessary unless there is a cmpelling clinical reasn fr the request. Fr individuals with a histry f multiple treatment episdes, the treatment plan needs t include clear interventins t identify and address the reasns fr previus nn-adherence/pr respnse and clear interventins fr the reductin f future risks. Telephnic sessins are nt cnsidered t be a substitute fr face-t-face therapy and are apprved nly when an individual cannt access direct patient/prvider care, either due t being gegraphically remte r when the individual is incapacitated and unable t attend face-t-face treatment, r when there is a state mandate f parity fr telephnic visits. Cigna des nt authrize treatment that is nt HIPAA cmpliant. As such, requests fr therapy sessins via ppular scial media apps r ther nn-hipaa cmpliant means f cmmunicatin cannt be apprved. Nte: Lw Intensity Outpatient Prgrams and Aftercare Services are smetimes ffered by facilities that prvide an intermediate step between Intensive Outpatient Treatment and rutine Outpatient care. These prgrams are t be reviewed as grup therapy, utilizing the guidelines fr Outpatient Mental Health and/r Substance Abuse Treatment. Page 41 f 111

42 Medical Necessity Criteria - Outpatient Behaviral Health Treatment Criteria fr Admissin All f the fllwing must be met: 1. All basic elements f medical necessity must be met. 2. Fr all mdalities f psychtherapy ALL f the fllwing must be met: A. The individual reprts r expresses a subjective level f distress. B. Clinical symptms result in functinal impairment (impairment in ability t cmplete activities f daily living, ccupatinal functining, and/r scial functining that is nt characteristic f the persn when nt symptmatic) C. The individual is mtivated fr, r amenable t, treatment by a mental health prfessinal. Criteria fr Cntinued Stay All f the fllwing must be met: 1. All basic elements f medical necessity must be met. 2. The individual cntinues t experience bth psychiatric symptms and functinal impairment. 3. The individual (and family as apprpriate) has participated in the develpment f an individualized treatment plan. The treatment plan shuld include clearly defined, measurable, and realistic gals and discharge criteria, with an expected timeframe fr cmpletin. In additin, Cntinued Stay guidelines are NOT met if any f the fllwing are the case: 1. The individual is uncperative r nncmpliant with treatment, and the absence f treatment pses n imminent risk f harm t the welfare f the individual r thers. 2. The individual s histry prvides evidence that additinal utpatient therapy will nt create further symptm relief and/r change. 3. Treatment is primarily supprtive in nature. 4. Treatment is fcused n phase f life, life transitin, r quality f life issues (fr example, career dissatisfactin, adjusting t new life circumstances in the absence f functinal impairments) rather than n treating a psychiatric illness. Page 42 f 111

43 Halfway Huse fr Behaviral Health & Substance Use Disrders Standards and Guidelines Nte: Halfway Huse placement is excluded under many Cigna Behaviral Health benefit plans, and may be gverned by federal and/r state mandates. Please refer t the applicable benefit plan dcument t determine benefit availability and the terms and cnditins f cverage. 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 - Halfway Huse fr Behaviral Health Disrders will: Be licensed t prvide services fr individuals with substance abuse disrders and/r ther behaviral health disrders by an apprpriate state licensing certificatin bard in the state where the care is prvided. Prvide 24-hur mnitring f the individual and the immediate physical envirnment t ensure a safe, clean and sber envirnment, where an individual in treatment fr substance abuse prblems can cntinue his/her recvery. Have clinical versight prvided by licensed medical prfessinals r substance abuse cunselrs. Have the capability t prvide medical and psychiatric referrals fr treatment and fllw up f underlying physical and/r psychiatric illnesses, and Require abstinence frm md-altering chemicals unless apprpriately prescribed by a licensed physician. Be used fr stabilizatin f the individual and preparatin fr transitin t a less restrictive level f care with a gal f reintegratin int the individual s cmmunity. Admissin Cnsideratins fr Halfway Huse fr Behaviral Health Disrders: A Halfway Huse admissin may be cnsidered when an apprpriate, less restrictive level f care is unavailable. Relapse shuld nt be the sle criteria fr transferring an individual t a mre intensive level f care. When apprpriate, an evaluatin shuld be perfrmed t assess the extent f the relapse, its effects n the individual and family, the risk f danger r harm t the individual r thers, and the reasn fr the relapse. An updated and mdified treatment plan shuld then include addressing the barriers t cntinued relapse, the relapse triggers, and the preventin plan. Fr individuals with a histry f multiple relapses, 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. Page 43 f 111

44 Expectatins fr Halfway Huse fr Behaviral Health Disrders: Staff will actively wrk with the individual t ensure he/she fully participates in substance abuse treatment, which can include n-site r cmmunity-based utpatient individual, grup, and family treatment, all while residing in the halfway huse. The staff and prgram f the Halfway Huse are fcused n reducing the risk f relapse, reinfrcing pr-scial behavirs, and assisting in cmmunity reintegratin. The Halfway Huse will have a dcumented and regularly updated care plan that addresses the individuals behaviral health needs. The discharge plan will include: 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. Medical Necessity Criteria - Halfway Huse fr Behaviral Health Disrders Criteria fr Admissin All f the fllwing must be met: 1. All basic elements f medical necessity must be met. 2. All f the fllwing criteria must be met: A. The individual is medically stable and nt experiencing medical cmplicatins that wuld preclude active participatin in treatment. The individual is cgnitively able t actively participate in and benefit frm behaviral health treatment. B. The individual demnstrates an interest in wrking tward the gal f rehabilitatin. C. The individual is actively engaged in treatment, which must include n-site r cmmunity-based utpatient individual, grup, and family treatment, r IOP/PHP, and staff at the halfway huse have reviewed and agree with the treatment plan. One r mre f the fllwing criteria must be met: D. While residing in a nn-halfway Huse setting, the individual: i) Has been unsuccessful in achieving sustained abstinence f 6 mnths r mre fllwing active participatin in an utpatient rehabilitatin prgram (intensive utpatient and/r partial hspitalizatin) during the past 12 mnths, OR ii) Has failed t fllw-thrugh with utpatient rehabilitatin, including intensive utpatient and/r partial hspitalizatin, OR iii) Has demnstrated a repeated inability t cntrl his/her impulses t use drugs/alchl. Fr an individual with a histry f repeated relapses and treatment histry invlving multiple treatment episdes, there must be evidence f the rehabilitatin ptential fr the prpsed admissin, with clear interventins, and definitin f nncmpliance and its management. OR E. The individual s living envirnment is such that his/her ability t successfully achieve abstinence is jepardized. Examples wuld be: the family is ppsed t the treatment effrts, the family is actively invlved in their wn substance abuse, and/r the living situatin is severely dysfunctinal, OR F. The individual s scial, family, and ccupatinal functining is severely impaired secndary t substance abuse, such that mst daily activities revlve arund btaining, using, and recuperating frm substance abuse. While the individual is expressing an interest in abstinence, he/she requires 24-hur supprtive living envirnment t engage and maintain therapeutic gains. Page 44 f 111

45 Criteria fr Cntinued Stay All f the fllwing must be met: 1. All basic elements f medical necessity cntinue t be met. 2. One r mre f the fllwing criteria must be met: The individual recgnizes r identifies with the severity f the behaviral health prblem, hwever, s/he still: A. Requires supprt t maintain cntinued sbriety, OR B. Requires supprt t maintain insight int self-defeating behavirs assciated with behaviral health, OR C. Requires supprt t maintain the prblem slving skills necessary t address their behaviral health, OR D. Requires supprt t manage persnal triggers assciated with relapse. 3. All f the fllwing must be met: A. The individual is actively engaged in n-site r cmmunity-based utpatient individual, grup, and/r family treatment r IOP/PHP. B. The individual is actively pursuing independent living arrangements. C. There is clinical evidence as t why ther living arrangements, with r withut the use f ther treatment services, wuld nt sustain the individual s prgress. D. The individual is imprving clinically and prgressing twards discharge frm the present level f care. E. The individual and family are invlved t the best f their ability in the treatment and discharge planning prcess. Page 45 f 111

46 IV. Substance Use Disrders Treatment Sectin 4 Page 46 f 111

47 Acute Inpatient Drug and Alchl Detxificatin 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 Inpatient Drug and Alchl Detxificatin is utilized when the fllwing services are needed: Arund-the-clck intensive, psychiatric/medical, and nursing care including cntinuus bservatin and mnitring. Apprpriate medical prfessinals are available, including physician visits at least nce each day and 24-hur nursing staff mnitring. 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 Inpatient Drug and Alchl Detxificatin is utilized when the fllwing services are needed: This level f care may be cnsidered after the individual has been evaluated medically in a face-tface assessment prir t the admissin t determine if this level f care is medically necessary and clinically apprpriate due t a significant risk f a severe withdrawal syndrme. This level f care is nt justified by simple intxicatin r fear f withdrawal. Therefre, elevated bld alchl level withut any assciated withdrawal symptms is nt enugh t justify detxificatin treatment. It is recgnized that life threatening intxicatin/pisning (i.e. endangering vital functins - central nervus system, cardiac, respiratry) may need acute medical attentin, but that attentin is generally nt cnsidered detxificatin. In such cases, treatment at a medical/surgical unit may be needed and medical necessity criteria are applied when the individual has acute and severe medical prblems such as: Acute nset f seizures, severe electrlyte imbalance, gastrintestinal bleeds, cardiac cmplicatins, acute liver failure, r ther serius medical cmplicatins, OR Underlying substance abuse is f such severity that it will likely cause severe and acute medical cmplicatins in the near future requiring acute medical management. Expectatins fr Acute Inpatient Drug and Alchl Detxificatin: A thrugh Evaluatin by a psychiatrist r addictinlgist 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 r addictinlgist. Physician fllw-up ccurs daily r mre frequently as needed. Page 47 f 111

48 Indicated medical evaluatins are cmpleted in a prmpt, timely manner. 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. Fr individuals under the age f 18 wh present with a substance use disrder, a face-t-face assessment that includes bth the child/adlescent and the family is cmpleted within 72 hurs f admissin by a licensed behaviral health prfessinal with training and experience cnsistent with the age and prblems f children and adlescents. The facility must be able t rapidly assess and address any urgent behaviral and/r physical issues. Crdinatin f treatment planning with cmmunity treatment prviders, emplyers, r any invlved legal authrities is an essential part f treatment and 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. 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 relapses, re-admissins, and treatment episdes, the treatment and discharge plan needs t include clear interventins t identify and address the reasns fr previus nn-adherence/pr respnse and clear interventins fr the reductin f future risks. 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.) Discharge planning. 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 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. Page 48 f 111

49 Medical Necessity Criteria - Acute Inpatient Drug and Alchl Detxificatin 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 diagnsis f a mderate-t-severe substance use disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders. 3. The individual is at risk fr a severe withdrawal syndrme as evidenced by abnrmal vital signs (bld pressure, temperature, pulse, and respiratins), clinically-based scales such as Clinical Institute Withdrawal Assessment (CIWA) r Clinical Opiate Withdrawal Scale (COWS), and ne r mre f the fllwing: A. Severe Alchl and/r Sedative-Hypntic Withdrawal as evidenced by recent use f these substances AND sme r all f the fllwing bservable, bjective symptms: agitatin, tremr, sweating, diarrhea, headache, nausea and vmiting, cluding f sensrium, delirium, seizures, and/r hallucinatins, OR B. Severe Opiate Withdrawal as evidenced by recent use f these substances AND sme r all f the fllwing bservable, bjective symptms: agitatin, sweating, diarrhea, dilated pupils, irritability, insmnia, teary eyes, muscle spasms, erectin f the hair n the skin, runny nse, rapid breathing, and/r yawning, OR C. Prir cmplicated and ptentially life-threatening withdrawal with a histry f seizures, delirium tremens, r hallucinatins assciated with alchl and/r sedative-hypntic use r withdrawal. AND 4. One r mre f the fllwing must apply: A. The presenting signs and symptms require active treatment that can nly be safely and effectively prvided in a 24-hur per day setting with nursing care and daily medical interventins. OR B. The Individual is currently suffering frm symptms f a severe mental illness r has such irratinal r bizarre thinking that he/she culd nt be safely treated in a less intensive 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. 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 and the individual cntinues t suffer frm severe withdrawal symptms that require active treatment effrts that can nly be prvided by arund-the-clck intensive nursing care and daily mnitring by a physician, OR C. The individual has develped new symptms and/r behavirs that require this intensity f service fr safe and effective treatment. Page 49 f 111

50 2. 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, unless there is a dcumented clinical cntraindicatin. 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 50 f 111

51 Ambulatry Drug and Alchl Detxificatin 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 - Ambulatry Drug and Alchl Detxificatin is utilized when there is a need fr medical mnitring f mild t mderate withdrawal symptms. Medicatins are prescribed and adjusted as indicated t assure that the individual has a safe and effective withdrawal frm alchl, sedative-hypntic medicatins, r piates. Apprpriate medical prfessinals are available, which may include a Psychiatrist r an Addictinlgist and daily mnitring by nursing staff. There is 24 hur access t a physician shuld unexpected symptms r wrsening f symptms ccur. Admissin Cnsideratins - Ambulatry Drug and Alchl Detxificatin: Prir t admissin, there has been a face-t-face individual assessment by a licensed physician r nurse practitiner with training and experience in acute psychiatric emergencies and medical detxificatin, t determine if this level f care is medically necessary and clinically apprpriate. The individuals managed at this level f care d nt require medical mnitring n a 24 hurs a day basis. The facility has the ability t step up the individual t an inpatient detxificatin level f care, if needed. Expectatins fr Ambulatry Drug and Alchl Detxificatin: Daily active, cmprehensive care by a treatment team that wrks under the directin f a Bard eligible/bard certified psychiatrist r addictinlgist. This level f care is used as a time-limited level f interventin t stabilize acute withdrawal symptms, facilitating a transitin t lwer levels f care when clinically indicated. Individuals and/r their families/significant thers are capable f accessing emergency services, if needed. Individuals in this level f care live in the cmmunity withut the restrictins f a 24-hur supervised setting The prgram facilitates engagement f individuals in treatment and recvery prgrams, including cmmunity based self-help grups, and develpment f a scial supprt netwrk t ensure lng-term sbriety. Crdinatin with cmmunity treatment prviders, emplyers, r any invlved legal authrities is part f the treatment and discharge planning Page 51 f 111

52 Psychiatric and/r substance use treatment is addressed cncurrently, as needed; t imprve the individual's ptential fr recvery. Fr individuals under the age f 18 wh present with a substance use disrder, a face-t-face assessment that includes bth the child/adlescent and the family is cmpleted within 72 hurs f admissin by a licensed behaviral health prfessinal with training and experience cnsistent with the age and prblems f children and adlescents. 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). All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant c-mrbid cnditins. Interventins utilizing medicatin management, individual, grup, marital and family therapies as apprpriate. The gal is t imprve symptms, develp apprpriate discharge criteria and planning invlving 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 relapses, re-admissins, and treatment episdes, the treatment and discharge plan needs t include clear interventins t identify and address the reasns fr previus nn-adherence/pr respnse and clear interventins fr the reductin f future risks. 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 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 that 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 - Ambulatry Drug and Alchl Detxificatin 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 diagnsis f a mderate-t-severe substance use disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders. 3. The individual is at risk fr a withdrawal syndrme as evidenced by abnrmal vital signs (bld pressure, temperature, pulse, and respiratins), clinically-based scales such as Clinical Institute Page 52 f 111

53 Withdrawal Assessment (CIWA) r Clinical Opiate Withdrawal Scale (COWS), and ne r mre f the fllwing: A. Alchl and/r Sedative-Hypntic Withdrawal as evidenced by recent use f these substances AND sme r all f the fllwing bservable, bjective symptms: agitatin, tremr, sweating, diarrhea, headache, nausea and vmiting, OR B. Opiate Withdrawal as evidenced by recent use f these substances AND sme r all f the fllwing bservable, bjective symptms: irritability, lack f appetite, sweating, diarrhea, dilated pupils, insmnia, teary eyes, muscle spasms, erectin f the hair n the skin, runny nse, rapid breathing, yawning. AND 4. The presenting signs/symptms must be causing clinically significant distress r impairment f scial, ccupatinal, r ther imprtant area f functining, AND 5. The individual des nt require arund-the-clck nursing 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 and the individual cntinues t suffer frm severe withdrawal symptms that require active treatment effrts that can nly be prvided by arund-the-clck intensive nursing care and daily mnitring by a physician, 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, unless there is a dcumented clinical cntraindicatin. 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 53 f 111

54 Acute Inpatient Treatment fr Substance Use Disrders 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 Inpatient Substance Use Disrders Treatment is utilized when the fllwing services are needed: Arund-the-clck intensive, psychiatric/medical, and nursing care including cntinuus bservatin and mnitring. Timely assessment and medically-necessary treatment f c-existing acute medical r psychiatric prblems. Acute management t prevent harm r significant deteriratin f functining and t ensure the safety f the individual and/r thers. Daily mnitring f medicatin effects and side effects. A cntained envirnment fr specific treatments that culd nt be safely dne in a nn-mnitred setting. NOTE: Acute Inpatient Substance Use Disrders Treatment may als be identified as Inpatient Rehabilitatin, Mentally Ill Chemical Abuse (MICA) Treatment, r Dual Diagnsis Inpatient Treatment. Admissin Cnsideratins fr Inpatient Treatment fr Substance Use Disrders: Prir t admissin, there has been a face-t-face individual assessment by a licensed clinician, with experience in acute psychiatric and medical emergencies, 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. Alternative medical, substance use detxificatin, psychiatric treatment prgrams, are cnsidered and referrals made when clinically indicated. Substance abuse inpatient treatment may be a cnsideratin when apprpriate alternative less restrictive levels f care are unavailable. Expectatins fr Inpatient Treatment fr Substance Use Disrders: A thrugh Evaluatin by a Psychiatrist r Addictinlgist 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 r Addictinlgist. A medical wrk-up is cmpleted as needed r apprpriate. Page 54 f 111

55 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. Fr individuals under the age f 18 wh present with a substance use disrder, a face-t-face assessment that includes bth the child/adlescent and the family is cmpleted within 72 hurs f admissin by a licensed behaviral health prfessinal with training and experience cnsistent with the age and prblems f children and adlescents. The facility must be able t rapidly assess and address any urgent behaviral and/r physical issues There is adequate nursing supprt, alng with staffing by apprpriately-trained clinicians, and availability f apprpriate physician expertise (such as Psychiatrist r Addictinlgist). The facility has the capability f btaining necessary cnsultatin(s) based n individual s clinical needs such as pain management specialist fr individuals with significant pain issues. The facility has the capability f mnitring individual s daily, medical functining. Such clinical mnitring may include measurement f the vital signs, perfrming bjective clinical assessment(s) t mnitr fr prlnged withdrawal and btaining necessary labratry wrk up, as indicated. Treatment is fcused n initial engagement in substance abuse rehabilitatin and develpment f a plan fr successful transitin t less restrictive settings and cmmunity re-integratin. 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). The treatment plan results in interventins utilizing medicatin management, individual, grup, marital and family therapies as apprpriate. The gal is t imprve symptms, develp apprpriate discharge criteria and planning invlving crdinatin with cmmunity resurces t allw a smth transitin back t utpatient services, family integratin, and cntinuatin f the recvery prcess. The Treatment Plan is nt based n a pre-established prgrammed plan r time frames. Fr individuals with a histry f multiple relapses, re-admissins, and treatment episdes, the treatment and discharge plan needs t include clear interventins t identify and address the reasns fr previus nn-adherence/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.) Discharge planning. 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 55 f 111

56 A prescriptin fr any prescribed medicatins sufficient t bridge the time between discharge and the scheduled fllw-up psychiatric appintment. Medical Necessity Criteria Acute Inpatient Treatment fr Substance Use Disrders 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 diagnsis f a mderate-t-severe substance use disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders. All f the fllwing must be met: A. Withdrawal symptms, if present, are nt life threatening and can be safely mnitred. B. The individual is nt experiencing medical cmplicatins that wuld preclude active participatin in treatment, AND C. The individual is cgnitively able t actively participate and benefit frm the treatment prvided, 3. One r mre f the fllwing criteria must be met: A. The individual demnstrates a clear and reasnable danger f imminent harm t self r thers that is caused by r exacerbated by the current active substance use disrder as evidenced by ne f the fllwing: i) Current plan r intent t harm self with an available and lethal means, OR ii) Highly lethal attempt t harm self with cntinued imminent risk as demnstrated by pr impulse cntrl r an inability t plan reliably fr safety. OR B. Inability t care adequately fr ne s physical safety due t disrdered, disrganized r bizarre behavir, OR C. Current plan/intent t harm thers with available and lethal means with inability t plan reliably fr safety, OR D. Vilent, unpredictable, r prly cntrlled behavir that represents an imminent serius harm t thers, OR E. The individual s medical cnditin and cntinued substance use places the individual in imminent danger f serius damage t his/her physical health r t a current pregnancy. The individual requires 24 hur mnitring, but nt the full resurces f an acute care hspital, OR F. 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. At least ne 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 Page 56 f 111

57 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, unless there is a dcumented clinical cntraindicatin. 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 57 f 111

58 Residential Substance Use Disrders Treatment 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 Substance Use Residential Treatment: A Substance Use Residential Treatment Facility is either a stand-alne substance abuse/ health facility r a physically and prgrammatically-distinct unit within a facility licensed fr this specific purpse with 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. Substance Abuse Residential Treatment Facilities are staffed by a multidisciplinary treatment team under the leadership f a Bard Certified/Bard Eligible Psychiatrist r Addictinlgist wh cnducts a face-t-face interview with each individual within 24 hurs f admissin and as frequently as clinically indicated thrughut the duratin f the admissin, but n less than nce weekly. 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 nt primarily fr the purpse f maintaining lng-term gains made in an earlier prgram. Residential treatment is transitinal in nature fr the purpse f returning the individual t the cmmunity with cntinued ambulatry treatment services as needed. Residential treatment cverage is nt based n a preset number f days. The length f a standardized prgram such as a 28-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 Residential Treatment Facilities fr Substance Use Disrders and that d nt meet all f the abve criteria. A few examples fllw: 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. Page 58 f 111

59 Therapeutic (Barding) Schls: The primary purpse f these facilities is t prvide specialized educatinal prgrams that may als be supplemented by psychlgical and psychiatric services. These facilities may serve varied ppulatins f students, many f which als have difficulties in scial and academic areas. These prgrams generally d nt have specialized nurses n site and/r a psychiatrist available at all times t assist with medical issues/crisis interventin and medicatin administratin as needed. Wilderness Prgrams and/r Outward Bund Prgrams: These are prgrams that prvide therapeutic alternatives t bt camps 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, physicians, and licensed therapists wh are cnsistently invlved in the care f the individual. These prgrams nearly universally d nt meet standards fr certificatin as residential treatment prgrams fr substance use disrders 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 within the justice system r prtective services system, r as an alternative t specialized schling (which shuld be prvided by the lcal schl system) 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 Substance Use Residential Treatment: Prir t the time f admissin, there has been a face-t-face evaluatin with the individual and family/significant thers by a licensed behaviral health prfessinal with training and experience in the assessment and treatment f individuals with substance use disrders. This assessment includes a clinically-based recmmendatin fr the need fr this level f care. 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 r Addictinlgist 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. Nte: Relapse shuld nt be the sle criterin fr managing an individual in a mre intensive level f care. When apprpriate, an evaluatin shuld be perfrmed t assess the extent f the relapse, its effects n the individual and the family; the risk f danger r harm t the individual r thers; and the reasn fr the relapse. Expectatins fr Substance Use Residential Treatment: Residential treatment shuld ccur as clse as pssible t the hme and cmmunity t which the individual will be discharged Page 59 f 111

60 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. Fr individuals under the age f 18 wh present with a substance use disrder, a face-t-face assessment that includes bth the child/adlescent and the family is cmpleted within 72 hurs f admissin by a licensed behaviral health prfessinal with training and experience cnsistent with the age and prblems f children and adlescents. 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 is 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. 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 treatment mdalities that are apprpriate t the clinical needs f the individual. Fr individuals with a histry f multiple relapses 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. Page 60 f 111

61 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 - Residential Substance Use Disrders Treatment Criteria fr Admissin All f the fllwing must be met: 1. All basic elements f medical necessity must be met. 2. The individual is expressing willingness t actively participate in this level f care. 3. The individual has a dcumented diagnsis f a mderate-t-severe substance use disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders. 4. Nne f the fllwing are present: A. Life-threatening symptms f withdrawal. B. Current withdrawal symptms that preclude active participatin in treatment. C. Medical r psychiatric impairments that preclude active participatin in treatment. 5. Fr individuals with a histry f repeated relapses and/r multiple failed treatment episdes, he/she is expected t actively engage in the implementatin f a treatment plan that specifically addresses prir nn-adherence and pr respnse t treatment and includes elements that are likely t reduce the frequency and severity f future relapse. 6. At least ne f the fllwing criteria must be met: A. The individual suffers frm a severe, uncntrlled, c-ccurring psychiatric illness r severe behaviral disturbance that interferes with his/her ability t successfully participate in a less restrictive level f care B. The individual s living envirnment is such that his/her ability t successfully achieve abstinence is seriusly jepardized by either: i) A hme envirnment that includes family/significant thers that are actively ppsed t the treatment effrts, r ii) A hme envirnment that includes family/significant thers that are actively invlved in their wn substance abuse C. The individual s scial, family, r ccupatinal functining is severely impaired secndary t substance abuse such that mst f his/her daily activities revlve arund btaining, using and recuperating frm substance abuse, D. The individual has demnstrated an inability t achieve sustained sbriety at less restrictive levels f care, as evidenced by ne f the fllwing: i) In the past 12 mnths, the individual has nt been successful in achieving sustained abstinence f 6 mnths r mre fllwing active engagement in multiple utpatient rehabilitatin prgrams, including intensive utpatient treatment and/r partial hspitalizatin. OR ii) In the past 12 mnths, fllwing multiple inpatient detxificatins, the individual has nt attempted t fllw-up with utpatient rehabilitatin prgrams, including intensive utpatient treatment and/r partial hspitalizatin. E. The individual has demnstrated a repeated inability t cntrl his/her impulses t use illicit substances and is at imminent risk f causing (medical r behaviral) harm t self r thers. This is f such severity that it requires 24-hur mnitring/supprt/interventin. Page 61 f 111

62 Criteria fr Cntinued Stay All f the fllwing must be met: 1. The individual cntinues t meet all basic elements f medical necessity. 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. 2. 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 62 f 111

63 Partial Hspitalizatin fr Substance Use Disrders 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 - Partial Hspitalizatin fr Substance Use Disrders prvides a 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 Partial Hspitalizatin fr Substance Use Disrders: May present nging risk f harm t him/her r thers, but is able t develp a plan t maintain safety in the cmmunity withut 24 hur supervisin. Is having acute Substance Use Disrder symptms that are cmprmising daily functining with wrk, parenting, schl, and/r with ther activities f daily living Has the ability: T make age-apprpriate basic decisins fr him/herself AND T accept age-apprpriate respnsibility fr his/her wn actins and behavir, Admissin Cnsideratins fr Partial Hspitalizatin fr Substance Use Disrders: Within 72 hurs prir t admissin, there has been a face-t-face evaluatin by a licensed behaviral health prfessinal with training and experience in the assessment and treatment f substance use disrders. This assessment includes a clinically-based recmmendatin fr the need fr this level f care. The admissins prcess shuld als include: Page 63 f 111

64 A dcumented current diagnsis f a substance use 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 r Addictinlgist 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 72 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 when indicated. Discharge planning. Expectatins fr Partial Hspitalizatin fr Substance Use Disrders: 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, except as age-apprpriate fr children and adlescents. Fr individuals under the age f 18 wh present with a substance use disrder, a face-t-face assessment that includes bth the child/adlescent and the family is cmpleted within 72 hurs f admissin by a licensed behaviral health prfessinal with training and experience cnsistent with the age and prblems f children and adlescents. 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 r addictinlgist. 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: Page 64 f 111

65 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. 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 relapses, re-admissins, and treatment episdes, the treatment and discharge plan needs t include clear interventins t identify and address the reasns fr previus nn-adherence/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 - Partial Hspitalizatin fr Substance Use Disrders 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 diagnsis f a mderate-t-severe substance use disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders. 3. The individual is expressing willingness t actively participate in this level f care. 4. Nne f the fllwing are present: A. Life-threatening symptms f withdrawal. B. Current withdrawal symptms that preclude active participatin in treatment. C. Medical r psychiatric impairments that preclude active participatin in treatment. 5. Fr individuals with a histry f repeated relapses and/r multiple failed treatment episdes, he/she is expected t actively engage in the implementatin f a treatment plan that specifically addresses prir nn-adherence and pr respnse t treatment and includes elements that are likely t reduce the frequency and severity f future relapse. 6. One r mre f the fllwing must be met: A. The individual is demnstrating significant impairments in functining secndary t a substance use disrder, as evidenced by bth f the fllwing: Page 65 f 111

66 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). 7. The individual is mentally and emtinally capable t actively engage in the treatment prgram 8. The individual is able t live in the cmmunity withut the restrictins f a 24-hur supervised setting, except as age-apprpriate fr children and adlescents. 9. 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. 10. 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. 11. 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. 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. 2. 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 66 f 111

67 Intensive Outpatient Treatment fr Substance Use Disrders 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 - Intensive Outpatient Treatment fr Substance Use Disrders 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 Intensive Outpatient Treatment fr Substance Use Disrders: Has the ability: a) T make basic decisins fr him/herself AND b) T accept respnsibility fr his/her wn actins and behavir, Is experiencing psychscial stressrs and ften-cmplex family dysfunctin, such that a multidisciplinary treatment team is needed t stabilize the individual. Is nt at imminent risk fr serius bdily injury due t aggressin tward self r thers. IOP is apprpriate t cnsider fr cmplex clinical situatins that wuld therwise result in the need fr a mre restrictive level f care. The duratin f treatment and frequency f attendance are cntinually evaluated and adjusted accrding t the individual severity f signs and symptms. 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 returned t a less structured utpatient setting. Nte: Lw Intensity Outpatient Prgrams and Aftercare Services are smetimes ffered by facilities that prvide an intermediate step between Intensive Outpatient Treatment and rutine Outpatient care. These prgrams are reviewed as grup therapy, utilizing the guidelines fr Outpatient Treatment. Admissin Cnsideratins fr Intensive Outpatient Treatment fr Substance Use Disrders: Within 72 hurs 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 Page 67 f 111

68 substance use disrders, 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 Intensive Outpatient Treatment fr Substance Use Disrders: 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. 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, if an individual is barding at a facility, during nn-prgram hurs, the individual must have the freedm t interact with the cmmunity independently, withut being accmpanied by staff r thers, except as age-apprpriate fr children and adlescents. Fr individuals under the age f 18 wh present with a substance use disrder, a face-t-face assessment that includes bth the child/adlescent and the family is cmpleted within 72 hurs f admissin by a licensed behaviral health prfessinal with training and experience cnsistent with the age and prblems f children and adlescents. The facility prvides a structured prgram, which is staffed by trained prfessinals in the treatment f chemical dependency and abuse. A psychiatrist r addictinlgist 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. The gal is t reduce symptms, develp apprpriate discharge criteria and planning invlving 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 relapses, re-admissins, and treatment episdes, the treatment and discharge plan needs t include clear interventins t identify and address the reasns fr previus nn-adherence/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. Page 68 f 111

69 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. 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 - Intensive Outpatient Treatment fr Substance Use Disrders 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 diagnsis f a substance use disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders. 3. The individual is expressing willingness t actively participate in this level f care. 4. The individual is demnstrating difficulties in functining secndary t a substance use disrder t the extent that: 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. 5. The individual is mentally and emtinally capable t actively engage in the treatment prgram 6. The individual is able t live in the cmmunity withut the restrictins f a 24-hur supervised setting, except as age-apprpriate fr children and adlescents. 7. The individual is and the family are 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/guardians 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. Page 69 f 111

70 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 70 f 111

71 V. Eating Disrders Treatment Sectin 5 Page 71 f 111

72 Acute Inpatient Treatment fr Eating Disrders 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 Inpatient Treatment fr Eating Disrders is utilized when the fllwing care services are needed: Arund-the-clck intensive, psychiatric/medical, and nursing care including cntinuus bservatin and mnitring. Acute treatments t cntrl behavir and symptms requiring stabilizatin. Acute management t prevent harm r significant deteriratin f functining and t insure the safety f the individual and/r thers. Daily mnitring f psychiatric medicatin effects and side effects. A cntained envirnment fr specific treatments that culd nt be safely dne in a less-restrictive setting. Admissin Cnsideratins fr Inpatient Treatment fr Eating Disrders: Prir t admissin, there has been a face-t-face medical and psychiatric evaluatin f the individual 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. The medical evaluatin shuld particularly fcus n weight, cardiac status, metablic status, vital signs, and relevant lab values. The level f care determinatin shuld nt be based n a single r limited number f physical parameters such as weight alne. Eating Disrder Inpatient care shuld be driven by the severity f symptms present, the level f risk t the patient, and the severity f physical and psychlgical cmplicatins that wuld require 24-hur medical management and mnitring. Mst individuals with uncmplicated Bulimia Nervsa r a Binge-Eating Disrder d nt meet medical necessity criteria fr this level f care unless there are: Severe disabling symptms that have nt respnded t a less intensive levels f care, and/r Serius cncurrent general medical prblems (e.g., metablic abnrmalities, hematemesis, vital sign changes, r the appearance f uncntrlled vmiting). Expectatins fr Inpatient Treatment fr Eating Disrders: A thrugh Psychiatric evaluatin is cmpleted within 24 hurs f admissin. A medical evaluatin is cmpleted and indicated bld and urine specimens are btained fr labratry analysis within 24 hurs f admissin. Page 72 f 111

73 All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant cmrbid cnditins. Within 48 hurs f admissin, utreach will be dne with existing prviders and family members t btain any relevant histry and clinical infrmatin. The facility will rapidly assess and address any urgent behaviral and/r physical issues. 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. Onging academic schling is prvided fr children and adlescents t facilitate a transitin back t the child s previus schl setting. Yung children (12 years and yunger) will be admitted t a unit exclusively fr children. 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, individual, grup, marital and family therapies as apprpriate. The gal is t imprve symptms, develp apprpriate discharge criteria and planning invlving 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 and discharge plan needs t include clear interventins t identify and address the reasns fr previus nn-adherence/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 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 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. Page 73 f 111

74 Medical Necessity Criteria - Inpatient Treatment fr Eating Disrders 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 diagnsis f Anrexia Nervsa, Bulimia Nervsa, r Other Specified Eating Disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders One r mre f the fllwing criteria must be met: A. The individual has medical instability with abnrmalities in sme r all vital signs: heart rate (less than 40 in adults r less than 50 in children/adlescents) temperature (less than 97 F), bld pressure (less than 90/60 mm Hg in adults r less than 80/50 fr children/adlescents), rthstatic pulse increase (mre than 20 beats per minute), rthstatic bld pressure decrease (mre than mm), OR B. The individual has abnrmal relevant lab values secndary t the Eating Disrder such as lw serum glucse (less than 60 mg/dl), electrlyte imbalances, lw ptassium (less than 3.2 meq/l), lw phsphrus, r lw magnesium, OR C. The individual has significant medical symptms secndary t the Eating Disrder such as evidence f dehydratin, significantly impaired liver, kidney, r heart functin; r prly cntrlled diabetes needing acute stabilizatin, OR D. The Individual has significant decrease in Ideal Bdy Weight, as indicated by ne f the fllwing: i) A Bdy Mass Index (BMI) less than 16, OR ii) Fr children and Adlescents, a rapid, recent, cntinuing weight decline due t fd refusal. Grwth charts shuld be utilized fr children and adlescents, OR E. If BMI is greater than 16 and less than 30, AND there is evidence f ne f the fllwing: i) Weight lss r fluctuatin f tw r mre punds per week, OR ii) Weight lss assciated with medical instability unexplained by any ther medical cnditin F. The individual s cnditin requires arund the clck medical/nursing interventin: i) Fr issues f imminent risk f harm t self r thers, OR ii) There is a need t prvide immediate interruptin f fd restrictin, excessive exercise, binging and purging, and/r use f laxatives/diet pills/diuretics, OR iii) T avid impending life threatening harm due t medical cnsequences, OR iv) T avid impending life threatening cmplicatins due t a c-mrbid medical cnditin (e.g. pregnancy, uncntrlled diabetes), G. In additin t a primary eating disrder that requires treatment at this level f care, there is a cccurring psychiatric disrder and/r risk f self-harm requiring 24 hur medical /nursing interventin. OR, H. The individual s eating disrder symptms require arund the clck medical/nursing interventin. 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 Page 74 f 111

75 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 75 f 111

76 Residential Treatment fr Eating Disrders 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 Eating Disrder Residential Treatment: An Eating Disrder Residential Treatment Facility is either a stand-alne specialized mental health facility r a physically and prgrammatically-distinct unit within a facility licensed fr this specific purpse with 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. Eating Disrder Residential Treatment Facilities are staffed by a multidisciplinary treatment team under the leadership f a Bard Certified/Bard Eligible Psychiatrist with training and experience in the assessment and treatment f eating disrders 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 int the cmmunity. 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 Eating Disrder Residential Treatment Facilities, r the equivalent, and that d nt meet all the abve criteria... A few examples fllw: Page 76 f 111

77 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. Therapeutic (Barding) Schls: The primary purpse f these facilities is t prvide specialized educatinal prgrams that may als be supplemented by psychlgical and psychiatric services. These facilities may serve varied ppulatins f students, many f which als have difficulties in scial and academic areas. These prgrams generally d nt have specialized nurses n site and/r a psychiatrist available at all times t assist with medical issues/crisis interventin and medicatin administratin as needed. Wilderness Prgrams, Bt Camps, and/r Outward Bund Prgrams: These prgrams prvide therapeutic alternatives fr trubled and struggling individuals, 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 eating disrder 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 within the justice system r prtective services system, r as an alternative t specialized schling (which shuld be prvided by the lcal schl system) 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 Residential Eating Disrders Treatment: Within 72 hurs prir t admissin, there has been a face-t-face assessment with the individual and family/significant thers by a licensed behaviral health prfessinal with training and experience cnsistent with the age and prblems f the individual. This assessment includes a clinically-based recmmendatin fr the need fr this level f care. The admissins prcess shuld als include: A dcumented current diagnsis f Anrexia Nervsa, Bulimia Nervsa, r Other Specified Eating 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 with training and experience in the assessment and treatment f eating disrders 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 Eating Disrders Residential Treatment: Residential treatment shuld ccur as clse as pssible t the hme 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. Page 77 f 111

78 Within 72 hurs f admissin, there is utreach with existing prviders and family members t btain needed histry and ther clinical infrmatin Family Invlvement The treatment shuld be family-centered with bth the patient and the family included in all aspects f care. Therefre, prmpt, timely 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 is 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 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. A Preliminary Treatment Plan is cmpleted within 48 hurs f admissin and a Cmprehensive Treatment Plan is t be cmpleted within 72 hurs. 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 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 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-t-face 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 patient. 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 medical appintment. Page 78 f 111

79 Medical Necessity Criteria - Eating Disrders Residential Treatment 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 diagnsis f Anrexia Nervsa, Bulimia Nervsa, r Other Specified Eating Disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders 3. If there are medical issues, they can be safely managed in a residential level f care 4. Fr individuals diagnsed with Anrexia Nervsa, the bdy mass Index (BMI) is greater than 16. Grwth charts shuld be utilized fr children and adlescents. 5. Admissin t this level f care is determined by: A. The severity f physical and psychlgical symptms and the level f risk t the individual B. Evidence that a less restrictive level f care is nt likely t prvide safe and effective treatment. 6. Additinal cnsideratins include, but are nt limited t, ne f the fllwing criteria: A. Structure and supervisin is needed at all meals t prevent restricting r binging-purging and the family/supprt system is unable t prvide this level f mnitring at a less intensive level f care, OR B. The individual s cnditin requires arund the clck interventin t prvide interruptin f the fd restrictin, excessive exercise, binging, purging and/r use f laxatives/diet pills/diuretics, t avid impending life threatening medical cnsequences r t avid impending life threatening cmplicatins due t a c-mrbid medical cnditin (e.g. pregnancy, uncntrlled diabetes), OR C. Alng with a primary eating disrder that is requiring active treatment, there is a c-ccurring psychiatric disrder r risk f self-harm requiring 24 hur supervisin 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 79 f 111

80 Partial Hspitalizatin fr Eating Disrders 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 - Partial Hspitalizatin fr Eating Disrders prvides a 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 Partial Hspitalizatin fr Eating Disrders: May present nging risk f harm t him/her r thers, but is able t develp a plan t maintain safety in the cmmunity withut 24 hur supervisin. Is having acute eating disrder symptms that are cmprmising daily functining with wrk, parenting, schl, and/r with ther activities f daily living Has the ability: T make age-apprpriate basic decisins fr him/herself AND T accept age-apprpriate respnsibility fr his/her wn actins Admissin Cnsideratins fr Partial Hspitalizatin fr Eating Disrders: Within 72 hurs prir t admissin, there has been a face-t-face assessment by a licensed behaviral health prfessinal with training and experience in the assessment and treatment f eating disrders. This assessment includes a clinically-based recmmendatin fr the need fr this level f care. The admissins prcess shuld als include: Page 80 f 111

81 A dcumented current diagnsis f Anrexia Nervsa, Bulimia Nervsa, r Other Specified Eating 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 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 when indicated. Discharge planning. Expectatins fr Partial Hspitalizatin fr Eating Disrders: 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, ther than age apprpriate limitatins fr children and adlescents. 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, except as age-apprpriate fr children and adlescents. 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 81 f 111

82 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 and discharge plan needs t include clear interventins t identify and address the reasns fr previus nn-adherence/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 - Partial Hspitalizatin fr Eating Disrders 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 Anrexia Nervsa, Bulimia Nervsa, r Other Specified Eating Disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders 3. The individual is mentally and emtinally capable t actively engage in the treatment prgram and is able t cmply with the requirements and structure f a partial hspital prgram, as demnstrated by ALL f the fllwing: A. The individual is expressing willingness t engage in treatment. B. 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. C. The individual has a supprt system that includes individuals 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. 4. Current medical Issues can be safely managed in a partial hspital level f care, AND 5. One r mre f the fllwing must be met: A. The individual is demnstrating significant impairments in functining secndary t an eating disrder t the extent that: i) The individual is nt able t cmplete daily rutine scial, family, schl, and/r wrk activities, AND Page 82 f 111

83 ii) The individual is nt able t emply the necessary cping skills t cmpensate fr this. B. The individual requires a structured prgram t avid cmplicatins f a c-existing medical cnditin (e.g., pregnancy, uncntrlled diabetes). OR C. 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 6. The individual is mentally and emtinally capable t actively engage in the treatment prgram 7. The individual is able t live in the cmmunity withut the restrictins f a 24-hur supervised setting, except as age-apprpriate fr children and adlescents. 8. The individual is expressing willingness t engage in treatment. 9. The individual and the family are 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. 10. 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. 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. All f the fllwing must be met: D. The individual and family are invlved t the best f their ability in the treatment and discharge planning prcess. E. Cntinued stay is nt primarily fr the purpse f prviding a safe and structured envirnment. F. Cntinued stay is nt primarily due t a lack f external supprts. Page 83 f 111

84 Intensive Outpatient Treatment fr Eating Disrders 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 - Intensive Outpatient Treatment fr Eating Disrders 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 Intensive Outpatient Treatment fr Eating Disrders: Has the ability: a) T make basic decisins fr him/herself AND b) 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. Is nt at imminent risk fr serius bdily harm tward self r thers. Is apprpriate t cnsider fr cmplex clinical situatins that wuld therwise result in the need fr a mre restrictive level f care 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. Nte: Lw Intensity Outpatient Prgrams and Aftercare Services are smetimes ffered by facilities that prvide an intermediate step between Intensive Outpatient Treatment and rutine Outpatient care. These prgrams are reviewed as grup therapy, utilizing the guidelines fr Outpatient Treatment. Admissin Cnsideratins fr Intensive Outpatient Treatment fr Eating Disrders: Prir t admissin, there has been a face-t-face individual assessment with the individual and the family/significant thers by a licensed behaviral health clinician, with experience in Eating Disrders, 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. Page 84 f 111

85 Expectatins fr Intensive Outpatient Treatment fr Eating Disrders: 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. 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 behaviral health prfessinals wh are trained and experienced in the treatment f eating 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 and discharge plan needs t include clear interventins t identify and address the reasns fr previus nn-adherence/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.) Discharge planning. A Discharge Plan that starts at the time f admissin and includes: Page 85 f 111

86 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 - Intensive Outpatient Treatment fr Eating Disrders 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 Anrexia Nervsa, Bulimia Nervsa, r Other Specified Eating Disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders, 3. Current medical issues can be safely managed in an intensive utpatient level f care 4. The individual is demnstrating difficulties in functining secndary t an eating disrder t the extent that: A. The individual has demnstrated an inability t maintain a healthy weight and/r medical stability withut frequent structured interventins f greater intensity/frequency than in rutine utpatient treatment fr eating disrders, OR B. The individual has dcumented evidence f repeated relapses, and inability t carry ut treatment plan bjectives in rutine utpatient treatment fr eating disrders. OR C. The individual cannt reduce incidents f purging in an unstructured setting. The individual requires sme degree f structure fr eating full meals and gaining weight but nt as much as typically prvided in a partial hspitalizatin prgram. 5. The individual is mentally and emtinally capable t actively engage in the treatment prgram. 6. The individual is able t live in the cmmunity withut the restrictins f a 24-hur supervised setting, except as age-apprpriate fr children and adlescents. 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. Page 86 f 111

87 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 87 f 111

88 VI. Behaviral Health Assessment and Treatment Prcedures Sectin 6 Page 88 f 111

89 Crisis Stabilizatin 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 c) Required t meet the essential health needs f the patient; d) Cnsistent with the diagnsis f the cnditin fr which they are required; e) Cnsistent in type, frequency and duratin f treatment with scientifically-based guidelines as determined by medical research; f) Required fr purpses ther than the cnvenience f the prvider r the cmfrt f the patient g) Rendered in the least intensive setting that is apprpriate fr the delivery f health care. Descriptin - 23-Hur Crisis Stabilizatin/Observatin prvides evaluatin and interventin fr individuals with acute symptms f a behaviral health disrder when the clinical presentatin des nt immediately indicate the need fr a higher level f care. It is cnsidered when an individual presents with: Acute symptms f mental illness Impairments caused by abuse f substances. Behavir prblems f a serius magnitude which cause immediate interference with the individual s ability t functin at wrk, in schl, within the family, r in scial interactins. Settings where service can be prvided include: A hspital nly when the facility is able t prvide this service fr n mre than 23 hurs. A Licensed Crisis Interventin Center (either free-standing r attached t a hspital) that is able t prvide the service fr n mre than 23 hurs. An utpatient clinical setting. The ultimate setting is determined by the individual's clinical presentatin, available resurces, and by the facility's ability t begin active interventins within six hurs f presentatin. Fcus f the interventin: Psychscial factrs relevant t the crisis. Assessment fr risk f harm t self r thers. Assessment f supprt netwrks. A cmplete medical evaluatin and basic medical prcedures as indicated. All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant cmrbid cnditins. Identificatin and mbilizatin f ther available services. Evaluatin f the individual s willingness and reliability t participate in a mutually-acceptable treatment plan. Nte: This level f care is nt apprpriate when, based n clinical presentatin r histry, there is a strng likelihd that the individual will need the intensive structure f Acute Inpatient Treatment fr mre than 23 hurs. Page 89 f 111

90 Descriptin - Crisis Stabilizatin Unit (greater than 23 hurs): The use f Crisis Stabilizatin Unit (greater than 23 hurs) is likely t be infrequent, but may apply in thse cases where a Crisis Stabilizatin Unit exists utside f an accredited hspital, but where 24-hur supervised and medically mnitred services are available. This service prvides: The same type and intensity as a Crisis Stabilizatin Prgram ffering interventin fr 23 r less, but where 24-hur supervised and medically mnitred services are available fr thse hurs individuals needing: Lnger perids f bservatin t assess the crisis and determine risk. Safe envirnment fr mre than 23 hurs. Psychiatric cnsultatin -- t ccur ideally as sn as pssible fllwing admissin, but definitely prir t discharge. A cmplete medical evaluatin and basic medical prcedures as indicated. Evaluatin f family and scial supprt systems that identify bth pprtunities and challenges, and a plan t address the latter. Linkage and referrals t lng-term services/cmmunity services. When medical services are nt available n site, the prgram must be able t ensure that the individual will be linked t apprpriate treatment and prviders within a reasnable timeframe. Fcus f the Interventin The gals f the interventin at this level f care are similar t the gals f a 23 hur-r less Crisis Stabilizatin prgram and include similar criteria: Reductin f ptential fr harm t self r thers and reductin f symptms due t psychsis r substance use. Ability t begin active interventins within 6 hurs f admissin by a mental health prfessinal Identificatin and mbilizatin f available resurces including supprt netwrks The crisis stabilizatin interventin shuld fcus n factrs relevant t the crisis. Apprpriate Interventins include assessment f supprt netwrks, identificatin and assessment f available services, mbilizatin f thse services, and an estimate f the individual's ability t access services and participate in the treatment plan. Nte: This level f care is nt apprpriate fr an individual wh, by clinical presentatin r histry, requires the intensive structure f Acute Inpatient Treatment fr safely and stabilizatin. The facility setting fr a crisis stabilizatin bed, whether less than r greater than 23-hurs, is within a unit that prvides arund-the-clck nursing and/r mental health staff supervisin and cntinuus bservatin and cntrl f behavirs t insure the safety f the individual and/r thers.. Descriptin - Outpatient Crisis Stabilizatin: Outpatient Crisis Stabilizatin ccurs as an ambulatry sessin. The services prvided are rapid with immediate evaluatin and triage t avid further decrease in level f functining and/r acute hspitalizatin. The services are intensified as needed and are available 24 hurs a day, seven days per week. This service prvides: Assessments t determine risk f harm t self r thers and/r determine need fr secure envirnment. Evaluatin fr medical emergency and ability t safely transprt t medical facility if necessary. Interventin in any ne f a number f settings including utpatient therapy ffice, facility-based utpatient department, r in the hme f an individual with safety f all parties a primary cncern. Page 90 f 111

91 Fcus f the Interventin Psychscial factrs relevant t the crisis. Assessment fr risk f harm t self r thers. Assessment f supprt netwrks. Identificatin and mbilizatin f ther available services. Evaluatin f the individual s willingness and reliability t access and participate in a mutuallyacceptable treatment plan. Develpment f a shrt-term, evidence-based treatment plan than includes a family r supprt system evaluatin r therapy sessin. Plan fr fllw-up that includes cllabratin with family, the individual s psychiatrist, ther mental health prviders, the individual s primary care physician, and/r ther cmmunity resurces as apprpriate. Nte: This level f care des nt include crisis stabilizatin services prvided within an emergency rm setting. Emergency Rm services are generally cvered by an individual s health plan benefits. Medical Necessity Criteria - Crisis Stabilizatin 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 is expressing suicidal ideatin, and/r hpelessness and helplessness likely t lead t self-injury, which must cntinue t be evaluated fr severity and lethality. Because f lack f mre immediately available supprt systems, this cannt be evaluated in a less restrictive setting, OR B. The individual is threatening harm t thers r has acted in unpredictable, disruptive r bizarre ways that require further immediate bservatin and evaluatin. This evaluatin includes attempting t discern the etilgy f such behavirs, especially if suspected t be chemically r rganically induced, OR C. The individual is presenting with significant emtinal and/r thught prcess disturbances which interfere with his/her judgment s as t seriusly endanger the individual if nt evaluated and stabilized n an emergency basis, OR D. The individual is shwing severe signs f an acute stress reactin t a recent destabilizing event that threatens t lead t significant emtinal and/r behaviral deteriratin withut rapid interventin, evaluatin, and treatment. In additin, there is a need fr a time-limited interventin t allw time fr mbilizatin f additinal resurces and supprts, OR E. The individual is in current treatment but the nature f the individual s curse f illness is ne characterized with recurrent presentatins f self-injury r impaired thinking that respnds rapidly t structured interventins. This level f care shuld nly be cnsidered when supprt systems and/r the previusly designed crisis plan f the individual and his/her therapist have nt been sufficient and the likelihd fr further deteriratin is high, OR F. The individual is presenting with intxicatin that causes significant emtinal, behaviral, medical, r thught prcess disturbance that interfere with his/her judgment s as t seriusly endanger the individual if nt mnitred and evaluated fr the need f ambulatry r inpatient detxificatin. Page 91 f 111

92 Criteria fr Cntinued Stay in Crisis Stabilizatin Unit (greater than 23 hurs): 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 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 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, unless there is a dcumented clinical cntraindicatin. 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 92 f 111

93 Electrcnvulsive Therapy (ECT) 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 - Electrcnvulsive Therapy (ECT) ECT is mst ften used t treat severe depressin that fails t respnd t medicatins r fr individuals wh are unable t tlerate the side effects assciated with the medicatins. ECT may be the treatment f chice When there is a need fr rapid stabilizatin fr individuals wh are at acute risk f harm due t severe agitatin, delusins, suicidality, nt eating r drinking. OR Fr individuals with acute catatnia (a ptentially life threatening trance-like state). OR Fr stabilizatin f biplar illness during extreme episdes f mania r depressin and T halt psychtic episdes assciated with schizphrenia. Nte: This treatment may be administered n either an utpatient r inpatient basis. Treatment Cnsideratins fr Electrcnvulsive Therapy (ECT): The severity f the psychiatric illness requires a rapid, definitive respnse. The risk f ECT is less than the risks f ther treatments. There is a histry f gd respnse t ECT r pr respnse t medicatin in previus episdes f illness; r The individual r legal representative, having discussed all alternative treatments, and being aware f and able t cmprehend the risks and ptential benefits f ECT, chses ECT as his r her preferred treatment. If the individual receiving ECT has a severe psychiatric illness that requires Acute Psychiatric Hspitalizatin, the individual may then cntinue this treatment n an utpatient basis nce stabilized t a pint that 24-hur inpatient care is n lnger a medical necessity. Inpatient hspitalizatin may als be indicated fr the initial few treatments fr individuals with cexisting medical cnditins that may seriusly increase the risk f the prcedure. Fr mst individuals, ECT is generally safe and effective n an utpatient basis when there is n medical necessity fr mre restrictive levels f care. Expectatins fr Electrcnvulsive Therapy (ECT): The initiatin f ECT is preceded by certain assessments and prcedures: A psychiatric evaluatin that establishes that the diagnstic criteria are met fr a cnditin that evidence has shwn t be likely t psitively respnd t ECT. Page 93 f 111

94 A medical assessment t evaluate fr any medical cnditins that might increase the risks assciated with ECT r anesthesia, as well as an evaluatin by a qualified nurse anesthetist r anesthesilgist t determine if there are any cnditins that may indicate a need fr special precautins. All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant cmrbid cnditins. Educatin f the individual and family abut the prcedure that includes disclsure f ptential risks and benefits and that results in written, infrmed cnsent by the individual r legal guardian, with the understanding that such cnsent may be withdrawn at any time. The ECT prcedure is administered by a psychiatrist wh has participated in nging cntinuing educatin n ECT and wh maintains all legally-required certificatins. An assessment f currently prescribed medicatins has been cmpleted, and if the individual is cntinuing t take certain medicatins that might pssibly negatively impact the prcedure (e.g., thephylline, lithium, benzdiazepines, and/r anticnvulsants), there is dcumentatin f the clinical reasns fr cntinuatin f these medicatins. Nte: If there is evidence f any f the fllwing medical cnditins, there needs t be dcumented evidence that the risks and benefits f ECT vs. ther frms f treatment vs. n further treatment have been thrughly cnsidered and reviewed with the individual r guardian, and that the individual s cnditin requires a rapid, definitive respnse: Unstable r severe cardivascular disease Aneurysm r arterivenus malfrmatin Recent strke Severe lung disease American Sciety f Anesthesilgy physical status classificatin level Fur r Five. Medical Necessity Criteria - Electrcnvulsive Therapy (ECT) Criteria fr Initiatin f Treatment 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 a diagnsis f Majr Depressin, mderate r severe, r Mania, AND i) Is resistant t treatment with medicatins, as evidenced by a lack f respnse t trials f at least three medicatins with adequate dse, duratin and cmpliance t meet an expectatin f imprvement, OR ii) Is intlerant f the side effects r adverse effects f psychpharmaclgic agents, r is unable t take such agents due t drug interactins with a medically necessary medicatin deemed t be less likely r less severe with ECT, OR iii) Experiences deteriratin f a psychiatric cnditin that creates a need fr a rapid, definitive respnse t ensure the safety f the individual, OR iv) Is experiencing a high degree f symptm severity and functinal impairment. OR v) Has a histry f favrable respnse t ECT B. The individual has a diagnsis f a psychtic disrder with (ne f the fllwing): i) Abrupt r recent nset f psychtic symptms, OR ii) Catatnia, OR iii) A histry f favrable respnse t ECT, OR Page 94 f 111

95 iv) Experiences deteriratin f a psychiatric cnditin that creates a need fr a rapid, definitive respnse t ensure the safety f the individual, OR v) Is experiencing a high degree f symptm severity and functinal impairment. 3. All f the fllwing must be met: A. A medical evaluatin has been cmpleted t assess ptential risks assciated with ECT. B. Risks and ptential benefits f ECT have been explained and understd by the individual r guardian, and written, signed, infrmed cnsent has been btained. C. Where applicable state laws require it, a secnd pinin cnsultatin has been cmpleted. Secnd pinin cnsultatins shuld als be cnsidered fr wmen wh are pregnant r fr children/adlescents under age 18. D. There is n evidence f increased intracranial pressure (mst cmmnly due t an inflammatry cnditin in r arund the brain r spinal crd). Criteria fr Cntinued Treatment Curse f Electrcnvulsive Therapy 1. All f the fllwing must be met: A. The initial curse f treatment cnsists f tw t three treatments per week, generally n nncnsecutive days. (Nte: the frequency f treatments may be reduced if delirium r severe cgnitive dysfunctin ccurs). B. The number f treatments is a functin f the individual s respnse, but shuld be in the range f 6 t 12 but nt t exceed 20 sessins. C. If there is n clinical imprvement after 8-10 sessins, the ptential benefits f cntinued ECT shuld be reassessed by the Attending Physician. 2. Cntinuatin ECT (cntinuatin f treatment fr 6 mnths at intervals f 1 week r lnger) is indicated if bth f the fllwing are met: A. The individual has respnded well t ECT. B. Interval psychiatric and medical evaluatins are cmpleted prir t each treatment, C. Frequency f sessins is at the minimum which sustains remissin. D. Cntinued need fr Cntinuatin ECT is reassessed every mnth. E. Clinical treatment plans and cnsents are updated every mnth. 3. Maintenance ECT (cntinuatin f treatment fr lnger than 6 mnths at intervals f 2 weeks r lnger) is indicated if all f the fllwing are met: A. The individual has respnded well t ECT. B. Interval psychiatric and medical evaluatins are cmpleted prir t each treatment. C. Frequency f sessins is at the minimum which sustains remissin. D. Cntinued need fr Maintenance ECT is reassessed every six mnths. E. Clinical treatment plans and cnsents are updated every six mnths. Page 95 f 111

96 Psychlgical/Neurpsychlgical Testing 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 - Psychlgical/Neurpsychlgical Testing is the use f ne r mre standardized measurements, instruments r prcedures t assess intellectual/cgnitive ability, psychpathlgy, psychiatric symptmatlgy, persnality, interpersnal prcesses, behaviral functining, and/r adaptive skills. May be used t guide differential diagnsis in the treatment f psychiatric disrders and t prvide treatment recmmendatins. The use f validated psychlgical testing instruments is cnsidered adjunctive t ther assessment tls that may include a face-t-face clinical interview, infrmatin gathering and review use f behaviral rating scales, cnsultatin with cllateral surces, and the individual s histry. Psychlgical testing may be an apprpriate adjunctive interventin when its use is expected t have a unique, specific, and direct impact n treatment utcme. Exclusin: Educatinal testing is nt cnsidered a medically necessary service under the behaviral health benefits. Educatinal testing is the use f psychlgical tests fr educatinal purpses (e.g., t rule ut a learning disability, determine learning style, and/r assess academic achievement), t prvide supprt fr an academic accmmdatins request, r fr vcatinal purpses. Parents f children lking fr educatinal testing are encuraged t check with their public schl district fr resurces. Psychlgical Testing In Alchl and Drug Treatment The individual s cmprmised cgnitive functining ften cnfunds the results f psychlgical testing in the cntext f early treatment fr alchl and drug dependence. Therefre, there shuld be a minimum f 30 days abstinence prir t the administratin f testing fr a md disrder, and a minimum f 90 days abstinence fr the assessment f cgnitive functining/impairment. Expectatins fr Psychlgical/Neurpsychlgical Testing: Psychlgical testing is t be cnducted by a licensed psychlgist (Ph.D., Psy.D. r Ed.D.). Neurpsychlgical testing is t be cnducted by a licensed dctral level psychlgist (Ph.D. r Psy.D.) wh has specialized training in the administratin, scring, and interpretatin f neurpsychlgical instruments. Testing by a psychmetrist is allwed when the psychmetrist has received apprpriate training and is wrking under the direct supervisin f a licensed psychlgist/neurpsychlgist. Page 96 f 111

97 When a psychmetrist/psychlgical assistant are used, the psychlgist/neurpsychlgist must cnduct the clinical interview and design the test battery befre the psychmetrist begins t administer any tests. When administratin f psychlgical/neurpsychlgical testing is delegated t a psychmetrist r psychlgical assistant, the reprt must be signed by the fully licensed psychlgist r neurpsychlgist wh is respnsible fr the interpretatin f test results. Nte: Psychlgical testing results fr inpatient cases shuld be reprted (at least infrmally) within 24 hurs and fr utpatient cases shuld be reprted within ne week. Medical Necessity Criteria - Psychlgical/Neurpsychlgical Testing All f the fllwing must be met: 1. Psychlgical/Neurpsychlgical Testing may be clinically apprpriate when the administratin f such testing is expected t ffer unique, specific and direct infrmatin regarding the develpment r mnitring f the treatment plan 2. One r mre f the fllwing criteria must be met: A. A diagnsis cannt be made with infrmatin derived frm a thrugh clinical interview, behaviral bservatin, cnsultatin with cllateral surces f infrmatin, and a review f histry, OR B. Develpment f a treatment plan wuld be ineffective and/r inefficient withut infrmatin that can nly be btained by psychlgical testing, OR C. The individual has undergne a curse f psychlgical r psychiatric treatment and the respnse is nt as expected frm the treatment plan, OR D. T assist with the differential diagnsis f a psychiatric versus neurlgical r ther medical diagnsis that may be assciated with psychiatric symptms. Psychlgical/Neurpsychlgical Testing is generally NOT cnsidered medically necessary when ne (r mre) f the fllwing are present: 1. Other surces f the same infrmatin are available (e.g., clinical interview, behaviral bservatins r review f individual s histry), OR 2. The diagnsis appears clear withut testing (testing is nt required t validate a diagnsis), OR 3. The results f testing wuld have n significant effect n the design and implementatin f a treatment plan fr a psychlgical disrder, OR 4. A diagnsis has already been rendered, and the individual has shwn imprvement via the treatment plan already in place. (e.g., individual s MD is currently prescribing medicatin fr ADHD but wants testing t validate the diagnsis), OR 5. The ratinale fr testing is vague, r the diagnstic questin lacks specificity (e.g., Parents want t knw what s ging n, The pediatrician is asking fr it, Just want t get a bigger picture. ), OR 6. Testing appears t be primarily fr educatinal purpses (e.g., t rule ut a learning disability, determine learning style and/r assess academic achievement), t prvide supprt fr an academic accmmdatins request, r fr vcatinal purpses, OR 7. The individual has a histry f prblematic drug r alchl use/dependence and has nt been able t demnstrate a sustained perid f sbriety fr 30 days prir t testing fr a md disrder/90 days when assessing cgnitive functining, OR 8. Testing is requested primarily fr legal purpses including custdy evaluatins, parenting assessments, r ther curt r gvernment rdered/requested testing AND the request des nt therwise meet the criteria fr testing, OR 9. Testing is requested primarily fr wrk-related cncerns/return t wrk AND the request des nt therwise meet the criteria fr testing, OR Page 97 f 111

98 10. Results f testing are used primarily fr admissin t a treatment facility AND the individual wuld nt therwise meet criteria fr testing, OR 11. The requested test battery wuld nt answer the referral questin, OR 12. There is cncern abut the specific tests being requested: A. The requested tests are utdated, OR B. The reliability and validity fr the requested tests are nt established, OR C. Apprpriate nrmative data are nt available fr the requested tests. Ntes: Psychlgical/neurpsychlgical testing may be managed by Cigna Behaviral Health, Cigna Health Care, OR the individual s medical carrier (Refer t Mixed Services Prtcl). Emplyer grup requirements may vary regarding preauthrizatin and review fr psychlgical and neurpsychlgical testing. Need t cnfirm the emplyer grup requirements prir t rendering services. Cigna Cverage psitin #0258 Neurpsychlgical Testing clarifies diagnses fr which Cigna cnsiders neurpsychlgical testing t be experimental, Investigatinal r unprven. Page 98 f 111

99 Autism Behaviral Interventin Therapies (ABIT) Standards and Guidelines Basic Elements f Medical Necessity - In cnsidering the apprpriateness f any level f care, all 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. Nte: Autism Behaviral Interventin Therapies (als described as Early Intensive Behaviral Therapies) are excluded under many CIGNA Behaviral Health benefit plans, but may be gverned by federal and/r state mandates. Please refer t the applicable benefit plan dcument t determine benefit availability and the terms and cnditins f cverage (Plans that d nt have wrding fr ABIT will fllw Cigna's Cverage Psitin fr therapy type). CIGNA s Cverage Psitin shuld be referenced fr individual interventin (such as Applied Behaviral Analysis) t treat Autism Spectrum Disrder. Descriptin - Autism Behaviral Interventin Therapies (ABIT): Autism Spectrum Disrder causes serius, lifelng impairments in behavir, cgnitin, and scial develpment. Etilgy is hetergeneus and there is n knwn cure. Early identificatin and implementatin f intensive behaviral interventins have, in many cases, been knwn t enhance behaviral and cgnitive deficits interfering with the typical develpmental prcess. The purpse f intensive behaviral interventin is fur-fld: Identify current behavirs interfering with typical develpmental prcesses Mdify interfering behavirs by altering relatinships between behavir and the envirnment Imprve individuals functinal capacity in: Cmmunicatin Develpment f scial relatinships Reduce maladaptive behavirs that: Are repetitive, restricted and/r steretypic Interfere with skills and activities f daily living Expectatins fr Autism Behaviral Interventin Therapies (ABIT): The Treatment Assessment Initiating an assessment fr intensive behaviral interventin requires a review f the fllwing: Diagnsis f an Autism Spectrum Disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders, Assessment f current functining cmpleted by develpmental pediatrician, pediatric neurlgist, psychlgist, psychiatrist, r ther independently licensed mental health prfessinal using standardized assessment tls such as the VB-MAPP Vineland Adaptive Scales, ABLLS, etc. Page 99 f 111

100 Name and credentials f independently licensed mental health prfessinal r Bard Certified Behaviral Analyst perfrming assessment. During the Assessment a cmplete develpmental histry shuld be cnducted. Histry shuld include the fllwing, as applicable: Pre/pst-natal events (e.g., length f gestatin, maternal alchl r drug use; maternal illness, lw Apgar scres, etc.) Accidents, illnesses r injuries (e.g., head trauma, brken bnes, knwn expsure t txins, respiratry prblems, etc.) Knwn medical syndrmes r genetic anmalies (Dwn s syndrme, Fragile X, Klinefelter s Syndrme, Tuberus Sclersis, seizures, palsies r dystrphies, etc.) Develpmental milestnes in speech and language, fine and grss mtr, etc. Visin and hearing screenings Cnstellatin f family members including parents r caregivers understanding f Autism Spectrum Disrder All medical and psychiatric evaluatins shuld include cnsideratin f the pssibility f relevant cmrbid cnditins. The Interventin Plan Results f the assessment determine the interventin plan which must include: A clearly stated recmmendatin fr Autism Behaviral Interventin Therapies (ABIT), including number f hurs per day/week fr individual t demnstrate functinal imprvement Prviders with the fllwing Qualificatins Supervisr - must be a Bard Certified Behavir Analyst (BCBA, BCBA-D) r an independently licensed mental health prfessinal Treatment Planning - must be prvided by a Bard Certified Behavir Analyst (BCBA, BCBA-D) r an independently licensed mental health prfessinal Behaviral Clinician (respnsible fr 1:1 wrk with child) - BCBA, Bard Certified Assistant Behavir Analyst (BCaBA), Registered Behaviral Technician, independently licensed mental health clinician and/ r behaviral technician with specific behaviral training. Behaviral Targets Baseline data n all behavirs identified fr interventin Expected imprvement ver baseline; After the first six mnths, imprvement is expected t be realistic with regard t initial gains in each dmain Methds t ensure generalizatin in multiple envirnments Number f hurs requested t meet targets Parent/Caregiver Participatin Supervisin Methd f training parents in behaviral interventin strategies Parent/Caregiver gals designed t assist caregiver in implementing the treatment plan and behaviral interventins independently in the hme and cmmunity Gals shuld be designed t transitin treatment t parents/caregivers upn discharge Plan fr ensuring cnsistency f parent/caregiver respnse ver time Assesses quality f the prgram delivery, mnitrs prgress, identifies barriers t prgress and initiates changes where needed Page 100 f 111

101 Ensures effective cllabratin between the treatment team and parent(s)/caregivers Occurs at the rate f 1 hur fr every 10 hurs f 1:1 treatment time Treatment Planning Supervisr is respnsible fr prvisin f Treatment Planning Treatment Planning shuld be used t cntinuusly develp interventin plan and nte individual prgress. Place f Service Direct Service can be center-based, hme based, r cmmunity based (must be cnsistent with realistic treatment gals). Cannt take the place f mandated educatinal services prvided t an individual thrugh state r federal legislatin Althugh placement in a private educatinal institutin is a parental right, it des nt preclude the state frm its mandated respnsibilities Transitin and/r Discharge Criteria Medical Necessity Criteria - Autism Behaviral Interventin Therapies (ABIT) Criteria fr Initiatin f Treatment with ABIT All f the fllwing must be met: 1. All basic elements f medical necessity must be met. 2. Diagnsis f an Autism Spectrum Disrder, per the mst recent versin f the Diagnstic and Statistical Manual f Mental Disrders, 3. A full and cmprehensive evaluatin as nted abve has been cmpleted. 4. There is evidence frm the evaluatin that suggests the individual is capable f making behaviral and cgnitive gains. 5. There is a cmprehensive and individualized behaviral treatment plan that includes specific targeted behavirs fr imprvement, alng with measurable, achievable, and realistic gals fr imprving thse behavirs. 6. Treatment des nt replace r interfere with educatinal services, if applicable. 7. The treatment plan includes a plan fr the individual s parents t cntinue behaviral interventins in the hme envirnment. Criteria fr Cntinued Treatment All f the fllwing must be met: 1. The individual cntinues t meet all elements f medical necessity 2. Treatment cntinues t fllw expectatins fr ABIT services as detailed abve 3. The individual s treatment plan has been updated t include addressing new behavirs and ensuring maintenance f acquired skills 4. The individual s caregivers cntinue t have active participatin and are shwing prficiency twards parent/caregiver gals as prescribed by the treatment plan 5. There is evidence f measurable and nging imprvement in targeted behavirs as demnstrated with the use f a reliable and valid assessment instrument (e.g., ABLLS, VB-MAPP) 6. The treatment prgram is crdinated with gvernment mandated/schl services and ther medical and mental health therapies, as apprpriate 7. Dcumentatin f plan fr transitin, fade plan, and discharge criteria fr services Page 101 f 111

102 Medicatin Assisted Treatment (MAT) fr Opiid Dependence 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 - Medicatin Assisted Treatment (MAT) fr Opiid Dependence is an apprved standard f practice fr maintenance, detxificatin and medically supervised withdrawal. There are currently tw medicatins that are available and apprved fr use in piid maintenance treatment: methadne and sublingual frmulatins f buprenrphine. Opiid maintenance treatment can ffer pharmaclgic benefits that help t supprt an individual s effrts t achieve and sustain abstinence. It als can help with retentin in treatment, s that medical and psychscial issues may be addressed. Admissin Cnsideratins fr Medicatin Assisted Treatment (MAT) fr Opiid Dependence: This level f care shuld be cnsidered nly after a cmplete substance abuse assessment, and cnsideratin f all available alternative levels f care. At times, MAT may als be utilized as part f a cmprehensive prgram that includes substance abuse treatment at ther levels f care as well. Nte: Methadne maintenance treatment is explicitly excluded under many CIGNA Behaviral Health benefit plans, and may be gverned by federal and/r state mandates. Please refer t the applicable benefit plan dcument t determine benefit availability and the terms and cnditins f cverage. Expectatins fr Medicatin Assisted Treatment (MAT) fr Opiid Dependence: Medicatin Assisted Treatment (MAT) fr Opiid Dependence is limited t prviders r prgrams that have the apprpriate DEA certificatins and meet all legally mandated requirements. Page 102 f 111

103 Medical Necessity Criteria - Medicatin Assisted Treatment (MAT) fr Opiid Dependence Criteria fr Initiatin f Treatment All f the fllwing must be met: 1. All basic elements f medical necessity must be met. 2. The individual has a diagnsis f piate dependence. 3. One r mre f the fllwing criteria must be met: A. The individual has a ne-year histry f dependence n piates, OR B. The individual is currently pregnant. 4. All f the fllwing must be met: A. The individual is willing t adhere t treatment plans and recmmendatins. B. The individual is actively engaged in treatment, which may include n-site r cmmunity-based utpatient individual, grup, r family treatment, r IOP, r PHP. C. The individual has an understanding f the need fr cmpliance with medicatin dsages. D. The individual has a supprtive and cnsistent recvery envirnment. E. If under 18, the individual s parental cnsent is btained. F. The individual des nt meet any f the fllwing exclusin criteria as defined belw: Exclusin Criteria: 1. The individual has the presence f active suicidal thughts. 2. The individual has active alchl abuse r dependence withut engagement in an active treatment plan. 3. The individual has mental illness that wuld interfere with cmpliance r adherence t treatment prtcls. 4. The individual has a histry f prir adverse reactins t MAT. 5. The individual has a severe medical illness that makes dsing unsafe. 6. The individual is abusing/btaining piates frm ther surces r diverting medicatin t thers, and/r unwilling t participate in treatment plan changes. Nte: Fr medicatin-assisted treatment, methadne maintenance is cnsidered the treatment f chice in pregnant wmen, althugh buprenrphine may als be useful in selected cases Criteria fr Cntinuatin f Treatment All f the fllwing must be met: 1. The individual s MAT medicatin dse is safe and adequate. 2. The individual is cmpliant with attendance and dsing plans. 3. The individual remains willing t fllw thrugh with treatment plans and recmmendatins. Page 103 f 111

104 4. The individual has a supprtive and cnsistent recvery envirnment. 5. Rutine, peridic drug screening results are negative, r if psitive, have led t treatment plan changes. Vluntary Tapering and Discntinuatin: All f the fllwing must be met: 1. The individual has a cnsistent and supprtive recvery envirnment. 2. The individual is actively invlved in a relapse preventin prgram. 3. The individual has the necessary supprt systems in place t make a lng-term treatment cmmitment: i.e. transprtatin, supprt grups as well as familial r scial cntacts. Page 104 f 111

105 References Page 105 f 111

106 1) American Psychiatric Assciatin Practice Guidelines, American Psychiatric Assciatin Publishing, Arlingtn, VA, ) Practice Parameters, The American Academy f Child and Adlescent Psychiatry, Washingtn, DC, 3) Behaviral Health Levels f Care, Milliman Care Guidelines, 17th Editin, Seattle, WA, MCG Health, LLC, ) American Psychiatric Assciatin, Diagnstic and Statistical Manual f Mental disrders, Fifth Editin (DSM-5), American Psychiatric Publishing, Arlingtn, VA, May, ) Psychiatric Residential Treatment Facilities (PRTF) Clarificatin, Center fr Medicaid and State Operatins/Survey and Certificatin Grup, Ref: S&C-07-15, February 16, ) Preauthrizatin Requirements fr Residential Treatment Center Care, TRICARE Plicy Manual M, August 1, 2002, Chapter 7, Sectin 3.4.State Regulatin f Residential Facilities fr Adults with Mental Illness, U.S. Department f Health and Human Services, Substance Abuse and Mental Health Services Administratin, Center fr Mental Health Services, 7) Standards & Guidelines fr Partial Hspitalizatin Prgrams, Fifth Editin, Assciatin fr Ambulatry Behaviral Healthcare (AABH), ) Definitin f Partial Hspitalizatin. The Natinal Assciatin f Private Psychiatric Hspitals and the American Assciatin fr Partial Hspitalizatin, Psychiatric Hsp. 21(2):89-90, ) Outpatient Hspital Psychiatric Services, Medicare Benefit Plicy Manual, Chapter 6, Sectin 70 - Hspital Services Cvered Under Part B, A , HO (Rev. 157, ) 10) Medicare Hspital Manual, Sectin 230.7, Outpatient Partial Hspitalizatin Prgrams (PHP), Department f Health and Human Services (DHHS), Health Care Financing Administratin (HCFA), ) Principles f Care fr Treatment f Children and Adlescents with Mental Illnesses in Residential Treatment Centers, American Academy f Child and Adlescent Psychiatry, June ) TRICARE/CHAMPUS standards fr Residential Treatment Centers (RTCs) Serving Children and Adlescents, TRICARE Reimbursement Manual M, August 1, 2002, Chapter 7, Addendum H. 13) Practice Guidelines fr the Treatment f Patients with Substance Use Disrders, American Psychiatric Assciatin Publishing, Arlingtn, VA, ) ASAM Patient Placement Criteria fr the Treatment f Substance-Related Disrders, Secnd Editin- Revised (PPC-2), The American Sciety f Addictin Medicine, Chevy Chase, MD, ) Texas Cmmissin n Alchl and Drug Abuse (TCADA) Guidelines, Standards fr Reasnable Cst Cntrl and Utilizatin Review fr Chemical Dependency Treatment Centers, Texas Administrative Cde, Title 28, Part 1, Chapter 3, Subchapter HH, ) SAMHSA/CSAT Treatment Imprvement Prtcl (TIP) Series. Rckville (MD): Substance Abuse and Mental Health Services Administratin (US); i) Clinical Issues in Intensive Outpatient Treatment. (Treatment Imprvement Prtcl (TIP) Series, N. 47) ii) Detxificatin and Substance Abuse Treatment. (Treatment Imprvement Prtcl (TIP) Series, N. 45) iii) Medicatin-Assisted Treatment fr Opiid Addictin in Opiid Treatment Prgrams. (Treatment Imprvement Prtcl (TIP) Series, N. 43) iv) Clinical Guidelines fr the Use f Buprenrphine in the Treatment f Opiid Addictin. (Treatment Imprvement Prtcl (TIP) Series, N. 40) Page 106 f 111

107 v) Brief Interventins and Brief Therapies fr Substance Abuse. (Treatment Imprvement Prtcl (TIP) Series, N. 34) vi) 17) Practice Guidelines fr the Treatment f Psychiatric Disrders, Treatment f Patients with Eating Disrders, Third Editin, American Psychiatric Assciatin Publishing, ) Natinal Institute fr Clinical Excellence, Eating Disrders, Clinical Guide 9, January ) American Academy f Family Physicians, Diagnsis f Eating Disrder in Primary Care, Table 6, Level f Care Criteria fr patients with eating disrders, ) Vlkmar,F., Siegel,M., et al, and the American Academy f Child and Adlescent Psychiatry Cmmittee n Quality Issues, Practice Parameter fr the Assessment and Treatment f Children and Adlescents With Autistic Spectrum Disrder, J Am Acad Child Adlesc Psychiatry. 2014; 53: ) Practice Parameter fr Use f Electrcnvulsive Therapy with Adlescents, AACAP Official Actin, J. Am. Acad. Child Adlesc. Psychiatry, 2004; 43(12): ) Sachs, M. and Madaan, V., Electrcnvulsive Therapy in Children and Adlescents: Brief Overview and Ethical Issues, Spnsred by AACAP Ethics Cmmittee, January, Page 107 f 111

108 Editrial Bard Page 108 f 111

109 Editrs-in-Chief Dug Nemecek, MD, MBA Chief Medical Officer Behaviral Health Clinical Perfrmance and Quality Eden Prairie, MN William M. Lpez, MD, CPE Senir Medical Directr Clinical Perfrmance and Quality Eden Prairie, MN Alvin R. Blank, MD Lead Medical Directr Clinical Perfrmance and Quality Lutherville, MD Senir Editrial Bard Amy Ayrault, LCSW-C Prvider Services Manager Cigna Behaviral Health Lutherville, MD Lra Fisher, LCPC Clinical Team Leader Cigna Behaviral Health Lutherville, MD Tm Heritage, LPC Inpatient Team Leader Cigna Behaviral Health Plan, TX Assciate Editr Elizabeth B. Hver, MD Medical Directr Clinical Perfrmance and Quality Plan, TX Jeannie Kenney, MSW, LICSW Health Services Sr. Specialist Ttal Service/Claim Operatins Eden Prairie, MN Lauren Presti Mrrisn, MA, LCPC Autism Team Leader Cigna Behaviral Health Lutherville, MD Kim Rabel, LCSW-C Cntract Negtiatr Cigna Behaviral Health Clumbia, MD Page 109 f 111

110 Wrkgrup Leaders Cassie Andersn, LPLCC Clinical Team Leader Clinical Perfrmance and Quality Eden Prairie, MN Clleen M. Baldwin, LCPC Clinical Team Leader Clinical Perfrmance and Quality Lutherville, MD Rbert Cirelli, MD Medical Directr Clinical Perfrmance and Quality Lutherville, MD Michael Chen, MD Medical Directr Clinical Perfrmance and Quality Lutherville, MD Stephanie M Ferster, RN, BSN Lead Clinician Clinical Perfrmance and Quality Glendale, CA Sara R. Friedman, Ph.D. Health Services Senir Specialist Clinical Perfrmance and Quality Eden Prairie, MN Shawn Gravelle, M Ed, LPC Lead Clinician Cigna Behaviral Health Eden Prairie, MN Stuart L. Lustig, MD, MPH Lead Medical Directr, Child & Adlescent Care Clinical Perfrmance and Quality Glendale, CA Kenneth O'Krent, Ph.D. Lead Clinician Cigna Behaviral Health Plan, TX Kathleen J. Papatla, Ph.D. Health Services Senir Specialist Clinical Perfrmance and Quality Eden Prairie, MN Rbin Pedwitz, MD Medical Directr Clinical Perfrmance and Quality Plan, TX Kimberly Szager-Hemler, LCPC Lead Clinician Behaviral Specialty Care Management Lutherville, MD Kenneth Scggins, LPC Clinical Team Leader Cigna Behaviral Health Plan, TX Page 110 f 111

111 Cntributing Reviewers Jnathan Braverman, M.Sc, LMHC, LPC Lead Clinician Cigna Behaviral Health Eden Prairie, MN Delilah Byabat, MS, LPC Inpatient Care Manager Cigna Behaviral Health Plan, TX Mary N Cnigli, MSW, LCSW Inpatient Care Manager Cigna Behaviral Health Plan, TX Marie Frs, LMFT Inpatient Lead Clinician Cigna Behaviral Health Eden Prairie, MN Frederick C. Green Jr., MD Medical Directr Clinical Perfrmance and Quality Glendale, CA Jamie Kravitz, LCPC, LCADC Inpatient Care Manager Cigna Behaviral Health Lutherville, MD Debrah Lardy, MSN, CNS, RN Lead Clinician-Cncurrent Care Crdinatrs Team Cigna Behaviral Health Eden Prairie, MN Niki Lehnherr, MSW, LICSW Lead Clinician Cigna Behaviral Health Eden Prairie, MN Danielle Matthew, LMFT Inpatient Care Manager Cigna Behaviral Health Glendale, CA Kristin Mauritzen, MA, LPC Autism Lead Clinician Cigna Behaviral Health Plan, TX Jdi McKee, LPC-S, ATR-BC Case Manager Specialist Cigna Behaviral Health Plan, TX Debra Miller Rasmussen, MC, LPCC Clinical Team Supervisr Cigna Behaviral Health Eden Prairie, MN Martha Mntgmery, LMSW; LCSW; ACSW Appeals Clinician Cigna Behaviral Health Eden Prairie, MN Stacy O'Ferrall, LPC, M.Ed. Case Manager Specialist Cigna Behaviral Health Plan, TX Narendra Patel, MD Medical Directr Clinical Perfrmance and Quality Eden Prairie, MN Mhsin Qayyum, MD Medical Directr Clinical Perfrmance and Quality Plan, TX Jessica Rme, LCSW Inpatient Care Manager Cigna Behaviral Health Glendale, CA Gail Smith, MS LMFT Lead Clinician Cigna Behaviral Health Eden Prairie, MN Jhn L. Spry III, LCPC Inpatient Care Manager Cigna Behaviral Health Lutherville, MD Christy Thawley, MSW, LCSW-C Autism Care Manager Cigna Behaviral Health Lutherville, MD Barbara Thrsen, RN-BSN, MS Clinical Cnsultant Cigna Behaviral Health Eden Prairie, MN Melanie Trautman, MA, LPCC Clinical Team Leader Cigna Behaviral Health Eden Prairie, MN Bbby Watts, LCSW Appeals Clinician Cigna Behaviral Health Plan, TX Kevin Welks, LCSW-C Lead Clinician Cigna Behaviral Health Lutherville, MD Brandy C. Whyte, LCPC Inpatient Care Manager Cigna Behaviral Health Lutherville, MD Page 111 f 111