Medical Necessity Criteria

Medical Necessity Criteria 2015 Updated 03/04/2015

Appendix B Medical Necessity Criteria Purpose: In order to promote consistent utilization management decisions, all utilization and care management staff and physician reviewers shall use MHNet's Medical Necessity Criteria unless different criteria are required for a specific account. These medical necessity criteria are not intended to be construed or to serve as a standard of treatment. Standards of treatment are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns evolve. These criteria should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case. The behavioral health professional, in light of the clinical data presented by the member, must make the ultimate judgment regarding a particular location of care or treatment modality. Nor are these medical necessity criteria intended to replace sound clinical judgment or internal clinical guidance. When applying the criteria to an individual, case managers and medical directors must consider such factors as: Age of the member, Presence of co-morbidities, Complications, The progress of treatment, The psychosocial situation, and The home environment, when applicable. Case managers and medical directors must also consider the characteristics of the local delivery system that are available for the member, such as: Availability of alternative levels of care, MHNet's or the health plan's coverage of benefits for alternative levels of care, and Ability of local providers to provide all recommended services within the anticipated length of stay. MHNet also takes into account the benefit design as defined by the member s certificate of coverage and any specific state legislation. Confidential and Proprietary 2014 MHNet Behavioral Health

Table of Contents Adult Services Psychiatric Inpatient Services - Adult 4 Psychiatric Residential Services - Adult 8 Psychiatric Partial Hospitalization Services Adult/Geriatric 12 Substance Abuse Medically Monitored Services - Adult 16 Child and Adolescent Services Psychiatric Inpatient Services Child/Adolescent 20 Psychiatric Residential Services Child/Adolescent 23 Substance Abuse Medically Monitored Services Child/Adolescent 27 Psychiatric Partial Hospitalization Services- Child/Adolescent 31 General Services All Ages Hospital Based Detoxification 35 Outpatient Detoxification Services 38 Substance Abuse Partial Hospitalization Services 41 Substance Abuse Residential Services 45 Psychiatric Intensive Outpatient Services 49 Substance Abuse Intensive Outpatient Services 53 Substance Abuse Medically Managed Care 57 Outpatient Services 60 In-Home Services 64 Targeted Case Management Services 67 Assertive Community Treatment (ACT) 71 23 Hour Observation Beds 74 Methadone Maintenance 77 Illness Specific Services Eating Disorders Services 80 Partial Hospitalization/Day Services Autism Spectrum Disorders 85 Intensive Outpatient Services Autism Spectrum Disorders 89 Outpatient Services Autism Spectrum Disorders 93 Psychological and Neuropsychological Testing 96 Electroconvulsive Therapy (ECT) 108 Definitions Interpretation Guidelines Sexually Reactive Adolescents 111 State Specific Guidelines Kentucky Adult Therapeutic Rehabilitation Services 113 Confidential and Proprietary 2014 MHNet Behavioral Health

Child Therapeutic Rehabilitation Services 116 Targeted Case Management Services 119 Kentucky Medicaid Extended Care Units 121 Kentucky Child/Adolescent Psychiatric Residential Treatment 124 Kentucky Case Management Services 127 Kentucky Mobile Crisis Services 131 Kentucky Peer Support 134 Kentucky Crisis Stabilization 136 Kentucky Therapeutic Foster Care 140 Missouri Respite Care for the Seriously Mentally Ill 143 West Virginia Team Treatment Planning 146 Case Consultation Services 148 Skills Training and Development 150 Assertive Community Treatment 152 Comprehensive Community Support 154 Behavioral Health Clinic Day Treatment 156 Florida Treatment Plan Development and Modification 158 Community Support and Rehabilitative Services 160 Confidential and Proprietary 2014 MHNet Behavioral Health

PSYCHIATRIC INPATIENT SERVICES-ADULT ADMISSION CRITERIA: Admission to an adult psychiatric unit must be based on the following: Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and by Intensity of Services appropriate to this level of care. GLOBAL INDICATORS: 1. Patient presents at least one valid DSM-5 diagnosis, and 2. Patient's condition must be directly attributable to the designated mental disorder and not to Antisocial Personality or be a part of a pervasive pattern of antisocial conduct. 3. Treatment at a lower level of care is not possible because the individual requires 24- hour continuous observation and/or treatment, and 4. Professional intervention is considered likely to be effective and is essential to contain risks presented and provide for improvement, and 5. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the patient s condition or a recent course of treatment in a less restrictive setting with a prompt recurrence of symptoms post discharge. SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current condition indicates a level of severity appropriate to inpatient psychiatric care as evidenced by one or more of the following: Impairment in Safety: Patient presents an immediate risk of suicide or the patient presents a danger to others through assaultive or homicidal behavior. Impairment in Self Care: Patient presents a temporary and reversible inability to perform personal hygiene and bodily care activities of daily living and there are attendant risks to that person's safety and well being. Impairment in Reality Construction: Patient presents psychotic symptoms that must be controlled to prevent immediate risks to the patient or others.

Impairment in Social Functioning: Patient presents severely disruptive behavior that violates established social norms and/or violates the rights of others. Complicating Conditions: The patient s psychiatric condition complicates critical medical care, acute medical conditions complicate psychiatric care and/or close observation is required to manage complications that may attend the use of psychotropic medications or ECT. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further justification, the patient presents, with significant limitations in resources, to resolve presenting problems as indicated by: Limited Personal Resources: Patient does not currently have the cognitive and/or emotional coping skills to reduce risks presented. Limited Social Resources: Patient does not have adequate social support from family and/or friends to reduce risks presented. Exclusion - Limitations in personal or social resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: The patient should receive the following services to justify admission to this level of care: 1. A comprehensive, psychiatric assessment and initial treatment plan including a tentative discharge plan must be completed within 24 hours of admission. 2. A comprehensive medical examination including history, physical examination and laboratory testing within the first 24 hours of the admission for those clients who did not have them done immediately prior to admission. 3. There must be daily review of the treatment by a physician documented by the daily progress note. 4. Close supervision and observation aimed at evaluation of effects of psychotropic medications. 5. Observation and control measures (e.g., isolation or restraint) appropriate to risks to the patient or others.

6. Introduction of psychotropic medication appropriate to the higher risk symptoms presented. 7. Begin ECT, if ECT treatment justified admission to this level of care. 8. Multimodal plan of care requiring close medical supervision has been implemented. 9. Treatment and/or preventive measures to address complications of concern. 10. Intensive crisis intervention on an individual or group basis. 11. Intervention with the family of the patient to resolve crisis/emergent issues. CONTINUED STAY CRITERIA: In order to justify remaining in an adult inpatient unit the patient must continue to manifest symptoms justifying the principal DSM-5 diagnosis and one or more of the following: 1. Intensity of service being delivered should be appropriate to the risk level that justified the admission. 2. Continued evidence of symptoms reflecting significant risk to the patient or others (e.g., suicide). 3. Complications arising from initiation of, or change in, medications or ECT. 4. Need for continued close observation in regulation of higher risk psychotropic medications. 5. Persistence of higher risk psychotic symptoms such that continued close observation and control is required. 6. Increased risk of complications as a result of intervention or as a product of newly discovered conditions. 7. Progress reinforces the judgment that the disability is temporary and not chronic. 8. Effective discharge planning has begun and additional days will reduce the probability of a re-hospitalization. DISCHARGE CRITERIA: The patient is ready for discharge when they satisfy any of the following criteria: a) They complete the treatment plan. b) Their impairment in functioning no longer requires 24 hour observation or treatment. c) The patient leaves against medical advice (AMA).

d) The patient refuses treatment and/or the problem(s) that prompted admission are found to be refractory or chronic. Disposition under these circumstances must be predicated on assuring the patients safety, applicable state law, as well as the health plan benefit.

PSYCHIATRIC RESIDENTIAL SERVICES-ADULT PROGRAM DEFINITION: To qualify as a residential program the patient must be in a structured environment and be medically monitored, with 24-hour medical availability, 24-hour on-site nursing services and 24-hour 7-days-week supervision. This care includes treatment with a range of diagnostic and therapeutic behavioral health services that cannot be provided through existing community programs. A multidisciplinary treatment team (i.e., physicians, psychologists and therapists) must administer treatment. The treatment day consists of at least 7 hours of structured activity with at least 4 hours in individual and/or group therapy. The patient must participate in treatment daily. The patient s family, if applicable, must be actively involved in treatment at least 1 to 2 times per week. Treatment must be for the psychiatric condition. This level of care excludes custodial care, respite for the family, or legal problems and is not appropriate for the sole purpose of preventing relapse. Treatment for antisocial behavior is not a basis for residential care. ADMISSION CRITERIA: 1. Patient presents at least one valid DSM-5 diagnosis that is reasonably expected to improve as a result of psychiatric treatment. 2. Behavior indicates that the risk of suicide, assaultive, or homicidal behavior would be present at a lower level of care. 3. Patient is medically stable and not bed confined or has no medical complications that would prevent participation in residential care. 4. Patient has severe limitations or impairment in their family and other social support systems and consequently a more structured residential environment is required for substantial improvement in the patient's condition. 5. Patient has the cognitive ability to understand and process in both individual and group therapy modalities. 6. Patient has the emotional stability to participate in both individual and group therapies. 7. Patient has the capacity to develop and implement skills and strategies that will enable them to learn skills to function more independently.

GLOBAL INDICATORS: 1. Patient presents at least one valid DSM-5 diagnosis that is amenable to psychiatric treatment and failure to admit to this level of care is likely to result in significant psychological or social impairment which would require inpatient treatment for stabilization, and 2. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the patient s condition or a recent course of treatment in a les restrictive setting with a prompt recurrence of symptoms post discharge. SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current condition indicates a level of severity appropriate to residential care as evidenced by the following: Impairment in Safety: Presents a pervasive pattern of poor impulse control and highrisk behavior, assaultive or homicidal behavior and periods when the risk of harm to self or harm to others is considered high. Impairment in Self-Care: Presents significant impairment in capacity for self care without being monitored in a highly structured environment and as such, presents potential harm to self. Impairment in Reality Construction: Presents mild impairment in cognitive and perceptual function and attendant impairment in judgment and problem solving and as such, presents potential harm to self or others. Impairment in Social Functioning: Presents disturbances in age-appropriate adaptive functioning and interpersonal functioning manifested in the family, at work and other social settings and as such presents potential harm to self or others. Complicating Conditions: Physiological complications are minimal, coexisting medical problems will not significantly interfere. Care and complications from pharmacological intervention are considered manageable. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further evidence for acute care, the patient presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: Patient does not have the coping skills sufficient to reduce risk without this level of service.

Limited Social Resources: Patient does not have the family and/or the social support needed to reduce level of risk without this level of service. Exclusion - Limitations in resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within residential care, the patient should be receiving all of the following services as further justification of the admission: 1. A multidisciplinary assessment of social, psychological, and developmental and biological functioning. 2. An evaluation by a psychiatrist occurs within the first 24 hours of the admission and is followed by visits from the attending psychiatrist at least two times per week. 3. A comprehensive treatment plan with specific measurable goals, timelines for achievement of those goals and methods of intervention. 4. The treatment plan includes a discharge plan, which is initiated within the first 24 hours of treatment. The discharge plan shall include active participation of the patient/family and specify long term placement if necessary. 5. The family system is the subject of assessment and the family is actively involved in treatment. 6. A structured environment which provides the patient with systematic feedback regarding progress or lack of progress toward treatment goals. 7. Vocational and independent living skills training are addressed in the program when age appropriate and/ or applicable to permanent placement goals. 8. Focused group therapy that addresses goals identified in the plan of care. 9. Treatment plan includes methods and/or goals for addressing crisis management. CONTINUED STAY CRITERIA: In order to justify remaining in residential treatment the patient must continue to manifest all of the following related to the principal DSM-5 diagnosis: 1. Psychological disturbances continue to significantly impair level of functioning. 2. Persistence of problems that caused the admission to continue at a level that precludes transition to a less restrictive setting. 3. Patient and the patient's family are actively participating in the treatment process.

DISCHARGE CRITERIA: The patient is ready for discharge when any of the following are obtained: a) Patient no longer meets criteria for continued stay. b) Patient can sustain progress and resolve remaining treatment goals in a less restrictive environment. (i.e., IOP, traditional outpatient services). c) Patient has deteriorated and needs to be admitted to a higher level of care. d) Patient has not engaged in treatment and further progress is unlikely. e) During the course of treatment it is determined that the patient has a psychiatric disorder that is not amenable to structured psychiatric care. f) Patient leaves AMA. g) The patient s condition deteriorates and they are admitted to a higher level of care.

PSYCHIATRIC PARTIAL HOSPITALIZATION SERVICES- ADULT/GERIATRIC PROGRAM DEFINITION: This level of care is intended to be an alternative to acute psychiatric inpatient treatment for individuals who need intensive treatment but do not need 24 hour professional monitoring and therefore can continue to reside outside of the treatment facility. The level of acuity of the patient s symptoms, intensity of services and length of stay guidelines should all be similar to those of acute psychiatric inpatient treatment. Partial hospitalization should be the initial level of care authorized, and is not intended as a stepdown from acute psychiatric inpatient treatment or as an alternative to an Intensive Outpatient Program. To qualify as a partial hospitalization program, the patient must receive at least eight hours/day of individual and group therapy. The patient must participate in a structured program at least three days/week. ADMISSION CRITERIA: Admission to a partial hospitalization program must be based on the following Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and by Intensity of Services appropriate to partial hospitalization. GLOBAL INDICATORS: 1. Patient presents at least one valid DSM-5 diagnosis exclusive of substance abuse or substance dependence, failure to admit to a partial hospitalization program is likely to result in immediate deterioration requiring inpatient care, and 2. Patient s condition must be directly attributable to the designated mental disorder and not to Antisocial Personality Disorder, or be a part of a pervasive pattern of antisocial conduct, and 3. Patient s symptoms are amenable to acute treatment, and 4. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the patient s condition or a recent course of treatment in a less restrictive setting with a prompt recurrence of symptoms post discharge, and

5. Specialized intervention is considered likely to be effective and is essential to contain risks presented and to provide for improvement. SEVERITY OF ILLNESS: Patients must be able to benefit from cognitive therapies as evidenced by the absence of significant cognitive impairment (i.e., significant dementia). An objective, professional evaluation of the patient s current condition indicates an acute level of severity appropriate to partial hospitalization as evidenced by the following: Impairment in Safety: Patient may be experiencing suicidal/homicidal ideation with a plan and expressed intent. Patient must be able to contract for safety and have a social support system in place when outside of the partial hospital setting. Clinical evidence indicates that a less intensive outpatient setting is not appropriate. Impairment in Self-Care: Patient may be experiencing noticeable impairment in ADLs (i.e., disheveled clothing, unkempt appearance, and poor personal hygiene). Patient may be experiencing significant impairment in their eating and/or sleeping patterns. Patient is able to provide for whatever transportation needs required by the program, or has a system of social support to meet transportation needs. Impairment in Reality Construction: The patient is sufficiently intact to benefit from individual and group therapy. Impairment in Social Functioning: This level of care is considered appropriate for patients who are unable to function in unmonitored social/occupational settings. Patient s acute symptoms disable them from fulfilling occupational roles/responsibilities. Patient may be exhibiting/verbalizing a noticeable decrease in personal interactions. Patient can benefit from continuing involvement with family/social support system. Complicating Conditions: This level of care is appropriate for patients with a demonstrated need for intensive pharmacological intervention. Biomedical complications are minimal, coexisting psychological problems (e.g., depression) will not significantly interfere with partial hospital care and complications from pharmacological intervention are considered manageable. Exclusion In the adult/geriatric population, medical conditions in and of themselves, are not sufficient justification for admission. Exclusion In the adult/geriatric population, partial hospitalization should be delineated from non-acute residential day programs designed for social rehabilitation of patients with severe and persistent mental illness.

Exclusion Unless medically necessary, court-ordered treatment is considered an exclusion. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: Patient presents with limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources Patient has adequate cognitive and emotional coping skills to actively participate in care. Patient is capable of controlling their behavior and/or has the ability to seek professional assistance or other support when outside of the program. Limited Social Resources Patient has adequate social support system, including a suitable environment outside of the program to provide context for successful partial hospital treatment. Exclusion Limitations in resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within the partial hospitalization program all of the following program elements must be provided to satisfy medical necessity criteria: 1. A comprehensive psychiatric evaluation must be conducted and documented on the day of admission. This evaluation must include an initial treatment plan and tentative discharge plan. 2. Structured daily program, including nursing and medical supervision. 3. An individualized treatment plan with specific goals and intervention plans. 4. A structured activities schedule with both focused individual and group therapy. 5. A plan exists for management of crisis episodes, were they to occur. 6. Linkages with appropriate support groups (e.g., AA or Overeaters Anonymous). 7. A psychiatrist must be available every day of treatment providing daily supervision of care and ongoing medication monitoring and adjustment. CONTINUED STAY CRITERIA: In order to justify remaining in a partial hospitalization program, the patient must continue to manifest all of the following related to the principal DSM-5 diagnosis:

1. Admission criteria must be met. 2. Clinical documentation supports the patient s active progress toward treatment goals. 3. Clinical documentation shows that a less restrictive level of care would result in exacerbation of the patient s psychiatric illness. 4. Patient is cooperating with caregivers and actively involved in care. 5. Family involvement is appropriate to the goal of sustaining the progress that is being made. 6. Patient is actively participating in aftercare planning. DISCHARGE CRITERIA: The patient is ready for discharge when they satisfy any of the following criteria: a) Completes the treatment plan. b) Impairment in functioning can be managed with periodic outpatient treatment. c) Patient leaves AMA. d) Patient refuses treatment and/or the problems that prompted admission are found to be refractory or chronic. e) The patient s condition deteriorates and they are admitted to a higher level of care.

SUBSTANCE ABUSE MEDICALLY MONITORED -ADULT PROGRAM DEFINITION: To qualify as a medically monitored program the member must be in a structured environment and be medically monitored to manage a member s ancillary detoxification needs, with 24-hour medical availability, 24-hour on-site nursing services and 24 hours a day, 7-days-week supervision. This care includes treatment with a range of diagnostic and therapeutic behavioral health services that cannot be provided through existing community programs. A multidisciplinary treatment team (i.e., physicians, psychologists and therapists) must administer treatment. The treatment day consists of at least 8 hours of structured activity with at least 4 hours in individual and/or group therapy. The member must participate in treatment daily. The member s family, if applicable, must be actively involved in treatment at least 1 to 2 times per week. Treatment must be for a substance related disorder. This level of care excludes custodial care, respite for the family, or legal problems and is not appropriate for the sole purpose of preventing relapse. Treatment at this level of care is not appropriate when the sole purpose of treatment is due to the member s lack of compliance at a lower level of care or as a substitute for focused ambulatory treatment of relapse. ADMISSION CRITERIA: 1. The member presents at least one valid DSM-5 diagnosis of substance related disorder. 2. The member is medically stable, not bed confined and has no medical complications that would prevent participation in therapy. 3. There is a risk of exacerbation of serious concomitant medical complications due to continued substance abuse, which prohibits treatment from occurring safely at a lower level of care and requires 24-hour monitoring. 4. There continues to be a risk of withdrawal symptoms, which cannot be safely monitored at a lower level of care. 5. The member has the motivation and emotional stability to participate in both individual and group therapies. 6. The member has the capacity to develop and implement skills and strategies that will enable them to learn skills to function more independently. GLOBAL INDICATORS:

1. The member presents at least one valid DSM-5 diagnosis that is amenable to substance abuse treatment, and failure to admit to this level of care is likely to result in significant risk of harm to self which would require inpatient treatment for stabilization, and 2. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the member s condition or a recent course of treatment in a less restrictive setting resulted in a prompt recurrence of symptoms post discharge. SEVERITY OF ILLNESS: An objective professional evaluation of the member s current condition indicates a level of severity appropriate to residential care as evidenced by the following: Impairment in Safety: The member is at risk for severe withdrawal symptoms and/or is at risk for being a danger to themselves through suicide or a danger to others through assaultive or homicidal behavior. Impairment in Self-Care: The member presents significant impairment in capacity for self care without being monitored in a highly structured environment due to substance dependency and as such, presents potential harm to self. Impairment in Reality Construction: The member presents significantly diminished ability to obtain essential information from the environment, to problem solve effectively and to respond to treatment efforts at lower levels of care (i.e., outpatient). Impairment in Social Functioning: The pattern of substance use has seriously impaired the member s social, family and occupational functioning, there is a reasonable expectation that significant functioning can be restored with treatment and that such functioning is unlikely to be restored through treatment at a lower level of care. Complicating Conditions: Physical complications are minimal and coexisting psychological problems (e.g., depression) can be safely managed. Care and complications from pharmacological intervention are considered manageable. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further justification for acute care, the member presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: The member does not have the coping skills sufficient to reduce risk without this level of service.

Limited Social Resources: The member does not have the family and/or the social support needed to reduce level of risk without this level of service. Exclusion - Limitations in resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within medically monitored treatment, the member should be receiving all of the following services as further justification of the admission: 1. A multidisciplinary assessment of social, psychological, and developmental and biological functioning. 2. A comprehensive medical examination including history, physical examination and laboratory testing within the first 24 hours of the admission for those members who did not have them done immediately prior to admission. 3. An evaluation by an addictions medicine physician occurs within the first 24 hours of the admission and the member is followed by the attending physician at least twice a week. 4. A comprehensive treatment plan of behavioral health treatment and residential living support with specific measurable goals, timelines for achievement of those goals and methods of intervention. 5. Comprehensive treatment plan includes a discharge plan, which is initiated within the first 24 hours of treatment. The discharge plan shall include active participation of the member/family and specify long term placement if necessary. 6. The family system is the subject of assessment, and the family is actively involved in treatment. 7. A structured environment which provides the member with systematic feedback regarding progress or lack of progress toward treatment goals. 8. Vocational and independent living skills training are addressed in the program when age appropriate and/ or applicable to permanent placement goals. 9. Focused group therapy that addresses goals identified in the plan of care. 10. Treatment plan includes methods and/or goals for addressing crisis management and relapse prevention.

CONTINUED STAY CRITERIA: In order to justify remaining in medically monitored treatment, the member must continue to manifest all of the following related to the principal DSM-5 diagnosis: 1. The member continues to exhibit physical and/or behavioral symptoms that require continuous monitoring. 2. The member and their family are actively participating in the treatment process. 3. The member continues to be unable to perform activities of daily living essential to maintaining safety. 4. The current or revised treatment plan includes a linkage and/or coordination with the available structured and supportive community based resources with the goal of returning to his/her regular social environment as soon as possible, when appropriate. 5. The current or revised treatment plan can be reasonably expected to bring about significant improvement in the problems that caused the admission and the member s progress is documented at least three times per week. The treatment includes a plan for discharge. DISCHARGE CRITERIA: The member is ready for discharge when any of the following are obtained: a) They no longer meet criteria for continued stay. b) They can sustain progress and resolve remaining treatment goals in a less restrictive environment (i.e., IOP, traditional outpatient services). c) They have deteriorated and need to be admitted to a higher level of care. d) They are not engaged in treatment and further progress is unlikely. e) They leave AMA.

PSYCHIATRIC INPATIENT SERVICES-CHILD/ADOLESCENT ADMISSION CRITERIA: Admission to a hospital specializing in children and teens must be based on the following: Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and Intensity of Intervention appropriate to inpatient care. Laws regulating treatment of a minor are observed. Patients for whom there is no reasonable expectation that acute hospitalization will lead to a stable outpatient treatment program are excluded from admission. In addition, all admission decisions must be predicated on respect for the patient s autonomy by providing treatment in the least restrictive setting. GLOBAL INDICATORS: 1. Patient presents at least one valid DSM-5 diagnosis, and 2. Patient's condition must be directly attributable to the designated mental disorder and not a part of a pervasive pattern of antisocial conduct. 3. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the patient s condition or a recent course of treatment in a less restrictive setting with a prompt recurrence of symptoms post discharge. 4. Professional intervention is considered likely to be effective and is essential to contain risks presented and provide for improvement. SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current condition indicates a level of severity appropriate to hospital care as evidenced by one or more of the following: Impairment in Safety: Patient presents significant risk of suicide, immediate risk of harm to others (e.g., assault or homicide), or high risk behavior that places the patient or others in danger. Impairment in Self Care: Temporary and reversible disability of the patient to perform personal hygiene and bodily care activities of daily living without which risk obtains. Impairment in Reality Construction: Patient presents psychotic symptoms that lend themselves to acute intervention and which place the person, or others, at risk. Impairment in Social Functioning: Patient presents severe deficits in social functioning at school, home and/or in the community and this condition can improve with acute Confidential and Proprietary 2014 MHNet Behavioral Health

hospitalization. Impairment of social functioning in the absence of severe impairment in one or more of the above indicators does not justify hospitalization. Complicating Conditions: Patient presents medical conditions that complicate psychiatric treatment, psychiatric symptoms that complicate medical care, or patient requires intensive observation to manage potential complications that attend a planned medication regime. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further evidence for acute care, the patient presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: Patient does not have the coping skills sufficient to reduce risk without this level of service. Limited Social Resources: Patient does not have the family and/or the social support needed to reduce level of risk without this level of service. Exclusion - Limitations in resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within inpatient care, the patient should be receiving the following services as further justification of the admission: 1. Precautions (e.g., frequency of observation) appropriate to the risk level that justified the admission. 2. Intensive crisis intervention and appropriate family involvement. 3. Psychiatric assessment within 24 hours of admission and psychotropic medications ordered. 4. A comprehensive medical examination including history, physical examination and laboratory testing within the first 24 hours of the admission for those clients who did not have them done immediately prior to admission. 5. Active discharge planning with any placement issues identified within 24 hours of admission. 6. Family system and its contribution to the current crisis evaluated. 7. Evaluation of coexisting substance related disorders. 8. Efforts to resolve any temporary disability that justified hospital care. Confidential and Proprietary 2014 MHNet Behavioral Health

CONTINUED STAY CRITERIA: In order to justify remaining in hospital setting the patient must continue to manifest symptoms justifying the principal DSM-5 diagnosis and one or more of the following: 1. Intensity of service being provided is appropriate to level of risk currently being presented. 2. Continued risk to self or others is manifest in the patient's current behavior. 3. Continued close supervision and monitoring is essential given risks that attend prescribed psychotropic medications. 4. Complications have been identified or have arisen as a result of planned intervention. 5. Continued temporary disability in key areas of daily living and initial signs of success at reversing the temporary disability. 6. Persistence of psychotic symptoms, which would place the patient at risk if discharged. 7. Placement problems that put the patient or others at risk and which can be resolved within two days. DISCHARGE CRITERIA: The patient is ready for discharge when they satisfy any of the following criteria: a) They complete the treatment plan. b) Their impairment in functioning no longer requires 24 hour observation or treatment. c) The patient refuses treatment and/or the problem(s) that prompted admission are found to be refractory or chronic. Disposition under these circumstances must be predicated on assuring the patients safety, applicable state law, as well as the health plan benefit. d) At the time of discharge, the parents/guardians assume legal responsiblity for the patient. Confidential and Proprietary 2014 MHNet Behavioral Health

PSYCHIATRIC RESIDENTIAL SERVICES- CHILD/ADOLESCENT PROGRAM DEFINITION: To qualify as a residential program the patient must be in a structured environment and be medically monitored, with 24-hour medical availability, 24-hour on-site nursing services and 24-hours-a-day, 7-days-week supervision. This care includes treatment with a range of diagnostic and therapeutic behavioral health services that cannot be provided through existing community programs. A multidisciplinary treatment team (i.e., physicians, psychologists and therapists) must administer treatment. The treatment day consists of at least 7 hours of structured activity with at least 4 hours in individual and/or group therapy. The patient must participate in treatment daily. The patient s family, if applicable, must be actively involved in treatment at least 1 to 2 times per week. Treatment must be for the psychiatric condition. This level of care excludes custodial care, respite for the family or legal problems and is not appropriate for the sole purpose of preventing relapse. ADMISSION CRITERIA: 1. Patient may present developmental delays in capacity for self-regulation of affective experience and behavior. 2. Patient has severe limitations or impairment in their family and other social support systems; consequently, an alternative environment is required for substantial improvement in the patient's condition. 3. Patient has the cognitive ability to understand and process in both individual and group therapy modalities. 4. Patient has the emotional stability to participate in both individual and group therapies. 5. Patient has the capacity to develop and implement skills and strategies that will enable them to learn skills to function more independently. GLOBAL INDICATORS: 1. Patient presents at least one valid DSM-5 diagnosis, and failure to admit to this level of care is likely to result in significant psychological impairment which would require inpatient treatment for stabilization, and Confidential and Proprietary Page 1 of 4 2014 MHNet Behavioral Health

2. Patient's condition must be directly attributable to the designated mental disorder and not be a part of a pervasive pattern of behavioral and or conduct disorders, and 3. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the patient s condition or a recent course of treatment in a less restrictive setting with a prompt recurrence of symptoms post discharge. SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current Condition indicates a level of severity appropriate to residential care as evidenced by the following: Impairment in Safety: Presents a pervasive pattern of poor impulse control and highrisk behavior, assaultive or homicidal behavior and periods when suicide or homicide risk is considered high. Impairment in Self-Care: Presents significant impairment in capacity for self care without being monitored in a highly structured environment. Impairment in Reality Construction: Presents mild impairment in cognitive and perceptual function and attendant impairment in judgment and problem solving. Impairment in Social Functioning: Presents disturbances in age-appropriate adaptive functioning and interpersonal functioning manifested in the family, at school and other social settings. Complicating Conditions: Physical and psychological complications are not of sufficient severity to preclude active participation in treatment. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further evidence for acute care, the patient presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: Patient does not have the coping skills sufficient to reduce risk without this level of service. Limited Social Resources: Patient does not have the family and/or the social support needed to reduce level of risk without this level of service. Exclusion - Limitations in resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Confidential and Proprietary Page 2 of 4 2014 MHNet Behavioral Health

Within residential care, the patient should be receiving all of the following services as further justification of the admission: 1. A multidisciplinary assessment of social, psychological, and developmental and biological functioning. 2. An evaluation by a psychiatrist occurs within the first 24 hours of the admission and is followed by visits from the attending psychiatrist at least one time per week. 3. A comprehensive medical examination including history, physical examination and laboratory testing within the first 24 hours of the admission for those clients who did not have them done immediately prior to admission. 4. A comprehensive treatment plan with specific measurable goals, timelines for achievement of those goals and methods of intervention. 5. The comprehensive treatment plan includes discharge plan, which specifies long term placement. 6. The family system is the subject of assessment, and the family is actively involved in treatment. 7. A structured environment which provides the patient with systematic feedback regarding progress or lack of progress toward treatment goals. 8. Psychoeducational assessment with any identified needs being addressed in the educational component of the program including aftercare planning with the school system. 9. Vocational and independent living skills training are addressed in the program when age appropriate and/or applicable to permanent placement goals. 10. Focused group therapy that addresses goals identified in the plan of care. 11. Treatment plan includes methods and/or goals for addressing crisis management. CONTINUED STAY CRITERIA: In order to justify remaining in residential treatment the patient must continue to manifest the following related to the principal DSM-5 diagnosis: 1. Psychological disturbances continue to significantly impair level of functioning. 2. Progress is evident towards treatment goals. However, more consistency is needed to achieve treatment goals. 3. Patient and the patient's family are cooperating with the treatment process. 4. Behavior is indicative that risk of suicide, assaultive, or homicidal behavior would be present at a lower level of care. Confidential and Proprietary Page 3 of 4 2014 MHNet Behavioral Health

5. During a period of transition to a permanent placement, the patient failed to sustain progress made in the residential setting. 6. Continued authorization of residential care will significantly reduce the likelihood of recidivism. DISCHARGE CRITERIA: The patient is ready for discharge when any of the following are obtained: a) Patient no longer meets criteria for continued stay. b) Patient can sustain progress and resolve remaining treatment goals in a less restrictive environment (i.e., IOP, traditional outpatient services). c) The patient s condition deteriorates and they are admitted to a higher level of care. d) Patient has not engaged in treatment and further progress is unlikely. e) During the course of treatment it is determined that the patient has a psychiatric disorder that is not amenable to structured psychiatric care. f) Patient leaves AMA. Confidential and Proprietary Page 4 of 4 2014 MHNet Behavioral Health

SUBSTANCE ABUSE MEDICALLY MONITORED SERVICES- CHILD/ADOLESCENT PROGRAM DEFINITION: To qualify as a medically monitored program, the member must be in a structured environment and be medically monitored to manage their detoxification and/or acute behavioral needs, with 24-hour medical availability, 24-hour on-site nursing services and 24-hours-a-day, 7-days-week supervision. This care includes treatment with a range of diagnostic and therapeutic behavioral health services that cannot be provided through existing community programs. A multidisciplinary treatment team (i.e., physicians, psychologists and therapists) must administer treatment. The treatment day consists of at least 8 hours of structured activity with at least 4 hours in individual and/or group therapy. The member must participate in treatment daily. The member s family, if applicable, must be actively involved in treatment at least 1 to 2 times per week. The primary treatment must be for a substance related disorder. This level of care excludes custodial care, respite for the family or legal problems and is not appropriate for the sole purpose of preventing relapse. Treatment at this level of care is not appropriate when the sole purpose of treatment is due to the member s lack of compliance at a lower level of care or as a substitute for focused ambulatory treatment of relapse. ADMISSION CRITERIA: 1. The member presents with a primary DSM-5 substance related disorder, and 2. Risk of exacerbation of serious concomitant medical complications due to continued substance abuse, which prohibits treatment from occurring safely at a lower level of care and requires 24-hour monitoring, or 3. Risk of withdrawal symptoms, which cannot be safely monitored at a lower level of care, or 4. The member is at risk of serious injury or death as a result of continued use, or 5. There is a secondary acute behavioral problem that requires continuous monitoring, and, 6. The member has the capacity to develop and implement skills and strategies that will enable them to learn skills to function more independently. GLOBAL INDICATORS:

1. The member presents at least one valid DSM-5 diagnosis that is amenable to substance abuse treatment and failure to admit to this level of care is likely to result in significant risk of harm to self. 2. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the member s condition or a recent course of treatment in a less restrictive setting resulted in a prompt recurrence of symptoms post discharge. SEVERITY OF ILLNESS: An objective professional evaluation of the member s current condition indicates a level of severity appropriate to residential care as evidenced by the following: Impairment in Safety: The member presents a risk of danger to themselves through suicide or danger to others through assaultive or homicidal behavior.. Impairment in Self-Care: The member presents significant impairment in capacity for self care without being monitored in a highly structured environment due to substance dependency and, as such, presents potential harm to self. Impairment in Reality Construction: The member presents significantly diminished ability to obtain essential information from the environment, to problem solve effectively and to respond to treatment efforts at lower levels of care (i.e., outpatient). Impairment in Social Functioning: Pattern of dependence has seriously impaired the member s social, family and occupational functioning, there is a reasonable expectation that significant functioning can be restored with residential treatment and that such functioning is unlikely to be restored through treatment at a lower level of care. Complicating Conditions: Physical and psychological complications are not of sufficient severity to preclude active participation in treatment. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further evidence for acute care, the member presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: The member does not have the coping skills sufficient to reduce risk without this level of service. Limited Social Resources: The member does not have the family and/or the social support needed to reduce level of risk without this level of service. Exclusion - Limitations in resources, in and of themselves, are not sufficient justification for admission.

INTENSITY OF SERVICE ELEMENTS: Within this level of care, the member should be receiving all of the following services as further justification of the admission: 1. A multidisciplinary assessment of social, psychological, developmental and biological functioning. 2. A comprehensive medical examination including history, physical examination and laboratory testing within the first 24 hours of the admission for those members who did not have them done immediately prior to admission. 3. An evaluation by an addictions specialist physician occurs within 24 hours of the admission and daily follow-up by the physician thereafter. 4. A comprehensive treatment plan of behavioral health treatment and residential living support with specific measurable goals, timelines for achievement of those goals and methods of intervention. 5. The comprehensive treatment plan includes a discharge plan, which is initiated within the first 24 hours of treatment. The discharge plan shall include active participation of the member/family and specify long term placement if necessary. 6. The family system is the subject of assessment. The family is actively involved in treatment and the first family session occurs within the first 3 days of admission, followed by family sessions at least 2 times per week. 7. A structured environment, which provides the member with systematic feedback regarding progress or lack of progress toward treatment goals. 8. Treatment plan includes methods and/or goals for addressing crisis management and relapse prevention. CONTINUED STAY CRITERIA: In order to justify remaining in residential treatment, the member must continue to manifest all of the following related to the principal DSM-5 diagnosis: 1. Persistence of problems that caused the admission to a degree that they continue to meet criteria for admission. 2. The member continues to be unable to perform activities of daily living essential to maintaining safety. 3. The current or revised treatment plan includes a linkage and/or coordination with the available structured and supportive community based resources with the goal of returning to his/her regular social environment as soon as possible, when appropriate. 4. The current or revised treatment plan can be reasonably expected to bring about significant improvement in the problems that caused the admission, and the member s

progress is documented on a daily basis. The treatment plan is updated weekly and includes a plan for discharge. DISCHARGE CRITERIA: The member is ready for discharge when any of the following are obtained: a) They no longer meet criteria for continued stay. b) They can sustain progress and resolve remaining treatment goals in a less restrictive environment (i.e., IOP, traditional outpatient services). c) They have deteriorated and need to be admitted to a higher level of care. d) They have not engaged in treatment and further progress is unlikely. e) They leave AMA.

PSYCHIATRIC PARTIAL HOSPITALIZTION SERVICES- CHILD/ADOLESCENT PROGRAM DEFINITION: This level of care is intended to be an alternative to acute psychiatric inpatient treatment for individuals who need intensive treatment but do not need 24 hour professional monitoring and therefore can continue to reside outside of the treatment facility. The level of acuity of patients symptoms, intensity of services and length of stay guidelines should all be similar to those of acute psychiatric inpatient treatment. Partial hospitalization should be the initial level of care authorized, and is not intended as a stepdown from acute psychiatric inpatient treatment or as an alternative to an Intensive Outpatient Program. To qualify as a partial hospitalization program, the patient must receive at least eight hours/day of individual and group therapy. The patient must participate in a structured program at least three days/week. ADMISSION CRITERIA: Admission to a partial hospitalization program must be based on the following Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and by Intensity of Services appropriate to partial hospitalization. GLOBAL INDICATORS: 1. Patient presents a valid DSM-5 diagnosis exclusive of substance related disorder, failure to admit to a partial hospitalization program is likely to result in immediate deterioration requiring inpatient care, and 2. Patient s condition must be directly attributable to the designated mental disorder and not to patterns of disruptive behavior, or be a part of a pervasive pattern of antisocial conduct, and 3. Patient s behavior and symptoms are amenable to acute treatment, and 4. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the patient s condition or a recent course of treatment in a less restrictive setting with a prompt recurrence of symptoms post discharge, and

5. Specialized intervention is considered likely to be effective and is essential to contain risks presented and provide for improvement. SEVERITY OF ILLNESS: An objective, professional evaluation of the patient s current condition indicates an acute level of severity appropriate to partial hospitalization as evidenced by the following: Impairment in Safety: Patient may be experiencing suicidal/homicidal ideation with a plan and expressed intent. Patient must be able to contract for safety and have a social support system in place when outside of the partial hospital setting. Clinical evidence indicates that a less intensive outpatient setting is not appropriate. Impairment in Self-Care: Patient may be experiencing noticeable impairment in ADLs (i.e., disheveled clothing, unkempt appearance, and poor personal hygiene). Patient may be experiencing significant impairment in their eating and/or sleeping patterns. Patient has a system of social support able to provide for whatever transportation needs are required by the program. Impairment in Reality Construction: The patient is sufficiently intact to benefit from individual and group therapy. Impairment in Social Functioning: This level of care is considered appropriate for patients who are unable to function in unmonitored social/occupational settings. Patient s acute symptoms disable them from fulfilling occupational roles/responsibilities. Patient may be exhibiting/verbalizing a noticeable decrease in personal interactions. Patient can benefit from continuing involvement with family/social support system. Complicating Conditions: This level of care is appropriate for patients with a demonstrated need for intensive pharmacological intervention. Biomedical complications are minimal, coexisting psychological problems (e.g., depression) will not significantly interfere with partial hospital care and complications from pharmacological intervention are considered manageable. Exclusion In the child/adolescent population, partial hospitalization should be delineated from non-acute residential day programs designed for social rehabilitation of patients with pervasive developmental disorders. Exclusion Unless medically necessary, court-ordered treatment is considered an exclusion. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES:

Patient presents with limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: Patient has adequate cognitive and emotional coping skills to actively participate in care. Patient is capable of controlling their behavior and/or has the ability to seek professional assistance or other support when outside of the program. Limited Social Resources: Patient has adequate social support system, including a suitable environment outside of the program to provide context for successful partial hospital treatment. The patient s family must be willing and available to assist the patient outside of the partial hospital setting, and within the partial hospital setting when clinically indicated. Exclusion - 1. Limitations in resources, in and of themselves, are not sufficient justification for admission. 2. In the child/adolescent population, the need for an alternative academic setting in and of itself is not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within the partial hospitalization program, the patient should be receiving all of the following services as further justification of the admission: 1. A comprehensive psychiatric evaluation must be conducted and documented on the day of admission. This evaluation must include an initial treatment plan, tentative discharge plan, and a comprehensive family assessment (family assessment must be completed within 48 hours of admission). 2. The provision of educational services to meet patients individualized academic needs. 3. An individualized treatment plan with specific goals and intervention plans. 4. A structured activities schedule with both focused individual and group therapy. 5. A plan exists for management of crisis episodes, when they occur. 6. Linkages with appropriate support groups (e.g., AA or Overeaters Anonymous). 7. A psychiatrist must be available every day of treatment providing daily supervision of care and ongoing medication monitoring and adjustment. 8. Family involvement within the partial hospital setting, including family therapy, should occur twice weekly, unless frequent family involvement would result in clinical exacerbation of the patient s psychiatric illness.

CONTINUED STAY CRITERIA: In order to justify remaining in a partial hospitalization program, the patient must continue to manifest all of the following related to the principal DSM-5 diagnosis: 1. Admission criteria must be met. 2. Clinical documentation reflects the patient s active progress toward treatment goals. 3. Clinical documentation supports justification that a less restrictive level of care would result in exacerbation of the patient s psychiatric illness. 4. Patient is cooperating with caregivers and actively involved in care. 5. Family involvement is appropriate to the goal of sustaining the progress that is being made. 6. Patient is actively participating in aftercare planning. DISCHARGE CRITERIA: The patient is ready for discharge when they satisfy any of the following criteria: (a) Completes the treatment plan. (b) Impairment in functioning can be managed with periodic outpatient treatment. (c) Patient leaves AMA. (d) Patient refuses treatment and/or the problems that prompted admission are found not to be amenable to acute treatment. (e) The patient s condition deteriorates and they are admitted to a higher level of care.

HOSPITAL BASED DETOXIFICATION SERVICES PROGRAM DESCRIPTION: Acute hospital care is reserved for individuals who are at risks for serious medical complications if their substance abuse is not medically monitored. This would include individuals acutely intoxicated on drugs/alcohol as well as individuals withdrawing from drugs or alcohol. The facility must be a full service medical hospital that has the capability to provide intensive care services. ADMISSION CRITERIA: Admission to an acute hospital setting must be based on the following Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and by Intensity of Services appropriate to acute care. GLOBAL INDICATORS: 1. Patient presents at least one valid DSM-5 substance related diagnosis of either alcohol or sedative/hypnotic drug abuse. Withdrawal from other drugs of abuse (i.e. opiates, stimulants, cannabis, hallucinogens, inhalants) in the absence of a serious acute medical or psychiatric condition, can be accomplished in a less restrictive setting, and 2. Patient has a serious medical condition including withdrawal symptoms that puts them at risk for permanent disability or death if they are withdrawn without medical supervision and/or the patient is at serious risk for death or disability if withdrawal is done without medical supervision, and 3. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the patient s condition. 4. Professional intervention is considered likely to be effective and is essential to contain risks presented and provide for improvement. SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current condition indicates a level of severity appropriate to acute hospital care as evidenced by: 1. History of severe withdrawal symptoms (e.g., delirium, seizures, hallucinations), or 2. Continuous daily use with symptoms of severe withdrawal at the time of evaluation (e.g., CIWA > 20), or

3. An unstable medical condition that would result in significant risk to the patient if they went into severe withdrawal. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further justification the patient presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: Patient does not have the cognitive or emotional coping skills to facilitate effective outpatient detoxification. Limited Social Resources: Patient does not have the familial or social support to provide the context for outpatient detoxification. Exclusions - Limitations in resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within this acute care setting, the patient should be receiving all of the following services as further justification of the admission: 1. Skilled nursing care and level of observation appropriate to risks. 2. Patient receives biomedical intervention (e.g., IV fluids) appropriate to symptomatic presentation. 3. Nutritional status and other relevant general health status assessments. 4. Regular reassessments of mental status. 5. Appropriate pharmacological intervention for withdrawal symptoms as determined by the provider. 6. Discharge planning within 24 hours of admission. 7. Precautions appropriate to suicide potential or elopement risk. 8. Daily physician evaluation. CONTINUED STAY CRITERIA: In order to justify remaining in acute care, the patient must continue to manifest symptoms justifying the principle DSM-5 diagnosis along with one or more of the following:

1) Biomedical symptoms of intoxication or withdrawal remain, and those symptoms place the patient at risk. 2) Biomedical problems would likely interfere with the next stage of treatment. 3) Coexisting psychiatric disorder would significantly interfere with effective transfer to lower level of care. 4) Cognitive and perceptual impairment remains at a level that would produce risk if transferred or discharged. 5) Additional preparation for discharge or transfer will reduce probability of relapse or re-hospitalization. DISCHARGE CRITERIA: Patient is ready for discharge when one or more of the following criteria are satisfied: a) Withdrawal symptoms are sufficiently stable that they can be managed as an outpatient. b) Individual signs out AMA. c) The patient s condition deteriorates and they are admitted to a higher level of care.

OUTPATIENT DETOXIFICATION PROGRAM DESCRIPTION: Outpatient detoxification programs provide medical supervision for individuals who are committed to becoming abstinent and who are experiencing significant withdrawal symptoms. The program must have the capacity to treat individuals who are physically dependent on alcohol, sedative/hypnotics or opiates. Treatment of individuals who are abusing other drugs (e.g. hallucinogens, stimulants) can be provided in the event they need medical supervision. The program must have the capability to perform psychiatric and medical evaluations as well as laboratory testing. It must have the capacity to monitor patients for at least 4 hours. Medical supervision must be available 7 days/week. ADMISSION CRITERIA: Patient has been actively abusing drugs or alcohol, and they are at risk for injury, deterioration or disability if they don t receive medically care for withdrawal symptoms. GLOBAL INDICATORS: 1. Patient presents at least one valid DSM-5 diagnosis of substance related disorder, and 2. Patient's condition must be directly attributable to a substance-related disorder. 3. Specialized intervention is considered likely to be effective and to contain risks presented and provide for improvement. SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current condition indicates a level of severity appropriate to an outpatient detoxification facility as evidenced by one or more of the following: Impairment in Safety: Patient presents risks of deterioration, disability or death if they are not medically supervised during withdrawal. Impairment in Self Care: Substance dependency is such that capacity for essential selfcare has been temporarily diminished in a way that imposes immediate risk to the patient and the attendant risks can be reduced by medically supervised detoxification. Impairment in Reality Construction: Patient is sufficiently intact that they can, with the assistance of others, participate in outpatient treatment. Confidential and Proprietary 2014 MHNet Behavioral Health

Impairment in Social Functioning: Patient s social and/or family functioning must be sufficiently intact to permit outpatient detoxification. Complicating Conditions: Patient has underlying medical condition(s) that would be exacerbated if they do not receive medically supervised detoxification. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: Patient presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: None. Limited Social Resources: Patient must have sufficient resources to monitor their withdrawal and obtain emergency medical care, if necessary, on an outpatient basis. Exclusion - Limitations in personal or social resources, in the absence of a need for medically managed detoxification, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within this detoxification setting the patient should be receiving all of the following services as further justification of the admission: 1. Comprehensive medical/psychiatric/substance abuse history and physical examination. 2. Laboratory testing as appropriate 3. Individualized plan of care that recognizes unique characteristics, problems and motivations. The plan must include anticipated length of stay and frequency of follow-up visits. 4. Medical interventions appropriate to detoxification risks and/or physical complications that attend the patient's dependency. 5. Discharge planning within 24 hours of admission. 6. Co-morbid conditions identified and treated when appropriate (e.g., significant depression). CONTINUED STAY CRITERIA: In order to justify remaining in a detoxification program the patient must: 1. Remain abstinent from alcohol and drugs of abuse. Confidential and Proprietary 2014 MHNet Behavioral Health

2. Be receiving medications to manage the symptoms of withdrawal. 3. Patient is cooperating fully with the treatment team and is giving evidence of motivation to address dependency issues. 4. Patient continues to be at risk for deterioration, disability or death if not medically monitored. DISCHARGE CRITERIA: The patient is ready for discharge when they satisfy any of the following criteria: a) They complete the treatment plan. b) The risk of deterioration or disability can be managed in a less restrictive setting. c) The patient leaves AMA. d) The patient s condition deteriorates and they require admission to a higher level of care. Confidential and Proprietary 2014 MHNet Behavioral Health

SUBSTANCE ABUSE PARTIAL HOSPITALIZATION SERVICES PROGRAM DEFINITION: This level of care is intended to be an alternative to acute substance abuse inpatient treatment or residential treatment for individuals who need intensive treatment but do not need 24 hour professional monitoring and therefore can continue to reside outside of the treatment facility. The level of acuity of the member s symptoms, intensity of services and length of stay guidelines should all be similar to those of substance abuse residential treatment. Partial hospitalization is not intended as an automatic step-down from residential treatment or as an alternative to an Intensive Outpatient Program. To qualify as a partial hospitalization program, the member must receive at least six hours/day and twenty hours/week of structured therapy. ADMISSION CRITERIA: Admission to a partial hospitalization program (PHP) must be based on the following Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and by Intensity of Services appropriate to partial hospitalization. GLOBAL INDICATORS: 1. The member presents at least one valid DSM-5 substance related diagnosis and failure to admit to a partial hospitalization program is likely to result in immediate deterioration requiring a higher level of care and 2. The member is medically stable and not in acute withdrawal that would require 24- hour medical monitoring, and 3. The member s symptoms are amenable to PHP, require a structured program with medical supervision and/or treatment for part of each day, and 4. The member s substance use is excessive, and the member has attempted to reduce or control it, but has been unable to do so, and 5. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the member s condition or a recent course of treatment in a less restrictive setting resulted in a prompt recurrence of symptoms post discharge, and

6. Specialized intervention is considered likely to be effective and is essential to contain risks presented and provide for improvement. SEVERITY OF ILLNESS: An objective professional evaluation of the member s current condition indicates a level of severity appropriate to partial hospitalization care as evidenced by the following: Impairment in Safety: The member presents a risk of danger to themselves or a danger to others through assaultive or homicidal behavior. Impairment in Self-Care: The member presents significant impairment in capacity for self care without being monitored in a highly structured environment due to substance dependency and as such, presents potential harm to self. Impairment in Reality Construction: The member presents with a significantly diminished ability to obtain essential information from the environment, to problem solve effectively and to respond to treatment efforts at lower levels of care (i.e., outpatient). Impairment in Social Functioning: The member demonstrates a pattern of dependence that has seriously impaired their social, family and occupational functioning and there is a reasonable expectation that significant functioning can be restored with partial hospitalization care and that such functioning is unlikely to be restored through treatment at a lower level of care. Complicating Conditions: Physiological complications are minimal, coexisting psychological problems (e.g., depression) will not significantly interfere. Care and complications from pharmacological intervention are considered manageable. Exclusion In the adult/geriatric population, medical conditions in and of themselves, are not sufficient justification for admission. Exclusion Unless medically necessary, court-ordered treatment is considered an exclusion. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: The member presents with limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources The member has adequate cognitive and emotional coping skills to actively participate in care. The member is capable of controlling their

behavior and/or has the ability to seek professional assistance or other support when outside of the program. Limited Social Resources The member has adequate social support system, including a suitable environment outside of the program to provide context for successful partial hospital treatment. Exclusion Limitations in resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within the partial hospitalization program all of the following program elements must be provided to satisfy medical necessity criteria: 1. A comprehensive bio-psycho-social evaluation must be conducted and documented on the day of admission. This evaluation must include an initial treatment plan and tentative discharge plan. 2. Structured daily program, including nursing and medical supervision. 3. A physician with specialty training in addiction medicine must be available every day of treatment providing daily supervision of care and ongoing medication monitoring and adjustment. 4. An individualized treatment plan with specific goals and intervention plans. A specific treatment goal is the reduction in severity of symptoms and improvement in level of functioning sufficient to return member to a less intensive level of care. 5. The treatment plan includes a linkage and/or coordination with the available structured and supportive community based resources. 6. A structured activities schedule with both focused individual and group therapy. 7. Plan exists for management of crisis episodes, were they to occur. CONTINUED STAY CRITERIA: In order to justify remaining in a partial hospitalization program, the member must continue to manifest the following related to the principal DSM-5 diagnosis: 1. Admission criteria must be met. 2. Clinical documentation supports the member s active progress toward treatment goals. 3. Clinical documentation shows that a less restrictive level of care would result in exacerbation of the member s substance dependence. 4. The member is cooperating with caregivers and actively participating in care.

5. The current or revised treatment plan can be reasonably expected to bring about significant improvement in the problems that caused the admission, and the member s progress is documented at least three times per week. The treatment plan includes a plan for discharge. 6. The member is actively participating in aftercare planning. 7. Family involvement is appropriate to the goal of sustaining the progress that is being made. DISCHARGE CRITERIA: The member is ready for discharge when they satisfy any of the following criteria: a) They no longer meet criteria for continued stay. b) They can sustain progress and resolve remaining treatment goals in a less restrictive environment (i.e., IOP, traditional outpatient services). c) They have not engaged in treatment and further progress is unlikely. d) They leave AMA. e) Their condition deteriorates and they are admitted to a higher level of care.

SUBSTANCE ABUSE RESIDENTIAL SERVICES PROGRAM DESCRIPTION: Residential substance abuse services are designed for adolescents and adults in need of substance abuse services who cannot be safely managed in an outpatient setting. The program should consist of at least 8 hours per day of structured activities. Every individual must undergo a comprehensive assessment within 24 hours of admission. Every individual must have an initial evaluation by a physician trained in addiction medicine. In addition there must be daily availability of a physician. The program must include family therapy and family meetings if geographically feasible. Within 72 hours of admission, a discharge plan must be developed that identifies all barriers to discharge and develops strategies to address each behavior. ADMISSION CRITERIA: Admission to a residential unit for a substance-related disorder must be based on the following: Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and by Intensity of Services appropriate to a rehabilitation unit. GLOBAL INDICATORS: 1. The individual presents at least one valid DSM-5 substance related diagnosis, and 2. The individual's condition must be directly attributable to a substance-related disorder. 3. The individual is in need of intensive treatment including 24 hour monitoring prior to being transitioned to an outpatient substance abuse treatment program. 4. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the member s condition or a recent course of treatment in a less restrictive setting resulted in a prompt recurrence of symptoms post discharge. 5. Specialized intervention is considered likely to be effective and to contain risks presented and provide for improvement. 6. The individual has the capacity to develop and implement new skills and strategies that will permit them to function independently.

7. There is a basis for expecting a positive outcome from residential treatment for individuals who ve relapsed after one or more previous residential treatment programs. SEVERITY OF ILLNESS: An objective professional evaluation of the member s current condition indicates a level of severity requiring treatment in a residential facility as evidenced by one or more of the following: Impairment in Safety: The member presents a significant risk of danger to themselves or others as a result of uncontrollable substance abuse and such risk can be reduced through residential care. Impairment in Self Care: Substance use is such that capacity for essential self care has been temporarily diminished in a way that imposes immediate risk to the patient and the attendant risks can be reduced with residential care. Impairment in Reality Construction: Any impairment is not so severe as to preclude the ability to actively participate in all aspects of the rehabilitation program. Impairment in Social Functioning: Pattern of dependence has seriously impaired the member s social, family and scholastic/occupational functioning, there is a reasonable expectation that significant functioning can be restored with residential services and that such functioning is unlikely to be restored without residential services. Complicating Conditions: The member presents co-morbid conditions that substantially complicate outpatient care and can only be resolved through residential care. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: The member presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: The member does not currently possess coping skills that permit resolution of substance abuse problems on an outpatient basis. Limited Social Resources: The member lacks support from family or significant others that could provide the essential context for outpatient success. Exclusion - Limitations in personal or social resources, in and of themselves, are not sufficient justification for admission.

INTENSITY OF SERVICE ELEMENTS: Within this residential setting the member should be receiving all of the following services as further justification of the admission: 1. A comprehensive assessment within 24 hours of admission including an evaluation by a physician addiction specialist. 2. Individualized plan of care that recognizes unique characteristics, problems and motivations. 3. A treatment plan focused directly on abstinence from the substance or substances of concern. 4. There must be at least 8 hours per day of structured activities designed to maintain sobriety. 5. Treatment staff must be appropriately licensed in the residential unit s State. 6. At least twice weekly family therapy and regular family meetings. 7. Periodic urine drug testing. 8. Educational services for adolescents are available in the event of a prolonged stay. 9. Medical services are available for members with significant medical problems. 10. Co-morbid conditions identified and treated when appropriate 11. The program provides for transition to outpatient support groups (e.g., AA or NA) that can reduce relapse probability. 12. Discharge planning must begin within 24 hours of admission with a comprehensive discharge plan being developed within 72 hours of admission. CONTINUED STAY CRITERIA: In order to justify remaining in a residential unit the member must continue to manifest all of the following related to the principal DSM-5 diagnosis: 1. Intensity of service is appropriate to the level of care expected of a residential unit. 2. High-risk symptoms that justified the admission continue to manifest themselves. 3. The member is cooperating with the treatment team and is giving evidence of motivation to address dependency issues. 4. The member continues to be unable to perform activities of daily living essential for maintaining safety.

5. Additional time in the residential program is likely to reduce the risk of relapse and return to a hospital or rehabilitation setting. DISCHARGE CRITERIA: The member is ready for discharge when they satisfy any of the following criteria: a) Completing the treatment plan. b) Impairment in functioning no longer requires 24 hour observation or treatment. c) Leaving AMA. d) Refusing treatment and/or the problem(s) that prompted admission is/are found to be refractory or chronic. Disposition under these circumstances must be predicated on assuring the member s safety, applicable state law, as well as the health plan benefit. e) The member s condition deteriorates and they are admitted to a higher level of care.

PSYCHIATRIC INTENSIVE OUTPATIENT SERVICES PROGRAM DEFINITION: To qualify as an intensive outpatient program the patient must receive at least 2½ hours per day of individual and/or group therapy. The patient must participate in treatment at least three days per week. ADMISSION CRITERIA: 1. Patient has the cognitive ability to understand and process in both individual and group therapy modalities. 2. Patient has the emotional stability to actively participate in both individual and group therapies. 3. Patient has the capacity to develop and implement skills and strategies that will enable them to function more independently. 4. Patient has some limitations in their social support systems. GLOBAL INDICATORS: 1. Patient presents at least one DSM-5 diagnosis and, failure to admit to an intensive outpatient program is likely to result in significant psychological impairment, which would require a more structure level of care, and 2. Patient's condition must be directly attributable to the designated mental disorder and not be a part of a pervasive pattern of antisocial conduct, and 3. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the patient s condition or a recent course of treatment in a less restrictive setting with a prompt recurrence of symptoms post discharge.

SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current condition indicates a level of severity appropriate to IOP as evidenced by the following: Impairment in Safety: The patient may be experiencing suicidal or homicidal ideation without expressed intentions or a plan. Impairment in Self Care: The patient may be experiencing noticeable impairment in ADLs (i.e., disheveled clothing, unkempt appearance, and poor personal hygiene). Patient may be experiencing significant disturbances in their eating and/or sleeping patterns. Impairment in Reality Construction: The patient may experience disturbances in their thought processes but possess the cognitive ability to distinguish between them and reality. Impairment in Social Functioning: The patient may be exhibiting/verbalizing a noticeable decrease in personal interactions. Patient is displaying some signs of anhedonia. Patient is experiencing difficulty fulfilling roles and responsibilities (i.e., job, parenting,). Social and occupational functioning is at a level that will permit success of an IOP program. Patient will benefit from continuing involvement with family/significant others and at work during treatment. Complicating Conditions: Physical complications are minimal and any coexisting psychological problems (e.g., depression) will not significantly interfere with care. Any complications from pharmacological intervention are considered manageable. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further evidence for acute care, the patient presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: Patient does not have the coping skills sufficient to reduce risk without this level of service. Limited Social Resources: Patient does not have the family and/or the social support needed to reduce level of risk without this level of service. Exclusion - Limitations in resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS:

Within IOP, the patient should be receiving all of the following services as further justification of the admission: 1. A comprehensive psychiatric evaluation must be conducted and documented on the day of admission. This evaluation must include an initial treatment plan and tentative discharge plan. 2. An individualized treatment plan with specific goals and intervention plans. 3. A structured activity schedule with focused individual, family, and group therapy. 4. Plan exists for management of crisis episodes if they to occur. 5. Linkages with appropriate support groups if applicable (e.g., AA or Overeaters Anonymous). 6. An independently licensed mental health professional must be available every day of treatment providing daily supervision of care. 7. A medical director will oversee the program and be involved in the development of individual treatment plans. CONTINUED STAY CRITERIA: In order to justify remaining in an IOP program, the patient must continue to manifest all of the following related to the principal DSM-5 diagnosis: 1. Adequate progress is taking place, goals are being approximated and longer stay is essential to achieve goals. 2. Patient is being stabilized and maintained in a way that avoids hospitalization. 3. Patient is cooperating with caregivers and actively involved in care as evidenced by documentation of participation and attendance. 4. Family involvement is appropriate to the goal of sustaining the progress that is being made. 5. Aftercare planning is taking place and the patient is involved in those plans. 6. Patient has consistent attendance. DISCHARGE CRITERIA: The patient is ready for discharge when they satisfy any of the following criteria: a) Completes the treatment plan. b) Impairment in functioning can be managed with periodic outpatient treatment. c) Patient leaves AMA. d) The patient s condition deteriorates and they are admitted to a higher level of care.

e) Patient refuses treatment, and/or the problems that prompted admission are found to be refractory or chronic. f) Patient does not have consistent pattern of compliance with attendance prescribed in treatment plan.

SUBSTANCE ABUSE INTENSIVE OUTPATIENT SERVICES PROGRAM DEFINITION: To qualify as an intensive outpatient program (IOP) the member must receive at least 3hours/day and 9 hours/week of individual and/or group therapy. The member must participate in treatment at least three days/week. ADMISSION CRITERIA: 1. The member has failed to maintain sobriety despite personal efforts. 2. The member cannot be effectively treated in a less restrictive setting or has been discharged from a more restrictive level of care and requires significant structure and monitoring in order to maintain sobriety. 3. The member has the cognitive ability to understand and process in both individual and group therapy modalities. 4. The member has the emotional stability to actively participate in both individual and group therapies. 5. The member has the capacity to develop and implement skills and strategies that will enable them to function more independently. 6. The member has some limitations in their social support systems. GLOBAL INDICATORS: 1. The member presents at least one valid DSM-5 substance related diagnosis, and failure to admit to a intensive outpatient program is likely to result in immediate psychological deterioration and progression in substance abuse which would require a higher level of care then IOP, and 2. The member s condition must be directly attributable to the designated DSM-5 diagnosis and not to a Personality Disorder or be a part of a pervasive pattern of antisocial conduct, and 3. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the member s condition or a recent course of treatment in a less restrictive setting resulted in a prompt recurrence of symptoms post discharge.

SEVERITY OF ILLNESS: An objective professional evaluation of the member s current condition indicates a level of substance abuse/dependence appropriate to IOP as evidenced by the following: Impairment in Safety: The member may be experiencing significant cravings for substance(s) of choice but vital signs are within normal limits. May be experiencing suicidal or homicidal ideation without expressed intentionality or a plan with no prior history of attempts. Impairment in Self-Care: The member may be experiencing noticeable impairment in ADLs, (i.e., disheveled clothing, unkempt appearance and poor personal hygiene). May be experiencing significant disturbances in eating and/or sleeping patterns. Impairment in Reality Construction: Any impairment is not so severe as to preclude the ability to actively participate in all aspects of the rehabilitation program. Impairment in Social Functioning: The member may be exhibiting/verbalizing a noticeable decrease in personal interactions. The member is displaying some signs of anhedonia. The member is experiencing difficulty fulfilling roles and responsibilities (i.e., job, parenting,). Social and occupational functioning is at a level that will permit success of an IOP program. The member will benefit from continuing involvement with family/significant others and at work during treatment. Complicating Conditions: Physiological complications are minimal, coexisting psychological problems (e.g., depression) will not significantly interfere. Care and complications from pharmacological intervention are considered manageable. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further evidence for acute care, the member presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: The member does not have the coping skills sufficient to reduce risk without this level of service. Limited Social Resources: The member does not have the family and/or the social support needed to reduce level of risk without this level of service. Exclusion - Limitations in resources, in and of themselves, are not sufficient justification for admission.

INTENSITY OF SERVICE ELEMENTS: Within IOP, the member should be receiving all of the following services as further justification of the admission: 1. A comprehensive bio-psycho-social evaluation including an extensive substance abuse history must be conducted and documented on the day of admission. This evaluation must include an initial treatment plan and tentative discharge plan. 2. An individualized treatment plan with specific goals and intervention plans. 3. A structured activity schedule with focused individual, family, and group therapy 4. A plan exists for management of crisis episodes if they occur. 5. At a minimum documentation of weekly attendance at two to three support groups (e.g., AA, NA, Alanon, Alateen, etc.). 6. Random weekly drug/alcohol screenings to verify sobriety. 7. Obtaining and having regular documented contact with a sponsor. 8. An independently licensed mental health professional with substance abuse certification must be available every day of treatment providing daily supervision of care. 9. A medical director will oversee the programming and be involved in the development of individual treatment plans. CONTINUED STAY CRITERIA: In order to justify remaining in an IOP program, the member must continue to manifest all of the following associated with the principal DSM-5 substance related diagnosis: 1. Adequate progress is taking place, goals are being approximated, and longer stay is essential to achieve goals. 2. The member is being stabilized and maintained in a way that avoids an admission to a higher level of care.. 3. The member is cooperating with caregivers and actively involved in care. 4. Family involvement is appropriate to the goal of sustaining the progress that is being made. 5. Sobriety as evidenced by random weekly drug screens 6. Documentation of attendance at all weekly support group meetings required by treatment plan. 7. Ongoing documentation regarding the involvement of a sponsor as required by the treatment plan. 8. Aftercare planning is taking place, and the member is involved in those plans.

9. Active participation in relapse prevention planning. DISCHARGE CRITERIA: The member is ready for discharge when any of the following criteria are satisfied: a) They complete the treatment plan. b) Any impairment in functioning can be managed with periodic outpatient treatment, c) They leave AMA. d) They refuse treatment, and/or the problems that prompted admission are found to be refractory or chronic. e) They repeatedly fail weekly drug screens. f) They do not have consistent documented attendance at treatment program and/or support group meetings. g) They do not have consistent documented communication with their sponsor. h) Their condition deteriorates and they are admitted to a higher level of care.

SUBSTANCE ABUSE MEDICALLY MANAGED CARE PROGRAM DESCRIPTION: Medically managed substance abuse treatment is reserved for individuals who are at risks for serious medical or psychiatric complications during the withdrawal phase of their treatment. This would include individuals acutely intoxicated on drugs/alcohol as well as individuals withdrawing from drugs or alcohol. The treating facility must have comprehensive medical and psychiatric services. If it is a free-standing facility, it must have procedures in place for the immediate transfer of members to a full service medical facility. ADMISSION CRITERIA: Admission to a medically managed inpatient facility must be based on the following: Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and by Intensity of Services appropriate to acute care. GLOBAL INDICATORS: 1. The member presents at least one valid DSM-5 substance related diagnosis of either alcohol or sedative/hypnotic drug abuse. Withdrawal from other drugs of abuse (i.e. opiates, stimulants, cannabis, hallucinogens, inhalants) in the absence of a serious acute medical or psychiatric condition, can be accomplished in a less restrictive setting, and 2. The member has a serious medical condition including withdrawal symptoms that puts them at risk for permanent disability or death if they are withdrawn without medical supervision and/or the member is at serious risk for death or disability due to a behavioral disturbance if withdrawal is done without medical supervision, and 3. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the member s condition. 4. Professional intervention is considered likely to be effective and is essential to contain risks presented and provide for improvement.

SEVERITY OF ILLNESS: An objective professional evaluation of the member s current condition indicates a level of severity appropriate to acute inpatient care as evidenced by: 1. History of severe withdrawal symptoms (e.g., delirium, seizures, hallucinations), or 2. Continuous daily use with symptoms of severe withdrawal at the time of evaluation (e.g., CIWA > 20), or 3. An unstable medical condition that would result in significant risk to the member if they went into severe withdrawal. 4. A comorbid psychiatric condition that puts them at significant risk if withdrawn without medical supervision. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further justification the member presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: The member does not have the cognitive or emotional coping skills to facilitate effective outpatient detoxification. Limited Social Resources: The member does not have the familial or social support to provide the context for outpatient detoxification. Exclusions - Limitations in resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within this acute care setting, the member should be receiving all of the following services as further justification of the admission: 1. Treatment must be under the direct supervision of a physician trained in addiction medicine. 2. Skilled nursing care and level of observation appropriate to risks. 3. The member receives biomedical intervention (e.g., IV fluids) appropriate to symptomatic presentation. 4. Nutritional status and other relevant general health status assessments. 5. Regular reassessments of mental status.

6. Appropriate pharmacological intervention for withdrawal symptoms as determined by the attending physician. 7. Discharge planning within 24 hours of admission. 8. Precautions appropriate to suicide potential or elopement risk. 9. Daily physician evaluation. CONTINUED STAY CRITERIA: In order to justify remaining in acute care, the member must continue to manifest symptoms justifying the principle DSM-5 diagnosis along with one or more of the following: 1) Biomedical symptoms of intoxication or withdrawal remain, and those symptoms place the member at significant risk if not medically managed. 2) Biomedical problems would likely interfere with the next stage of treatment. 3) Coexisting psychiatric disorder would significantly interfere with effective transfer to lower level of care. 4) Cognitive and perceptual impairment remains at a level that would produce risk if transferred or discharged. 5) Additional preparation for discharge or transfer will reduce probability of relapse or re-hospitalization. DISCHARGE CRITERIA: The member is ready for discharge when one or more of the following criteria are satisfied: a) Withdrawal symptoms are sufficiently stable that they can be managed with medical monitoring. b) The member signs out AMA. c) The member s condition deteriorates and they are admitted to a higher level of care.

OUTPATIENT SERVICES ADMISSION CRITERIA: Admission to outpatient services must be based on the following Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and an Intensity of Services appropriate to outpatient care. GLOBAL INDICATORS: 1. Patient presents at least one valid DSM-5 diagnosis, other than Neurodevelopmental Disorders, Elimination Disorders, or Neurocognitive Disorders without behavioral disturbances, and 2. The patient has one or more specified behavioral disturbances that is/are amendable to short term intervention and/or require(s) ongoing treatment to prevent deterioration to the point of hospitalization and patient's condition must be directly attributable to the designated mental disorder and not to Antisocial Personality or be a part of a pervasive pattern of antisocial conduct, and 3. Professional intervention is considered likely to be effective and is essential to contain risks presented and provide for improvement. SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current condition indicates a level of severity appropriate to outpatient services as evidenced by one or more of the following: Impairment in Safety: Patient presents levels of risk to self or others that can be adequately managed in an outpatient setting. Impairment in Self Care: Patient has adequate self care skills to maintain themselves without substantial risk while being seen over time in an outpatient setting. Impairment in Reality Construction: Patient has adequate grasp of reality and capacity for judgment to contain risks while being seen on an outpatient basis. Impairment in Social Functioning: Impairment in social, family, occupational or educational functioning is not of sufficient magnitude to preclude obtaining benefit from outpatient therapy. Complicating Conditions: Complications are considered minimal. Confidential and Proprietary 2014 MHNet Behavioral Health

LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further justification, the patient presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: Patient has adequate coping skills to contribute to recovery through active participation and to carry out assigned tasks between sessions. Limited Social Resources: Patient has adequate family and/or social support to provide context for periodic outpatient intervention. Exclusions - Limitations in resources, in and of themselves, are not sufficient justification for services. INTENSITY OF SERVICE ELEMENTS: Within outpatient care the patient should be receiving the following services as further justification of the admission: 1. An individualized treatment plan with specific goals and attendant plans for evidence based intervention targeting specific symptoms/behaviors and functional impairments. 2. Symptoms described correspond to the diagnosis and meet criteria as specified in DSM-5. 3. Plans include interventions appropriate to crises were they to occur. 4. Frequency and duration of contact appropriate to the plan of care (e.g., weekly or monthly). 5. Patient strengths recognized and mobilized in service of obtaining the goals of care. CONTINUED STAY CRITERIA: In order to justify remaining in outpatient care the patient must continue to manifest symptoms justifying the principal DSM-5 diagnosis and one or more of the following: 1. Progress is being made at expected pace in obtaining the goals in the plan of care. 2. Additional sessions are required to achieve final goals and not interrupt current episode of care and goals of therapy are not primarily supportive or for self improvement. Confidential and Proprietary 2014 MHNet Behavioral Health

3. Patient is showing up for appointments and cooperating with homework assignments and other aspects of care including allowing coordination of care with other providers and involvement of family members where clinically indicated. 4. Changes in environmental stress have led to justifiable modification in the plan of care. FREQUENCY AND DURATION OF CARE: 1) Members receiving therapy a. Crisis management: During the initial phase of treatment if the member is at significant risk for decompensation that would result in a need for a higher level of care therapy more frequently than once per week may be appropriate. b. Active treatment: Once stabilized, once a week individual therapy to address the specific problems outlined in the treatment plan is appropriate. c. Discontinuation treatment: Once the problems identified in the treatment plan have been resolved and/or further treatment is not expected to result in any further significant reduction in behavioral disturbance or functioning, transition to community based services is appropriate. To maintain progress and/or minimize the risk of relapse, every other week therapy for several months followed by monthly therapy for several months is appropriate. 2) Members receiving medications a. Crisis Management: When members are at high risk for hospitalization medication management more frequently than once per week is appropriate. Included in this category would be members with acute psychosis, acute mania, severe depression with suicidal ideation or those in need of medical manage detoxification. b. Active Treatment: Once the possibility of hospitalization has been resolved the frequency of visits should range from once a week to once a month depending on the speed of response to a given class of medication. Weekly visits for members receiving stimulants, antipsychotics or anxiolytics may be necessary. Monthly visits for members receiving antidepressants are appropriate. c. Maintenance Treatment: Members receiving medications on a maintenance basis should be seen once every 3 to 6 months. DISCHARGE CRITERIA: Confidential and Proprietary 2014 MHNet Behavioral Health

Termination or interruption of outpatient care is appropriate under the following conditions: a) Goals of the plan of care have been attained. b) Patient is capable of functioning in community without professional help. c) Patient has proven uncooperative and further care is unlikely to be productive. d) Lack of progress has been documented and further care is not likely to result in additional meaningful reduction in symptoms of behavioral disturbance or improvement in functioning. e) Patient has discontinued attending therapy as scheduled. f) Patient terminated against clinical advice. g) The patient s condition deteriorates and they are admitted to a higher level of care. Confidential and Proprietary 2014 MHNet Behavioral Health

IN-HOME SERVICES ADMISSION CRITERIA: Admission to In-Home services must be based on the following Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and by Intensity of Services appropriate to this level of care. GLOBAL INDICATORS: 1. Patient presents with at least one valid DSM-5 diagnosis, and 2. Patient meets criteria for outpatient services but is physically or psychologically unable to attend programming without extraordinary assistance (i.e., ambulance service) and, patient is not in an institutional or residential setting, and patient s condition must be directly attributable to the designated mental disorder and not to a pervasive pattern of antisocial conduct, and 3. The patients psychiatric or physical condition precludes alternative treatment settings, and 4. Professional intervention is considered likely to be effective and is essential to contain risks presented and provide for improvement. SEVERITY OF ILLNESS: An objective professional evaluation of the patient s current condition indicates a level of severity appropriate to the services provided through In-Home treatment as evidenced by the following: Impairment in Safety: Patient presents minimal or manageable risk to self or others. Management of presenting symptoms can be successfully accomplished through outpatient services. Impairment in Self Care: Patient or legal custodian is able to meet daily self care needs but requires assistance and intervention in order to function successfully in the home setting. Compliance with medications is uncertain; In-Home services may facilitate the monitoring of compliance and prevent unnecessary hospitalizations. Impairment in Reality Construction: Patient has an adequate grasp of reality and has the capacity to contain risks without more restrictive interventions. Confidential and Proprietary 2014 MHNet Behavioral Health

Impairment in Social Functioning: There may be substantial social and environmental factors that contribute to impaired functioning. Complicating Conditions: Health problems may prevent the patient from participating in traditional, in-office treatment. In-home therapy presents the opportunity for therapy to be provided. There may also be strong suspicion that the home environment is contributing substantially to the mental disorder and without evaluating and intervening in the home setting, treatment success is unlikely. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further justification, the patient presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: Patient has adequate age-appropriate coping skills to contribute to treatment success through active participation and the ability to complete assigned tasks between sessions. The patient and family may require assistance in identifying available resources. Compliance with treatment, especially as it relates to medications, is questionable. Limited Social Resources: Patient has adequate family and/or social support to provide the successful context for In-Home interventions. The participation of family members or legal custodian(s) is essential for In-Home services to be successful. INTENSITY OF SERVICE ELEMENTS: Within In-Home care, the patient should be receiving all of the following services as further justification of the admission: 1. An individualized treatment plan with specific goals and attendant plans for intervention. 2. Plans include interventions appropriate to crises were they to occur (e.g., 24 hour call capacity). 3. Frequency and duration of contact appropriate to the plan of care (e.g., weekly or monthly). 4. Patient strengths recognized and mobilized in service of obtaining the goals of care. 5. There are circumstances that justify In-Home as opposed to in-office visits as the most efficient and appropriate method of delivering services (e.g., physical conditions that make leaving the home difficult). CONTINUED STAY CRITERIA: Confidential and Proprietary 2014 MHNet Behavioral Health

In order to justify receiving In-Home care the patient must continue to manifest symptoms justifying the principal DSM-5 diagnosis and one or more of the following: 1. Additional sessions are required to achieve final goals. Frequency of sessions is appropriate to the severity of symptoms and is adjusted appropriately as symptoms subside and the patient is able to function in an increasingly functional manner. 2. Patient and family strengths are recognized and mobilized in service of obtaining the goals of care. Progress is being demonstrated and benefit is being derived from treatment interventions, education, and other services. 3. Changes in the home environment have led to justifiable modifications in the plan of care. 4. The circumstances that justified In-Home as opposed to in-office visits continue to be relevant to the continued delivery of services. DISCHARGE CRITERIA: Termination or interruption of In-Home services is appropriate under the following conditions: a) Goals of the plan of care have been attained. b) Patient/legal custodian have been uncooperative and further care is unlikely to be productive. c) Lack of progress has been documented and further care is not deemed appropriate. d) The circumstances leading to In-Home services have subsided, allowing the patient and family to participate in in-office or other forms of treatment as needed. e) Patient or patient s legal guardian has terminated treatment. f) Substantial noncompliance has been documented. g) The patient s condition deteriorates and they are admitted to a higher level of care. Confidential and Proprietary 2014 MHNet Behavioral Health

TARGETED CASE MANAGEMENT SERVICES PURPOSE: Targeted case management is designed to coordinate the care of individuals with a serious and persistent mental illness who are receiving services from multiple providers and/or institutions. ADMISSION CRITERIA: Authorization of Targeted Case Management must be based on the following Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and an Intensity of Service appropriate to the objectives of Targeted Case Management. GLOBAL INDICATORS: 1. Patient presents with at least one valid DSM-5 diagnosis, other than Neurodevelopmental Disorders, Elimination Disorders, or Neurocognitive Disorders without behavioral disturbances, and 2. Patient s condition must be directly attributable to the designated mental disorder and not to Antisocial Personality or be a part of a pervasive pattern of antisocial conduct. SPECIFIC CIRCUMSTANCES THAT MAY REQUIRE TARGETED CASE MANAGEMENT: The following situations are frequently found to benefit from Targeted Case Management: 1. Pregnant patients whose pregnancy is at risk if their Axis I illness is not controlled. 2. Patients with a history of multiple recent inpatient admissions who are at high risk for readmission. 3. Patients with multiple recent episodes of ambulatory care who are likely to deteriorate and require a higher level of care. 4. Children or adolescents with a mental illness problem who are victims of abuse or neglect. 5. Recently discharged patients who require intensive community/social support in order to prevent deterioration and readmission.

6. Patients who have recently made a severe, life-threatening suicide attempt. 7. Patients who have been recently hospitalized who have a past history of noncompliance with outpatient care and/or patients whose guardians have been unsupportive of outpatient care. 8. Patients with multiple complicating factors (medical, social, financial) that require ongoing assistance in order to avoid deterioration and higher levels of care. SEVERITY OF ILLNESS: An objective professional evaluation of the patient s current condition indicates a level of severity appropriate to Targeted Case Management services as evidenced by one or more of the following: Impairment in Safety: Patient presents levels of risk to self and/or others that can be adequately managed in the home environment and outpatient setting. Impairment in Self Care: Patient can provide for self care or has the age-appropriate assistance in maintaining self care. Impairment in Reality Construction: Patient has adequate grasp of reality and demonstrates capacity for judgment to contain risks outside of a hospital or other structured setting. Impairment in Social Functioning: Impairment is not so substantial as to require a more restricted setting than what is available in the home environment. Complicating Factors: Multiple agencies and service delivery systems are frequently involved in the care of the patient. Impaired family functioning may contribute substantially to the mental illness/substance abuse of the identified patient. LIMITATION IN PERSONAL AND/OR SOCIAL RESOURCES: Personal Resources: Patient has adequate age-appropriate coping skills to contribute to treatment success through active participation and the ability to complete assigned tasks between sessions. The family or legal custodian requires help in effectively intervening on the pathological behaviors of the patient. The patient and family may require assistance in identifying available resources. In many instances, the appropriate recipient of Targeted Case Management services is one who is at high risk for repeated hospitalizations and who has multiple agencies involved in care. Social Resources: Patient has adequate family and/or social support to provide the successful context for Targeted Case Management services. The participation of family

members or legal custodian(s) is essential for Targeted Case Management services to be successful. INTENSITY OF SERVICE ELEMENTS: When Targeted Case Management is being provided, treatment should include the following services as further justification for continued care: 1. An individualized treatment plan with specific goals and attendant plans for interventions. The treatment plan includes the active participation and involvement of the family/legal custodian and identifies collaborative agencies and their roles in the comprehensive treatment of the patient. 2. Symptoms described correspond to the diagnosis and meet criteria as specified in the DSM-5. 3. Plans include interventions appropriate to crises as they occur (e.g., 24 hour call capacity). 4. Frequency and duration of contact are appropriate to the plan of care. 5. Multiple agencies are involved in delivering services. Coordination of services will help minimize redundancy as well as ensure a cohesive and efficient treatment planning approach. CONTINUED STAY CRITERIA: In order to justify continued Targeted Case Management services, the patient must continue to manifest symptoms justifying the principal DSM-5 diagnosis and one of the following: 1. The patient continues to obtain services from multiple agencies such that the coordination of such care is determined to be essential for the positive outcome of treatment. 2. The patient remains at high risk for multiple hospitalizations or other forms of intensive treatment. Targeted Case Management has reduced the risks associated with high utilization of treatment provided in restricted environments. 3. The patient and family is compliant with treatment and progress is being made in achieving treatment plan goals.

DISCHARGE CRITERIA: Termination or interruption of Targeted Case Management is appropriate under the following conditions: a) The patient s condition has improved to the point that treatment can proceed within the scope of traditional outpatient services. b) The patient and/or family are uncooperative with treatment and further progress seems unlikely. c) Progress as documented in the record does not justify continuation at this level of care. d) Another agency assumes responsibility for the care of the patient. e) Patient discharges AMA.

ASSERTIVE COMMUNITY TREATMENT (ACT) Assertive community treatment is a program for assisting seriously mentally ill individuals who are experiencing significant difficulties in essential functioning. Examples including an inability to attend to activities of daily living, inability to obtain food or shelter, repeated psychiatric hospitalizations, intractable severe symptoms such as suicidality, concomitant substance abuse and repeated involvement with the criminal justice system ACT involves the creation of a multidisciplinary team with 24 hour availability that can proactively intervene with their clients and thereby maintain and improve their level of functioning. There are numerous requirements that define ACT teams and their function: Each team includes a team leader, a psychiatrist, a registered nurse, a master s level counselor, a substance abuse specialist, a peer counselor along with behavioral health specialists. There should be at least one staff person for every 10 clients Seventy five percent or more of services are to be provided outside of the ACT team offices. An ACT team member must be available 24 hours a day to perform community interventions Each client must have a comprehensive history performed by appropriate specialists that covers: o Psychiatric history, mental status and diagnoses o Physical Health o Drug and alcohol use o Education and employment o Social development and functioning o Activities of daily living o Family structure and function Every client must have an individualized treatment plan based on the above assessment that addresses: o Service coordination o Crisis intervention o Symptom assessment and management o Medication management o Substance problems o Medical problems o Work related problems o Activities of daily living problems o Social/interpersonal; and family problems o Leisure and recreational problems o Educational problems Confidential and Proprietary Page 1 of 3 2014 MHNet Behavioral Health

ADMISSION CRITERIA: Eligible members must be diagnosed with a serious and persistent mental illness that causes significant impairment in functioning as evidence by frequent hospitalizations, inability to meet basic needs, concomitant substance abuse, dangerous behavior or repeated contact with the criminal justice system. Clients are frequently homeless, non-compliant with outpatient treatment and dually diagnosed. GLOBAL INDICATORS: 1) A valid DSM-5 diagnosis that is subsumed under seriously and persistently mentally ill. 2) Demonstrated inability to function independently or demonstrated inability to maintain independent functioning without support 3) Ability to participate and benefit from ACT team interventions. SEVERITY OF ILLNESS: The member must have historical evidence of behavioral dysfunction that resulted in marked impairment as evidenced by repeated psychiatric hospitalizations, inability to perform activities of daily living, chronic substance abuse, homelessness, treatment non-compliance and/or repeated contacts with the criminal justice system. LIMITATIONS IN PERSONAL/SOCIAL RESOURCES: There is a demonstrated lack of resources sufficient to sustain the member in the community without ongoing ACT team intervention. INTENSITY OF SERVICES:. 1. Twenty four hour availability of an ACT team member. 2. Regular ACT team meetings to review and update the treatment plan. 3. A designated team leader and a designated case manager to assure comprehensive coordinated care. 4. Ongoing participation by the essential clinical disciplines CONTINUED STAY CRITERIA: 1. The member is unable to sustain themselves with the aid of basic community services (e.g. enrollment in a community mental health center) 2. The member s skills would deteriorate leading to an inability to sustain themselves in the community without continued ACT team support. Confidential and Proprietary Page 2 of 3 2014 MHNet Behavioral Health

DISCHARGE CRITERIA: 1. The member has achieved all of the goals established by the ACT team and, 2. The member has demonstrated the ability to function in all major roles or 3. The member has relocated outside of the ACT teams area of responsibility, or. 4. The member refuses participation and requests discharge. Ref: www.nami.org National Program Standards for ACT Teams Confidential and Proprietary Page 3 of 3 2014 MHNet Behavioral Health

TWENTY THREE HOUR OBSERVATION BEDS PROGRAM DESCRIPTION: 23 hour observation beds are for children, adolescents and adults in acute psychiatric or substance abuse crisis who require continuous monitoring and nursing care, however are expected to improve to the point where they can be discharged to a lower level of care within 24 hours. Situations that may be suitable for 23 observation include: 1. Individuals who are in acute distress following a sudden unexpected loss or trauma. 2. Individuals who ve become acutely psychotic and are known to respond rapidly to medications. 3. Acutely intoxicated individuals who present an imminent danger to themselves or other and are not likely to require detoxification but who are expected to be safely discharged once sober. 4. Individuals in crisis who need extra time to fully evaluate and/or stabilize their situation (i.e. individuals where there is a need for collateral information to complete the assessment or there is a need to finalize a safe aftercare plan). ADMISSION CRITERIA: Admission to a 23 hour must be based on the following: Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and by Intensity of Services appropriate to this level of care. GLOBAL INDICATORS: 1. Patient presents at least one valid DSM-5 diagnosis, and 2. Patient's condition must be directly attributable to the designated mental disorder or substance abuse and not to Antisocial Personality or be a part of a pervasive pattern of antisocial conduct, and 3. Treatment at a lower level of care is not possible because the individual requires constant observation and continuous nursing care to protect their safety and/or the safety of others, and 4. Professional intervention is considered likely to stabilize the patient to the point where they can be discharged to outpatient treatment within 24 hours. Confidential and Proprietary Page 1 of 3 2014 MHNet Behavioral Health

SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current condition indicates a level of severity appropriate to a 23 hour observation bed as evidenced by one or more of the following: Impairment in Safety: Patient presents an immediate risk of suicide or the patient presents a danger to others through assaultive or homicidal behavior. Impairment in Self Care: Patient presents a temporary and reversible inability to perform personal hygiene and bodily care activities of daily living and there are attendant risks to that person's safety and well being. Impairment in Reality Construction: Patient presents psychotic symptoms that must be controlled to prevent immediate risks to the patient or others. Impairment in Social Functioning: Patient presents severely disruptive behavior that violates established social norms and/or violates the rights of others. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further justification, the patient presents, with significant limitations in resources, to resolve presenting problems as indicated by: Limited Personal Resources: Patient does not currently have the cognitive and/or emotional coping skills to reduce risks presented. Limited Social Resources: Patient does not have adequate social support from family and/or friends to reduce risks presented. Exclusion - Limitations in personal or social resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: The patient should receive the all of the following services to justify admission to this level of care: 1. A comprehensive, psychiatric assessment and treatment plan including a discharge plan that can be effected within 24 hours. 2. Close supervision and observation aimed at rapid stabilization through medication administration, and social service intervention. Confidential and Proprietary Page 2 of 3 2014 MHNet Behavioral Health

3. Observation and control measures (e.g., isolation or restraint) appropriate to risks are immediately available. 4. Continuous monitoring with nursing supervision. 5. Immediate availability of a physician either in person or telephonically DISCHARGE CRITERIA: The patient must be discharged within 24 hours. They are considered ready for discharge when they satisfy any of the following criteria: a) They stabilize to the point where they can be safely treated in an outpatient setting and aftercare plans are in place. b) The patient leaves against medical advice (AMA). c) The patient fails to respond to intensive interventions and requires admission to an inpatient or residential level of care. Confidential and Proprietary Page 3 of 3 2014 MHNet Behavioral Health

METHADONE MAINTAINENCE PROGRAM DESCRIPTION: Methadone for the purposes of maintaining abstinence in opiate addicted individuals can only be dispensed by Federally certified methadone treatment programs. These programs must meet Federal standards for staffing, treatment programs, monitoring, record keeping and quality improvement. ADMISSION CRITERIA: Individuals eligible for admission must have a diagnosis of opiate dependence and must have at least one year of opiate use. For individuals under the age of 18, there must be documented evidence of at least 2 failures to maintain abstinence post detoxification. GLOBAL INDICATORS: 1. The member has been diagnosed as suffering from opiate dependence. 2. Reasonable attempts to maintain abstinence have been unsuccessful. 3. Their use of opiates is not due to a chronic pain situation that should be addressed by a pain management specialist. 4. The member is in a stable living environment with a reasonable expectation that they can comply with the terms of treatment (attendance 6 days/week initially). SEVERITY OF ILLNESS An objective professional evaluation of the member s current condition indicates a level of severity that requires continuous monitoring by a caregiver. Impairment in Safety: The individual is at high risk to relapse to opiates. Impairment in Self Care: The individual is capable of obtaining all necessary care with available resources. Impairment in Reality Construction: Any impairment is not so severe as to preclude participation in all aspects of the program. Impairment in Social Functioning: Not applicable. Complicating Conditions: There are no other complicating conditions that preclude benefit from treatment. Confidential and Proprietary 2014 MHNet Behavioral Health

LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further evidence for acute care, the patient presents with sufficient resources to fully participate in the program as indicated by: Limited Personal Resources: Patient has the coping skills sufficient to comply with daily requirements of the program,. Limited Social Resources: Patient has the family, social support and finances needed to fully participate. Exclusions: None INTENSITY OF SERVICE ELEMENTS: The frequency and intensity of service will decrease over time as the individual demonstrates continued abstinence. 1. There must be an initial comprehensive medical, psychological, social and substance abuse evaluation including appropriate medical testing. 2. There must be an initial individualized treatment plan that includes short and long term goals that address any medical, psychological, substance abuse issues, educational, vocational, economic and legal issues. 3. There must be ongoing individual and group counseling related to substance abuse including progression, consequences and relapse prevention. 4. During the induction phase individuals must be evaluated on a daily basis for symptoms of over or under medication. The initial starting dose of methadone should not exceed 40 mg. 5. During the rehabilitation phase the individual participates in regular counseling, has periodic urine drug testing and may have additional dosage adjustments. 6. During the initial 90 days of treatment the individual must attend the program 6 days a week to obtain methadone. 7. During the second 90 days the individual must attend the program 5 days a week to obtain methadone. 8. For the remainder of the first year the individual must attend the program at least once a week. Thereafter, if there have been no relapses, they need to attend the program at least once a month. 9. Urine drug screening is required while the individual remains in treatment. Specific drugs to be screened for should be based on the individual s history and prevailing community drug abuse patterns. There should also be routine screening for alcohol use. During the induction phase urine testing should occur several times a week. Thereafter the frequency should be adjusted according to the individuals risk of relapse. Confidential and Proprietary 2014 MHNet Behavioral Health

10. There must be periodic re-evaluations and updates to the treatment plan every time there has been a significant change in the individual s situation. CONTINUED STAY CRITERIA: Continued stay is contingent on active participation in substance abuse rehabilitation and compliance with attendance requirements. DISCHARGE CRITERIA: 1. The individual has been successfully weaned off methadone. 2. The individual does not comply with the program requirements. 3. The individual has multiple relapses despite receiving methadone. REFERENCES: SAMHSA: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs SAMHSA: Guideline for the Accreditation of Opioid Treatment Programs Confidential and Proprietary 2014 MHNet Behavioral Health

EATING DISORDER SERVICES INTRODUCTION: There are four separate and distinct DSM-5 eating disorders, Anorexia Nervosa, Bulemia Nervosa, Binge Eating Disorder and Avoidant/Restrictive Food Intake Disorder. Anorexia nervosa is potentially life-threatening and requires an aggressive multidisciplinary approach. The other three conditions can be mild to severe. Invariably they can be treated with outpatient cognitive behavioral treatment supplemented with supportive group therapy and possibly medications. There are numerous residential treatment settings to help people develop healthy eating habits catering to individuals with obesity as well as Bulimia Nervosa. They are not considered to be medically based treatment facilities; and therefore, would not qualify for reimbursement under health insurance. Treatment of eating disorders requires therapists with specialized training. The treatment of Anorexia Nervosa requires a multi-disciplinary treatment approach. Treatment settings include inpatient, partial, IOP and outpatient. In the absence of a co-morbid condition, all other eating disorders can be treated with individual and group outpatient therapy. Therefore, Medical Necessity Criteria for psychiatric disorders can be applied to these conditions as long as the therapist has specialty training in the treatment of eating disorders. ANOREXIA NERVOSA DIAGNOSIS AND CARDINAL FEATURES: 1. Excessive thinness (15% below ideal body weight). 2. Distorted body image (experiences oneself as overweight). 3. Intense fear of gaining weight or becoming obese. 4. Weight control through restricting (doesn t eat), exercise (burning off calories) and/or purging (inducing vomiting or diarrhea). TREATMENT GOALS: 1. Stop weight loss. 2. Facilitate gradual return to normal body weight. 3. Retrain to healthy eating habits. 4. Avoid relapse. TREATMENT APPROACH:

The effective treatment of Anorexia Nervosa mandates a coordinated interdisciplinary approach. Effective treatment must include all of the following: 1. An internist/pediatrician to address medical concerns 2. A dietician to establish a healthy diet. 3. Individual and family therapy. 4. A psychiatrist to address co-morbid conditions (e.g., depression) and possible use of medications. TREATMENT CRITERIA FOR ANOREXIA NERVOSA: Admission to all levels of care for Anorexia Nervosa must be based on the following Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources. GLOBAL INDICATORS: 1. Patient meets DSM-5 criteria for Anorexia Nervosa, and 2. Specialized intervention is considered likely to be effective and is essential to contain risks presented and provide for improvement. SEVERITY OF ILLNESS: The level of care provided is dependent on an assessment of patient risk (need for safety) and the patient s personal resources. Impairment in Safety: The patient should be managed at the lowest level of care where safety can be managed. In the absence of a co-morbid condition, safety, is defined as the ability to maintain and/or increase weight. Impairment in Self-Care: The patient should be managed at the lowest level of care where the patient can be reasonably expected to be able to participate. Impairment in Reality Construction: Impairment in reality construction (excluding distorted body image), in the absence of a co-morbid condition, generally indicates severe medical compromise and the need for inpatient or partial hospitalization. The patient must be sufficiently intact to benefit from individual and group therapy once the acute medical condition is resolved. Limited Personal Resources: Lack of personal resources may require a higher level of care on a short-term basis to stabilize the patient s living situation. Otherwise it is not generally a factor in level of care decisions.

Limited Social Resources: Lack of social resources in and of itself does not impact level of care decisions except as noted above. SERVICE ELEMENTS FOR EACH LEVEL OF CARE: INPATIENT TREATMENT: Inpatient treatment should be conducted on units with specialty programs for eating disorders. The programs must include all of the following: 1. A behavioral approach to developing healthy eating habits with a primary focus on weight gain. 2. Individual, group and family therapy. 3. Daily involvement with a dietician. 4. Daily monitoring by a psychiatrist with specialty knowledge of anorexia nervosa. 5. Comprehensive medical evaluation with ongoing care as needed. PARTIAL HOSPITAL TREATMENT: Partial hospital treatment should be conducted in facilities with specialty programs for eating disorders. The programs must include all of the following: 1. A behavioral approach to developing healthy eating habits with a primary focus on weight gain. 2. At least 5 days/week, 6 hours/day of individual, group and family therapy. 3. Active involvement of the family, if appropriate. 4. Daily involvement with a dietician. 5. Daily contact with a psychiatrist. INTENSIVE OUTPATIENT TREATMENT: Intensive outpatient treatment should be conducted in facilities with specialty programs for eating disorders. The programs must include all of the following: 1. A behavioral approach to developing healthy eating habits with a primary focus on weight gain. 2. At least 3 days/week, 3 hours/day of individual, group and family therapy. 3. Active involvement of the family, if appropriate.

4. Participation in community based support groups. 5. Availability of a dietician every day. 6. Availability of a psychiatrist every day. OUTPATIENT TREATMENT: Outpatient treatment must include all of the following: 1. A behavioral approach to developing healthy eating habits with a primary focus on weight gain or maintenance. 2. Active involvement of the family. 3. Continuing involvement with a dietician. 4. Participation in community based support groups. 5. Continued monitoring by an internist/pediatrician. 6. Continued monitoring by a psychiatrist, if appropriate. CONTINUED STAY CRITERIA (all of the criteria must be met): INPATIENT AND PARTIAL HOSPITALIZATION: 1. Gaining weight at the rate of 1-3 lbs. /week. 2. Active participation in treatment, including family/significant others. 3. Inability to transition to a lower level of care due to an inability to sustain gains in a less intensive setting. INTENSIVE OUTPATIENT: 1. Gaining and/or maintaining weight. 2. Active participation in treatment including family/significant others. 3. Inability to transition to a lower level of care due to an inability to sustain gains in a less restrictive setting. OUTPATIENT: 1. Maintaining weight 2. Active participation with treatment recommendations. 3. Need for additional stabilization before transitioning to community support.

DISCHARGE PLANNING: 1. Since Anorexia Nervosa is a chronic, relapsing condition, discharge planning is directed towards educating the patient and family about signs and symptoms of relapse. 2. At the earliest sign of aberrant behavior the patient should be referred back to their therapist for brief behaviorally oriented refresher therapy. DISCHARGE CRITERIA: Patients should be discharged when: a) They have achieved treatment goals and are transitioned to community care. b) They have failed to make significant gains following 2 weeks of inpatient, partial or intensive outpatient treatment, or 4 weeks of outpatient treatment. c) They leave AMA. d) Their condition deteriorates and they are admitted to a higher level of care.

PARTIAL HOSPITALIZATION / DAY SERVICES- AUTISM SPECTRUM DISORDERS PROGRAM DEFINITION: This level of care is intended to be an alternative to Acute Psychiatric Inpatient treatment for individuals who need intensive treatment but do not need 24 hour professional monitoring and therefore can continue to reside outside of the treatment facility. The level of acuity of patients symptoms, intensity of services and length of stay guidelines should all be similar to those of Acute Psychiatric Inpatient treatment. To qualify as a Partial Hospitalization / Day Treatment program, the patient must receive six to eight hours per day of individual and group therapy. The patient must participate in such a structured program at least three days per week. ADMISSION CRITERIA: 1. Patient has the cognitive ability to understand and process in both individual and group/family therapy modalities. 2. Patient has the emotional stability to actively participate in both individual and group/family therapies. 3. Patient has the capacity to develop and implement skills and strategies that will enable them to function more independently. 4. Patient has some limitation(s) within their social support systems. GLOBAL INDICATORS: 1. The patient has been diagnosed with an Autism Spectrum Disorder as evidenced by an evaluation by a pediatrician, neurologist, child psychiatrist or psychologist/master s level counselor specializing in ASD s to exclude other conditions that may mimic ASDs and to confirm the diagnosis of an ASD. 2. The patient has one or more specified behavioral disturbances that is/are amendable to short term intervention and/or require(s) ongoing treatment to prevent deterioration.

3. Professional intervention is considered likely to be effective and is essential to improvement and prevention of regression or deterioration. 4. Alternative levels and locations of care, such as outpatient care have been attempted or seriously considered and rejected as clinically insufficient to meet the patient s needs. SEVERITY OF ILLNESS: An objective, professional evaluation of the patient s current condition indicates an acute level of severity appropriate to partial hospitalization as evidenced by the following: Impairment in Safety: Patient may be experiencing behavior that is harmful to self or others. Patient may not be able to contract for safety, but must have a social support system in place when outside of the Day Treatment / Partial Hospital setting. Clinical evidence indicates that a less intensive outpatient setting is not appropriate. Impairment in Self-Care: Patient may be experiencing noticeable impairment in ADLs when compared to baseline functioning (i.e., previously established patterns of personal hygiene, dressing, eating, toileting). Patient may be experiencing significant impairment in their eating and/or sleeping patterns. Impairment in Reality Construction: The patient may experience disturbances in their thought processes, but possesses the cognitive ability to distinguish between those and reality. Impairment in Social Functioning: This level of care is considered appropriate for patients who are unable to function in unmonitored social/occupational settings. Patient s acute symptoms may disable them from fulfilling age appropriate social/educational/occupational roles and responsibilities. The patient may be exhibiting/verbalizing a noticeable decrease (from baseline measures) in personal interactions. Patient can benefit from continuing involvement with family/social support systems. Complicating Conditions: This level of care is appropriate for patients with a demonstrated need for intensive pharmacological intervention. Biomedical complications are minimal or manageable within the Partial Hospitalization/Day Treatment setting, coexisting psychological problems (e.g., depression) will not significantly interfere with partial hospital care and complications from pharmacological intervention are considered manageable.

Exclusion Unless medically necessary, court-ordered treatment is considered an exclusion. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: Patient presents with limitations in resources to resolve presenting problems as indicated by: Limited Social Resources: Patient has adequate social support system, including a suitable environment outside of the program to provide context for successful partial hospital treatment. The patient s family must be willing and available to assist the patient outside of the Partial Hospital / Day Treatment setting, and within the Partial Hospital / Day Treatment setting when clinically indicated. Patient has a system of social support able to provide for whatever transportation needs are required by the program. Exclusion - 1. Limitations in resources, in and of themselves, are not sufficient justification for admission. 2. In the child/adolescent population, the need for an alternative academic setting in and of itself is not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within the Partial Hospitalization / Day Treatment Program, the patient should be receiving all of the following services as further justification of the admission: 1. A comprehensive evaluation must be completed within four service days of admission. This evaluation must include an initial treatment plan, tentative discharge plan, and a comprehensive family assessment. 2. The provision of services to meet the patient s individualized academic needs. 3. A comprehensive individualized treatment plan with specific goals and intervention plans will be formed. Such treatment plan: a. Identifies specific behaviors that will be addressed along with record keeping that indicates progress towards reducing the frequency of problem behaviors b. Defines the frequency of individual and family sessions. c. Delineates all individuals who will be providing care along with their responsibilities. d. Medication trials, if included, must specify behavioral goals that can demonstrate efficacy. e. Demonstrates oversight by an MHNet approved treatment provider (psychiatrist, psychologist or master s level provider). 4. A structured activity schedule with focused individual, family, and group therapy.

5. Plan exists for management of crisis episodes if they were to occur. 6. Linkages with appropriate support groups (e.g., Autism Speaks, TACA, or USAAA). 7. A psychiatrist must be available as appropriate, providing ongoing medication monitoring and adjustment as needed. 8. Family involvement within the Partial Hospital / Day Treatment setting, including family therapy, to provide training for procedure implementation in the home. Parent(s) should be able to implement behavioral training procedures with a minimum of 80% accuracy. Family therapy should occur weekly after the initial treatment plan is developed, unless frequent family involvement would result in clinical exacerbation of the patient s psychiatric illness. CONTINUED STAY CRITERIA: In order to justify remaining in a partial hospitalization program, the patient must continue to manifest all of the following related to the principal DSM-5 diagnosis: 1. Admission criteria must be met. 2. Clinical documentation reflects the patient s active progress toward treatment goals. 3. Clinical documentation supports justification that a less restrictive level of care would result in exacerbation of the patient s psychiatric illness. 4. Family involvement is appropriate to the goal of sustaining the progress that is being made. 5. Family is actively participating in aftercare planning. DISCHARGE CRITERIA: The patient is ready for discharge when they satisfy any of the following criteria: (a) Completes the treatment plan. (b) Impairment in functioning can be managed with ongoing outpatient treatment. (c) Patient leaves AMA. (d) Patient or family refuses treatment and/or the problems that prompted admission are found not to be amenable to acute treatment. (e) The patient s condition deteriorates and they are admitted to a higher level of care.

INTENSIVE OUTPATIENT SERVICES-AUTISM SPECTRUM DISORDERS PROGRAM DEFINITION: To qualify as an intensive outpatient program the patient must receive at least 3 to 4 hours per day of individual and/or group therapy. The patient must participate in treatment at least three days per week. ADMISSION CRITERIA: 1. Patient has the cognitive ability to understand and process in both individual and group/family therapy modalities. 2. Patient has the emotional stability to actively participate in both individual and group/family therapies. 3. Patient has the capacity to develop and implement skills and strategies that will enable them to function more independently. 4. Patient has some limitation(s) within their social support systems. Limitations in resources, in and of themselves, are not a basis for treatment. Court ordered, non-medically necessary treatment is also not a basis for treatment. GLOBAL INDICATORS: 1. The patient has been diagnosed with an Autism Spectrum Disorder as evidenced by an evaluation by a pediatrician, neurologist, child psychiatrist or psychologist/master s level counselor specializing in ASDs to exclude other conditions that may mimic ASDs and to confirm the diagnosis of ASD. 2. The patient has one or more specified behavioral disturbances that is/are amendable to short term intervention and/or require(s) ongoing treatment to prevent deterioration. 3. Professional intervention is considered likely to be effective and is essential to patient s improvement and prevention of regression or deterioration. 4. Alternative levels and locations of care, such as intensive outpatient treatment have been deemed to place patient at significant risk for deterioration, injury or permanent disability.

SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current condition indicates a level of severity appropriate to IOP as evidenced by the following: Impairment in Safety: The patient can be safely managed in an IOP setting. Impairment in Self Care: The patient may be experiencing noticeable impairment in ADLs compared to baseline (i.e., previously established patterns of personal hygiene, dressing, eating, toileting). Patient may be experiencing significant disturbances in their eating and/or sleeping patterns. Impairment in Reality Construction: The patient may experience disturbances in their thought processes, but possesses the cognitive ability to distinguish between those and reality. Impairment in Social Functioning: The patient may be exhibiting/verbalizing a noticeable decrease (from baseline measures) in personal interactions. Patient may be displaying some signs of anhedonia. Patient may be experiencing difficulty fulfilling age appropriate roles and responsibilities (i.e., educational tasks, chores). Social and occupational functioning is at a level that will permit success of an IOP program. Patient will benefit from continuing involvement with family/significant others and at work during treatment. Complicating Conditions: Physiological complications are minimal, and any coexisting psychological problems (e.g., depression) will not significantly interfere with IOP services. Care and complications from pharmacological intervention are considered manageable. INTENSITY OF SERVICE ELEMENTS: Within IOP, the patient should be receiving all of the following services as further justification of the admission: 1. A comprehensive evaluation must be completed and documented within four service days of admission. This evaluation must include an initial treatment plan, a tentative discharge plan, and a family assessment. 2. A comprehensive individualized treatment plan with specific goals and intervention plans will be developed. Such treatment plan: a. Identifies specific behaviors that will be addressed along with record keeping that indicates progress towards reducing the frequency of problem behaviors. b. Defines the frequency of individual and family sessions.

c. Delineates all individuals who will be providing care along with their responsibilities. d. Medication trials, if included, must specify behavioral goals that can demonstrate efficacy. e. Demonstrates oversight by an MHNet approved treatment provider(psychiatrist, psychologist or master s level counselor). 3. A structured activity schedule with focused individual, family, and group therapy. 4. Plan exists for management of crisis episodes if they were to occur. 5. Linkages with appropriate support groups if applicable (e.g., Autism Speaks, TACA, or USAAA). 6. An independently certified behavioral health professional must be available every day of treatment providing daily supervision of care. 7. A Psychologist or Board Certified Behavior Analyst will oversee the program and be involved in the development of individual treatment plans. CONTINUED STAY CRITERIA: In order to justify remaining in an IOP program, the patient must continue to manifest symptoms justifying the principal DSM-5 diagnosis and all of the following: 1. Adequate progress is taking place, goals are being approximated and longer stay is essential to achieve goals. 2. Patient is being stabilized and maintained in a way that avoids hospitalization. 3. Patient is cooperating with caregivers and actively involved in care as evidenced by documentation of participation and attendance. 4. Family involvement is appropriate to the goal of sustaining the progress that is being made. 5. Aftercare planning is taking place and the patient and family are involved in those plans. 6. Patient has consistent attendance. DISCHARGE CRITERIA: The patient is ready for discharge when they satisfy any of the following criteria: a) Completes the treatment plan. b) Impairment in functioning can be managed with ongoing outpatient treatment. c) Patient leaves AMA. d) The patient s condition deteriorates and they are admitted to a higher level of care.

e) Patient or family refuses treatment, and/or the problems that prompted admission are found to be refractory or chronic. f) Patient does not have consistent pattern of compliance with attendance prescribed in the treatment plan.

OUTPATIENT SERVICES AUTISM SPECTRUM DISORDER ADMISSION CRITERIA: 1. Patient has the cognitive ability to understand and process in either individual or family/group therapy modalities. 2. Patient has the emotional stability to actively participate in either individual or family/group therapies. 3. Patient has the capacity to develop and implement skills and strategies that will enable them to function more independently. 4. Patient has some limitation(s) within their social support systems. Exclusion: Court ordered treatment, in the absence of symptoms that meet medical necessity criteria for treatment, is not a covered benefit. GLOBAL INDICATORS: 1. The patient has been diagnosed with an Autism Spectrum Disorder as evidenced by an evaluation by a pediatrician, neurologist, child psychiatrist or a psychologist/ Master s level counselor specializing in ASDs to exclude other conditions that may mimic ASDs and to confirm the diagnosis of ASD. 2. The patient has one or more specified behavioral disturbances that is/are amendable to short term intervention and/or require(s) ongoing treatment to prevent deterioration. 3. Professional intervention is considered likely to be effective and is essential to patient improvement and prevention of regression or deterioration. SEVERITY OF ILLNESS An objective professional evaluation of the patient s current condition indicates a level of severity appropriate to outpatient services as evidenced by one or more of the following: Impairment in Reality Construction: Any impairment is not of sufficient magnitude to preclude active participation and benefit from the program. Impairment in Safety: Patient presents levels of risk to self and others that can be adequately managed in an outpatient setting.

Impairment in Self Care: Patient has an adequate support system to assure that any limitations in self-care will be addressed. Impairment in Social Functioning: Impairment in interpersonal functioning is not sufficient to preclude benefit from treatment. Complicating Conditions: There are no other complicating conditions that preclude benefit from treatment. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: By definition, patients with autism spectrum disorders often lack the personal and social resources necessary for recovery. Exclusions: The inability to obtain necessary care, in and of itself, is not sufficient justification for treatment. INTENSITY OF SERVICE ELEMENTS: Within outpatient care the patient should be receiving the all of following services as further justification of the admission: 1. The primary service provider will have specialty training in Autism Spectrum Disorders, and will have the capacity to coordinate care with other health care providers, schools, and social service agencies as needed. 2. Medication evaluation, if necessary, for psychiatric/behavioral symptoms that may or may not be a part of the ASD. 3. Integrated and coordinated services that include family, the school, social service agencies, the pediatrician and all other educational/behavioral/medical treatment providers. 4. A behavioral treatment plan will be developed that addresses specific deficits in behavior, communication and language. 5. This treatment plan: a. Identifies specific behaviors that will be addressed along with record keeping that indicates progress towards reducing the frequency of problem behaviors. b. Defines the frequency of individual and family sessions. c. Delineates all individuals who will be providing care along with their responsibilities. d. Medication trials, if included, must specify behavioral goals that can demonstrate efficacy. e. Demonstrates oversight by an MHNet approved treatment provider (psychiatrist, psychologist or master s level therapist).

CONTINUED STAY CRITERIA: Patients being treated for ASDs will be evaluated for continuing care every three months. Continuing care will be contingent on: 1. Active participation of family/caretakers in the treatment plan. 2. Continuing progress towards achieving behavioral goals or the maintenance of goals that would deteriorate without continuing treatment. 3. Evidence of ongoing coordination of care and integration with the patient s educational program. 4. Updated treatment plans (required every six months) including types and frequency of treatment. 5. Parents must be learning and applying ABA techniques for patient s home environment, with a goal of ability to implement behavioral training procedures with 80% accuracy. DISCHARGE CRITERIA: 1. Behavioral goals have been achieved and there is expectation they will be sustained without continuing treatment. 2. Failure of family/caretakers to participate in treatment. 3. Failure of the MHNet treatment provider to coordinate care with the patient s school and/or other treatment providers. 4. Failure to demonstrate positive response to treatment. 5. The patient s condition deteriorates and they are admitted to a higher level of care.

Neuropsychological and Psychological Testing Page 1 of 12 Close Window Aetna.com Home Help Contact Us Search Go Clinical Policy Bulletin: Neuropsychological and Psychological Testing Number: 0158 Policy History Last Review: 05/03/2013 Effective: 05/16/1997 Next Review: 02/13/2014 Review History Definitions Additional Information Policy Clinical Policy Bulletin Notes Aetna considers neuropsychological testing (NPT) medically necessary when provided to aid in the assessment of cognitive impairment due to medical or psychiatric conditions. Examples of situations for which NPT may be medically necessary include, but are not limited to: Assessment of neurocognitive abilities following traumatic brain injury, stroke, or neurosurgery or relating to a medical diagnosis, such as epilepsy, hydrocephalus or AIDS. Assessment of neurocognitive functions to assist in the development of rehabilitation and/or management strategies for persons with diagnosed neurological disorders. Differential diagnosis between psychogenic and neurogenic syndromes. Monitoring of the progression of cognitive impairment secondary to neurological disorders. Aetna considers neuropsychological (NPT) or psychological testing (PT) medically necessary when needed to enhance psychiatric or psychotherapeutic treatment outcomes after a detailed diagnostic evaluation if: Testing is needed to aid in the differential diagnosis of behavioral or psychiatric conditions when the member's history and symptomatology are not readily attributable to a particular psychiatric diagnosis and the questions to be answered by testing could not be resolved by a psychiatric/diagnostic interview, observation in therapy, or an assessment for level of care at a mental health or substance abuse facility; or Testing is needed to develop treatment recommendations after the member has been tried on various medications and/or psychotherapy, has not progressed in treatment, and continues to be symptomatic. NPT and PT generally are not considered medically necessary for pre-surgical http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 2 of 12 clearance. An evaluation by a psychologist or psychiatrist is sometimes required (for an example, see CPB 0157 - Obesity Surgery). NPT or PT is rarely considered medically necessary for uncomplicated cases of attention deficit disorder with/without hyperactivity (ADHD). However, referral to an outpatient mental health provider or outpatient chemical dependency rehabilitation may be considered medically necessary for the evaluation and comprehensive biopsychosocial treatment for these disorders in collaboration with primary care physicians and other specialists. NPT may be considered medically necessary for neurologically complicated cases of ADHD, (e.g., post head trauma, seizures). NPT or PT beyond standardized parent interviews and direct, structured behavioral observation is rarely considered medically necessary for the diagnosis of pervasive developmental disorders (see CPB 0648 - Pervasive Developmental Disorders). NPT is considered not medically necessary for diagnosis and management of persons with chronic fatigue syndrome. (Note: PT may be medically necessary to differentiate chronic fatigue syndrome from psychiatric diagnoses when criteria for PT are met.) NPT or PT is considered not medically necessary if the member is actively abusing substances, is having acute withdrawal symptoms, or has recently entered recovery, because test results may be invalid. Reimbursement Notes: NPT requested for the evaluation of a mental health diagnosis (e.g., serious psychiatric illness, alcohol and/or drug abuse) is considered for coverage through the mental health benefit. If NPT or PT is requested for evaluation of a medical diagnosis (e.g., traumatic brain injury, stroke, differentiation of brain damage from a depressive disorder, epilepsy, hydrocephalus, Alzheimer's disease, Parkinson disease, multiple sclerosis, or AIDS), it is considered for coverage under the medical benefit. NPT may also be used in evaluating the impact of chronic solvent or heavy metal exposure particularly in the occupational or environmental medicine realm. In these cases, NPT would not be covered under Aetna's medical or mental health benefits, but may be covered by the worker's compensation carrier. NPT or PT for educational reasons is not covered. This testing is usually provided by school systems under applicable state and federal rules. Most benefit plans exclude coverage of educational testing. Please check benefit plan descriptions. In addition, NPT or PT performed for educational reasons is not considered treatment of disease. NPT or PT for employment, disability qualification, or legal/court-related purposes is not covered as it is not considered treatment of disease. Background http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 3 of 12 Psychological tests assess a range of mental abilities and attributes, including achievement and ability, personality, and neurological functioning. Psychological testing, including neuropsychological assessment, utilizes a set of standardized tests, whose validity and reliability have been established empirically. They allow for an assessment of a patient's cognitive and behavioral functioning and an analysis of changes related to mental or physical disease, injury, or abnormal development of the brain. Research has shown that the scores from these tests are reproducible and can be compared to those of normal persons of similar age, sex and demographic background to yield valid conclusions. Psychological and neuropsychological tests provide a standardized means of sampling behavior, an objective method for evaluating responses, and a tool for comparing the functioning of an individual with peers. Standardized tests are administered under uniform conditions, scored objectively -- the procedures for scoring the test are specified in detail -- and designed to measure relative performance. Test results usually are interpreted with reference to a comparable group of people, the standardization, or normative sample. Psychological testing requires a clinically-trained examiner. All psychological tests should be administered, scored, and interpreted by a qualified professional, such as a licensed psychologist or psychiatrist, with expertise in the appropriate area. Psychological tests are only one element of a psychological assessment. They should never be used as the sole basis for a diagnosis. A detailed clinical interview, including a complete history of the test subject and a review of psychological, medical, educational, and other relevant records is required to lay the groundwork for interpreting the results of any psychological measurement. Psychological tests are used to address a variety of questions about people s functioning, diagnostic classification, co-morbidity, and choice of treatment approach. For example, personality tests and inventories evaluate the thoughts, emotions, attitudes, and behavioral traits that contribute to an individual s interpersonal functioning. The results of these tests determine an individual's personality strengths and weaknesses, and may identify certain disturbances in personality, or psychopathology. One type of personality test is the projective personality assessment, which asks a subject to interpret some ambiguous stimuli, such as a series of inkblots. The subject's responses can provide insight into his or her thought processes and personality traits. Neuropsychological testing is a subclassification of psychological testing anda wellestablished method for evaluating patients who demonstrate cognitive or behavioral abnormalities. Neuropsychological testing is used when a differentiation between organic versus functional disorders is needed to direct proper therapy (e.g., occupational, physical, or speech and language therapy), predict neuropsychological recovery, or monitor progress. Neuropsychological tests include: Halsted-Reitan neuropsychological battery or its components; Luria-Nebraska; Wechsler Adult Intelligence Scale (WAIS); Wechsler Intelligence Scales for Children - Revised (WISC-R); Wechsler Memory Scale; and the Reitan-Indiana neuropsychological test. Neuropsychological testing may be necessary for persons with documented http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 4 of 12 neurologic disease or injury (e.g., traumatic brain injury, stroke) when there is uncertainty about the degree of impairment, or when an organic deficit is present but information on anatomic location and extent of dysfunction is required. An organic deficit is defined as a symptomatic manifestation of structural cerebral or systemic medical pathology, as opposed to being considered psychological or emotional in nature (functional). Such testing can also be used to systematically track progress in rehabilitation after brain injury or other neurological disease. Serial assessment in nonprogressive conditions, such as head injury, documents the patient s rate of recovery and potential for returning to work. Neuropsychological testing is used in persons with documented changes in cognitive function to differentiate neurologic diseases (i.e., one of the types of dementia) or injuries (e.g., traumatic brain injury, stroke) from depressive disorders or other psychiatric conditions (e.g., psychosis, schizophrenia) when the diagnosis is uncertain after complete neurological examination, mental status examination, and other neurodiagnostic studies (e.g., CT scanning, MR imaging). The clinician presented with complaints of memory impairment or slowness in thinking in a patient who is depressed or paranoid may be unsure of the possible contribution of neurological changes to the clinical picture. Neuropsychological testing may be particularly helpful when the findings of the neurological examination and ancillary procedures are either negative or equivocal. The differential diagnosis of incipient dementia from depression is a casein point, particularly when computed tomography (CT) fails to yield definitive results. Neuropsychological testing may be indicated in persons with epilepsy or hydrocephalus. Neuropsychological testing is used in these patients to monitor the efficacy and possible cognitive side effects of drug therapy (e.g., new anticonvulsant drug therapy) by comparing baseline performance with subsequent testing performance. Neuropsychological testing is also used to assess postsurgical changes in cognitive functioning to guide further treatment services. Preferably, these tests should be administered by a certified psychologist trained to conceptualize the neuro-anatomical and the neuro-behavioral implications of the diagnostic entities under consideration and who is capable of interpreting patterns of test scores in view of principles of lateralization and localization of cerebral function. Neuropsychological testing is used for initial evaluation of cognitive deterioration associated with acquired immunedeficiency syndrome (AIDS), and for re-evaluation of persons with AIDS who show further deterioration, to distinguish between organicbased deterioration and deterioration from depression of chonic illness, in order to direct appropriate treatment. Neuropsychological testing is also used in the initial evaluation of cognitive deterioration associated with Alzheimer s disease. It is also used for persons diagnosed with Alzheimer s disease receiving medication for dementia, to evaluate deterioration in cognitive functioning to distinguish between diminished effect of the medication and organic worsening of the disease. Serial administration of parallel forms of memory tests has been employed to investigate the effects of cholinergic agents and other drugs on dementia of the Alzheimer s type. Available medications for Alzheimer disease provide only a temporary cessation of the organic deterioration associated with Alzheimer s disease, such that repeat testing may be necessary to aid in deciding whether or not to increase or discontinue the drug. http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 5 of 12 Neuropsychological testing typically takes up to 8 hours to perform, including administration, scoring and interpretation. It is not necessary, as a general rule, to repeat neuropsychological testing at intervals less than 3 months apart. In general, neuropsychological testing may not be as helpful in individuals over 65 years of age. Psychological and neuropsychological testing has been used to assess of the neurotoxic effects of alcohol and/or drug abuse or dependence. Chronic alcohol abuse can result in cognitive and memory defects which resolve to a varying degree depending on the duration of abstinence and the extent of neuronal loss or atrophy. However, it is inappropriate to perform psychological and neuropsychological testing in a patient to assess the neurotoxic effects of alcohol or drug abuse or dependence during the detoxification period or within the early period of abstinence from the offending drug. The results of psychological and neuropsychological assessment are unreliable when an individual is actively abusing alcohol or drugs and for some period of time after the acute phase of alcohol or drug withdrawal. Psychological and neuropsychological testing has been used in the educational context in children with suspicion of a learning disorder leading to changes in school performance, so as to differentiate between mental subnormality, emotional disturbance, and the specific learning disabilities in speech and reading (e.g., dyslexia). Psychological and neuropsychological testing are also used to develop a specialized treatment plan to help the child improve the performance of these cognitive functions leading to a better performance in school, work, and personal relationships. However, psychological and neuropsychological testing for educational reasons is not covered, as standard Aetna benefit plans exclude educational testing. In addition, psychological and neuropsychological testing performed for educational reasons is not considered treatment of disease. This testing is usually provided by school systems under applicable state and federal rules. Psychological and neuropsychological testing of children for the purpose of diagnosing attention deficit/hyperactivity disorder (ADHD) is not necessary, unless there is strong evidence of a possible neurological disorder. There are few medical conditions which present with ADHD-like symptoms and most patients with ADHD have unremarkable medical histories. In general, attention deficit disorders are best diagnosed through a careful history and the use of structured clinical interviews and dimensionally based rating scales. Most psychologists obtain behavior ratings at home from the parents and at school from the teacher. Examples of rating scales commonly used by psychologists are the Achembach Child Behavior Checklist,Connors Rating Scales, and the ADHD Symptoms Rating Scale. Psychological and neuropsychological testing may used to assess functional competence in relationship to legal matters. However, such use is not considered treatment of disease. Psychological and neuropsychological testing performed as part of a research program is also not considered treatment of disease. The types and numbers of neuropsychological tests given for each condition is not standardized. Most psychologists will perform an in depth interview after the patient has filled out a standardized questionaire asking questions about history, symptoms and functioning, and based on this evaluation the psychologist will plan the testing http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 6 of 12 regimen. While neuropsychological testing may be useful to distinguish cognitive decline due to dementia from cognitive decline due to depression, its use in patients with chronic fatigue syndrome (CFS) has yet to be established. Current evidence-based guidelines on chronic fatigue syndrome include no recommendation for neuropsychological testing in CFS. Michiels and Cluydts (2001) reviewed the current status of neurocognitive studies in patients with CFS. The authors concluded that the current research shows that slowed processing speed, impaired working memory and poor learning of information are the most prominent features of cognitive dysfunctioning in patients with CFS. Furthermore, to this date no specific pattern of cerebral abnormalities has been found that uniquely characterizes CFS patients. There authors stated that there is no overwhelming evidence that fatigue is related to cognitive performance in CFS, and researchers agree that their performance on neuropsychological tasks is unlikely to be accounted solely by the severity of the depression and anxiety. Claypoole et al (2007) noted that variable reports of neuropsychological deficits in patients with CFS may be partly attributable to methodological limitations. In this study, these researchers addressed these limitations by controlling for genetic and environmental influences and by assessing the effects of co-morbid depression and mode of illness onset. Specifically, these researchers performed a co-twin control study of 22 pairs of monozygotic twins, in which 1 twin met strict criteria for CFS and the co-twin was healthy. Twins underwent a structured psychiatric interview as well as comprehensive neuropsychological assessment evaluating 6 cognitive domains. Results indicated that twin groups had similar intellectual and visual memory functioning, but fatigued twins exhibited decreases in motor functions (p = 0.05), speed of information processing (p = 0.02), verbal memory (p = 0.02), and executive functioning (p = 0.01). Major depression did not affect neuropsychological functioning among fatigued twins, although twins with sudden illness onset demonstrated slowed information processing compared with those with gradual onset (p = 0.01). Sudden onset CFS was associated with reduced speed of information processing. If confirmed, these findings suggested the need to distinguish illness onset in future CFS studies and may have implications for treatment, cognitive rehabilitation, and disability determination. Binder et al (2004) reviewed several illnesses that expressed somatically, but do not have clearly demonstrated pathophysiological origin and are associated with neuropsychological complaints. Among them are CFS, non-epileptic seizures, fibromyalgia, Persian Gulf War unexplained illnesses, toxic mold and sick building syndrome, and silicone breast implant disease. Some of these illnesses may be associated with objective cognitive abnormalities, but it is not likely that these abnormalities are caused by traditionally defined neurological disease. Instead, the cognitive abnormalities may be caused by a complex interaction between biological and psychological factors. CPT Codes / HCPCS Codes / ICD-9 Codes http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 7 of 12 CPT codes covered if selection criteria are met: 96101 96102 96103 96116 96118 96119 96120 96125 ICD-9 codes covered if selection criteria are met: 290.0-290.43, 294.8 Dementia 310.1 Personality change due to conditions classified elsewhere 310.89 Other specified nonpsychotic mental disorders following organic brain damage 330.0-331.9 Cerebral degeneration 438.0 Late effects of cerebrovascular disease, cognitive deficits 780.97 Altered mental status 781.8 Neurologic neglect syndrome 800.00-804.99 Fracture of skull 850.0-854.19 Intracranial injury 905.0 Late effect of fracture of skull and face bones 907.0 Late effect of intracranial injury without mention of skull fracture 959.01 Head injury, unspecified ICD-9 codes not covered for indications listed in the CPB: 303.00-305.92 314.00-314.01 Alcohol dependence syndrome, drug dependence, and nondependent abuse of drugs [active abuse, having withdrawal symptoms, or recently entering recovery] Attention deficit disorder 315.00-315.9 Specific delays in development http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 8 of 12 780.71 Chronic fatigue syndrome V72.83 Other specified pre-operative examination V72.84 Pre-operative examination, unspecified V79.0 - V79.9 Special screening for mental disorders and developmental handicaps [when billed alone indicates no signs or symptoms] V80.0 Special screening for neurological conditions [when billed alone indicates no signs or symptoms] Other ICD-9 codes related to the CPB: 042 Human immunodeficiency virus [HIV] disease 259.0 Delay in sexual development and puberty, not elsewhere classified 290.0-302.9, 306.0-313.9, 314.2-314.9, 316-319 Other mental disorders 332.0-332.1 Parkinson's disease 340 Multiple sclerosis 345.00-345.91 Epilepsy and recurrent seizures 348.0-348.9 Other conditions of brain 433.00-438.9 Occlusion and stenosis of precerebral arteries, occlusion of cerebral arteries, transient cerebral ischemia, acute, but illdefined, cerebrovascular disease, other and ill-defined cerebrovascular disease, and late effects of cerebrovascular disease 741.00-741.03 Spina bifida with hydrocephalus 742.0-742.7 Congenital hydrocephalus 758.0-758.9 Chromosomal anomalies 963.8 Poisoning by heavy metal anti-infectives V79.0 - V79.9 Special screening for mental disorders and developmental handicaps The above policy is based on the following references: 1. Chouinard MJ, Braun CMJ. A meta-analysis of the relative sensitivity of http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 9 of 12 neuropsychological screening tests. J Clin Exp Neuropsychol. 1993;15:591-607. 2. Grant I, Adams KM. Neuropsychological Assessment of Neuropsychiatric Disorders. 2nd Ed. New York, NY: Oxford University Press; 1996. 3. Kovner R, Budman C, Frank Y, et al. Neuropsychological testing in adult attention deficit hyperactivity disorder: A pilot study. Int J Neurosci. 1998;96 (3-4):225-235. 4. Feifel D. Attention-deficit hyperactivity disorder in adults. Postgrad Med. 1996;100(3):207-211, 215-218. 5. Carter CS, Krener P, Chaderjian M, et al. Asymmetrical visual-spatial attentional performance in ADHD: Evidence for a right hemispheric deficit. Biol Psychiatry. 1995;37(11):789-797. 6. Szatmari P, Offord DR, Siegel LS, et al. The clinical significance of neurocognitive impairments among children with psychiatric disorders: Diagnosis and situational specificity. J Child Psychol Psychiatry. 1990;31 (2):287-299. 7. Trommer BL, Hoeppner JB, Lorber R, et al. Pitfalls in the use of a continuous performance test as a diagnostic tool in attention deficit disorder [see comments]. J Dev Behav Pediatr. 1988;9(6):339-345. 8. Lovell MR, Iverson GL, Collins MW, et al. Does loss of consciousness predict neuropsychological decrements after concussion? Clin J Sport Med. 1999;9 (4):193-198. 9. Finset A, Anke AW, Hofft E, et al. Cognitive performance in multiple trauma patients 3 years after injury. Psychosom Med. 1999;61(4):576-583. 10. Blostein PA, Jones SJ, Buechler CM, et al. Cognitive screening in mild traumatic brain injuries: Analysis of the neurobehavioral cognitive status examination when utilized during initial trauma hospitalization. J Neurotrauma. 1997;14(3):171-177. 11. Leahy BJ, Lam CS. Neuropsychological testing and functional outcome for individuals with traumatic brain injury. Brain Inj. 1998;12(12):1025-1035. 12. Weight DG. Minor head trauma. Psychiatr Clin North Am. 1998;21(3):609-624. 13. Koelfen W, Freund M, Dinter D, et al. Long-term follow up of children with head injuries-classified as 'good recovery' using the Glasgow Outcome Scale: Neurological, neuropsychological and magnetic resonance imaging results. Eur J Pediatr. 1997;156(3):230-235. 14. Massagli TL, Jaffe KM, Fay GC, et al. Neurobehavioral sequelae of severe pediatric traumatic brain injury: A cohort study. Arch Phys Med Rehabil. 1996;77(3):223-231. 15. Hu MT, Taylor-Robinson SD, Chaudhuri KR, et al. Evidence for cortical dysfunction in clinically non-demented patients with Parkinson's disease: A proton MR spectroscopy study. J Neurol Neurosurg Psychiatry. 1999;67 (1):20-26. 16. Ratti MT, Soragna D, Sibilla L, et al. Cognitive impairment and cerebral atrophy in 'heavy drinkers'. Prog Neuropsychopharmacol Biol Psychiatry. 1999;23(2):243-258. 17. Dugbartey AT, Rosenbaum JG, Sanchez PN, et al. Neuropsychological assessment of executive functions. Semin Clin Neuropsychiatry. 1999;4(1):5-12. 18. Gregory CA, Serra-Mestres J, Hodges JR. Early diagnosis of the frontal variant of frontotemporal dementia: How sensitive are standard neuroimaging http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 10 of 12 and neuropsychologic tests? Neuropsychiatry Neuropsychol Behav Neurol. 1999;12(2):128-135. 19. Lauer CJ, Gorzewski B, Gerlinghoff M, et al. Neuropsychological assessments before and after treatment in patients with anorexia nervosa and bulimia nervosa. J Psychiatr Res. 1999;33(2):129-138. 20. Salmon DP, Lange KL. Cognitive screening and neuropsychological assessment in early Alzheimer's disease. Clin Geriatr Med. 2001;17(2):229-254. 21. Powers JM. Diagnostic criteria for the neuropathologic assessment of Alzheimer's disease. Neurobiol Aging. 1997;18(4 Suppl):S53-S54. 22. Montgomery GK. A multi-factorial account of disability after brain injury: Implications for neuropsychological counseling. Brain Inj. 1995;9(5):453-469. 23. Mitrushina M, Abara J, Blumenfeld A. The neurobehavioral cognitive status examination as a screening tool for organicity in psychiatric patients. Hosp Community Psychiatry. 1994;45(3):252-256. 24. Feinberg TE, Roane DM, Miner CR, et al. Neuropsychiatric evaluation in an outpatient setting. J Neuropsychiatry Clin Neurosci. 1995;7(2):145-154. 25. Bernstein JH, Prather PA, Rey-Casserly C. Neuropsychological assessment in preoperative and postoperative evaluation. Neurosurg Clin N Am. 1995;6 (3):443-454. 26. Korkman M, Pesonen A-E. A comparison of neuropsychological test profiles of children with attention deficit-hyperactivity disorder and/or learning disorder. J Learn Disabil. 1994;27(6):383-392. 27. Ruijs MB, Keyser A, Gabreels FJM. Clinical neurological trauma parameters as predictors for neuropsychological recovery and long-term outcome in pediatric closed head injury: A review of the literature. Clin Neurol Neurosurg. 1994;96(4):273-283. 28. Reimer W, Van Patten K, Templer DI, et al. The neuropsychological spectrum in traumatically head-injured persons. Brain Inj. 1995;9(1):55-60. 29. Grant I, Hampton J, Hesselink JR, et al. Evidence for central nervous system involvement in the acquired immunodeficiency syndrome (AIDS) and other human immunodeficiency virus infections: Studies with neuropsychological testing and magnetic resonance imaging. Ann Intern Med. 1987;107(6):828-836. 30. Sherer M, Novack TA, Sander AM, et al. Neuropsychological assessment and employment outcome after traumatic brain injury: A review. Clin Neuropsychol. 2002;16(2):157-178. 31. Arnaiz E, Almkvist O. Neuropsychological features of mild cognitive impairment and preclinical Alzheimer's disease. Acta Neurol Scand Suppl. 2003;179:34-41. 32. National Heritage Insurance Company (NHIC). Neuropsychological testing. Medicare Part B Local Medical Review Policy. Policy No. 02-812-R3. Hingham, MA: NHIC: revised February 2, 2004. Available at: http://www.medicarenhic.com/ne_prov/updates/2002/neurotest.htm. Accessed March 23, 2004. 33. Frazier TW, Demaree HA, Youngstrom EA. Meta-analysis of intellectual and neuropsychological test performance in attention-deficit/hyperactivity disorder. Neuropsychology. 2004;18(3):543-555. 34. Henry JD, Crawford JR. Verbal fluency deficits in Parkinson's disease: A meta-analysis. J Int Neuropsychol Soc. 2004;10(4):608-622. 35. Pepping M, Ehde DM. Neuropsychological evaluation and treatment of http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 11 of 12 multiple sclerosis: The importance of a neuro-rehabilitation focus. Phys Med Rehabil Clin N Am. 2005;16(2):411-436, viii. 36. Osmon DC, Smerz JM. Neuropsychological evaluation in the diagnosis and treatment of Tourette's syndrome. Behav Modif. 2005;29(5):746-783. 37. de Vries P, Humphrey A, McCartney D, Consensus clinical guidelines for the assessment of cognitive and behavioural problems in tuberous sclerosis. Eur Child Adolesc Psychiatry. 2005;14(4):183-190. 38. Anastasi A. Psychological Testing. 7th edition. New York, NY: Macmillan; 1996. 39. American Educational Research Association (AERA), American Psychological Association (APA), and National Council on Measurement in Education. Standards for Educational and Psychological Testing. Revised Edition. Washington, DC: AERA; 1999. 40. American Academy of Neurology. Practice parameter: Screening and diagnosis of autism: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology. 2000;55;468-479. 41. Preston AS, Fennell EB, Bussing R. Utility of a CPT in diagnosing ADHD among a representative sample of high-risk children: A cautionary study. Child Neuropsychol. 2005;11(5):459-469. 42. American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention- Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry. 2007;46 (7):894-921. 43. Forbes GB. Clinical utility of the Test of Variables of Attention (TOVA) in the diagnosis of attention-deficit/hyperactivity disorder. J Clin Psychol. 1998;54 (4):461-476. 44. Michiels V, Cluydts R. Neuropsychological functioning in chronic fatigue syndrome: A review. Acta Psychiatr Scand. 2001;103(2):84-93. 45. Binder LM, Campbell KA. Medically unexplained symptoms and neuropsychological assessment. J Clin Exp Neuropsychol. 2004;26(3):369-392. 46. Claypoole KH, Noonan C, Mahurin RK, et al. A twin study of cognitive function in chronic fatigue syndrome: The effects of sudden illness onset. Neuropsychology. 2007;21(4):507-513. 47. Randolph C, Hilsabeck R, Kato A, et al; International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN). Neuropsychological assessment of hepatic encephalopathy: ISHEN practice guidelines. Liver Int. 2009;29(5):629-635. 48. Monaci L, Morris RG. Neuropsychological screening performance and the association with activities of daily living and instrumental activities of daily living in dementia: Baseline and 18- to 24-month follow-up. Int J Geriatr Psychiatry. 2012;27(2):197-204. 49. Rabin LA, Wang C, Katz MJ, et al. Predicting Alzheimer's disease: Neuropsychological tests, self-reports, and informant reports of cognitive difficulties. J Am Geriatr Soc. 2012;60(6):1128-1134. http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

Neuropsychological and Psychological Testing Page 12 of 12 Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change. CPT only copyright 2008 American Medical Association. All Rights Reserved. Copyright 2001-2014 Aetna Inc. Web Privacy Statement Legal Statement Privacy Notices Member Disclosure http://www.aetna.com/cpb/medical/data/100_199/0158.html 4/22/2014

ELECTROCONVULSIVE THERAPY (ECT) CREDENTIALING PROVIDERS: Psychiatrists must have specialized training to conduct ECT. MHNet will approve providers to perform ECT if they are currently credentialed to perform ECT by a JCAHO accredited hospital or they provide evidence of training in the procedure and they are currently providing at least 30 treatments/year. FACILITY REQUIREMENTS: Anesthesiologists with experience in ECT and/or Certified Registered Nurse Anesthetists trained in ECT who are supervised according to the regulations of the state where they are practicing must attend to all ECT procedures. The facility must have equipment that can continuously monitor vital signs and oxygen tension. The facility must have continuous oxygen available. There must be a cardiac defibrillator immediately available along with a full set of medications necessary to treat all medical complications associated with ECT and general anesthesia. PATIENT REQUIREMENTS: ECT is indicated for the treatment of major depression, mania or catatonia. Prior to initiating ECT a comprehensive psychiatric assessment must be performed to confirm the diagnosis. Although not required, all providers are strongly encouraged to obtain a second psychiatric opinion before initiating ECT. The primary indication for ECT is major depressive disorder. Electroconvulsive therapy is usually considered when medications fail, can not be tolerated, or may be dangerous, but it is a first-line treatment for severly depressed patients who require a rapid response because of a high suicide or homicide risk, extreme agitation, life-threatening inanition, psychosis or stupor. The average course of treatment for depression is 6 to 12 treatments, but some patients may require as many as 20 treatments. MEDICAL CLEARANCE: Patients must undergo a medical history, physical examination and laboratory testing prior to ECT. Although there are no absolute contraindications to ECT (outside of increased intra-cranial pressure), any medical condition that can be exacerbated by a seizure, the autonomic arousal associated with seizures, anesthetic medications or temporary paralysis should be considered relative contraindications to the procedure. An internist knowledgeable about the procedure and the medical risks involved must evaluate all patients. Consultation should be obtained for high-risk patients (e.g., obtaining a cardiology consultation for patients with significant cardiac disease). If there is a significant medical risk to the procedure, the treating psychiatrist should directly Confidential and Proprietary Page 2015 MHNet Behavioral Health

consult with the internist/specialist to properly assess the relative risks and benefits. This assessment should be shared with the patient and family. INFORMED CONSENT: As with any medical procedure the patient (or legal guardian) must give informed consent prior to initiating treatment. The consent must be obtained verbally and confirmed in writing. The psychiatrist must document the date, time and place that consent was obtained and the individuals present. Consent must include the known risks and benefits of ECT. The risks must include complications associated with the seizure (i.e., memory loss, confusion, cardiac arrhythmias, myocardial infarction, cerebrovascular accidents) as well as complications of anesthesia (drug reactions, hypoxia, an asthma attack, pneumonia). Although competent patients can give consent on their own, it is strongly advised that family be included in the consent process and their acceptance of the procedure be documented as well. PROCEDURE REQUIREMENTS: ECT should only be performed with a brief pulse stimulus generator that can monitor the patient s EEG. Prior to initiating treatment all patients should have sensors in place to monitor EKG, EEG, oxygen tension, blood pressure, and pulse. There should be confirmation that the patient has been medically cleared for ECT, that laboratory studies are normal or have been addressed and that the patient hasn t had anything to eat or drink in the previous 8 hours. If there has been a hiatus since the medical clearance and/or laboratory studies the psychiatrist should confirm that there has been no significant change in the patient s physical condition. The signed informed consent or a true copy must be present. STIMULUS AND ELECTRODE PLACEMENT: There is no consensus on the optimal initial stimulus for ECT or the optimal initial placement of the stimulus electrodes. The initial stimulus can be determined by titrating the dose up to the seizure threshold or empirically based on the patient s age and sex. Electrodes can be placed to affect a unilateral stimulus, a bi-frontal stimulus or a bitemporal stimulus. Once a treatment has been completed and the response determined one would adjust the stimulus according to the adequacy of the seizure and/or therapeutic response. One will adjust the electrode placement according to the therapeutic response and severity of confusion. NUMBER AND FREQUENCY OF TREATMENTS: In general, patients receive a single treatment (one seizure) three times a week until they are significantly improved, memory loss/confusion become severe, or they are deemed treatment refractory. On average, patients receive between 4 and 12 treatments with a mean of 8. Treating psychiatrists disagree as to how many treatments should be provided Confidential and Proprietary Page 2015 MHNet Behavioral Health

before determining that a patient is treatment refractory. The range is between 10 and 20 treatments. Therefore patients should receive at least 10 treatments but no more than 20 before deciding that they won t respond. In some patients, particularly the frail elderly, treatments may be administered twice a week to minimize confusion. CONTINUATION AND MAINTENANCE TREATMENT: Many individuals undergoing a course of ECT will demonstrate only a partial response or will relapse once the procedures are stopped. These individuals may be candidates for continuation or maintenance ECT. Continuation ECT involves gradually spreading out the frequency of treatments (i.e., three times a week, going to once a week, going to once every two weeks etc.) over a period of 2 to 6 months. Maintenance ECT involves administering a single treatment on a regular basis (once every 2 weeks to once every 6 weeks). Regardless of the situation, every patient should be re-evaluated every six months to assess the risks and benefits of continued ECT. MANAGEMENT OF COMPLICATIONS: Common complications of ECT include prolonged seizures, prolonged apnea, cardiac arrhythmias, hypertension, post-ictal agitation, delirium, headaches, and muscle pain. The treating psychiatrist must be well versed in these conditions and implement appropriate treatment strategies. Confidential and Proprietary Page 2015 MHNet Behavioral Health

GUIDELINES FOR INTERPRETING MHNET S MEDICAL NECESSITY CRITERIA FOR ADOLESCENTS WHO VE BEEN DESIGNATED AS SEXUALLY REACTIVE The term sexually reactive adolescents refers to individuals who ve engaged in behaviors with another individual that involves genital contact. Sexually reactive adolescents can be grouped according to their age, their sex, the sex of the individual they have contact with, the age of the individual they have contact with (peer versus child), the degree of aggression involved and the act itself. The most common psychiatric diagnosis associated with sexually reactive adolescents is conduct disorder. It is unclear if conduct disordered adolescents who act out sexually are significantly different from those who act out in a non-sexual manner. It is clear, however that our society reacts much differently to acts that have a sexual connotation. Since there is no specific psychiatric diagnosis that is associated with all sexually reactive adolescents, interventions designed to reduce recidivism are directed towards behavior modification and addressing stresses in the individual s life that may be increasing the urge to repeat the sexual behavior. Stresses may derive from the family, an academic setting, peer relations and an underlying psychiatric condition. Addressing the needs of a sexually reactive adolescent begins with a comprehensive outpatient evaluation. Admission to an inpatient unit would only be required if the individual is deemed to be an immediate danger to themselves or others. The outpatient evaluation should include details of the individual s sexual behavior, their current legal status, their understanding and insight into the deviant behavior, their home situation including relationships with parents and siblings, their academic standing and their peer relationships. In addition there should be a comprehensive review of psychiatric symptoms to determine if the individual has a diagnosable psychiatric condition. Following the initial evaluation a comprehensive treatment plan should be developed that includes individual, group and family therapy. The plan should be directed towards treating any underlying psychiatric condition, stabilizing the home environment and reducing the chances of repeating (i.e. relapse prevention). If there is an underlying psychiatric or substance abuse problem medical necessity criteria should be applied according to that condition. The level of care should be based on an assessment of the member s safety, ability at self-care, reality construction, social functioning and complicating conditions. In this context, being designated sexually reactive should be considered a complicating condition that needs to be factored into the decision, but is not, in and of itself a major determinant of level of care. Court ordered treatment, in the absence of symptoms that meet medical necessity criteria for treatment, is not a covered benefit.

Andre JT, Vincent GM, Saleh FM: Juvenile sex offenders: a complex population. J Forensic Sciences. 51(1):163-167, 2006 Caldwell MF: Sexual offense adjudication and sexual recidivism among juvenile offenders. Sexual Abuse: J Research Treatment 19(2):107-113, 2007 Caldwell MF, Dickinson C: Sex offender registration and recidivism risk in juvenile sexual offenders. Behavioral Sciences Law 27(6):941-946, 2009 Clift RJ, Rajlic G, Gretton HM: Discriminative and predictive validity of the penile plethysmograph in adolescent sex offenders. Sexual Abuse: J Research Treatment 21(3):335-362, 2009 Duwe G, Goldman RA: The impact of prison-based treatment on sex offender recidivism: evidence from Minnesota. Sexual Abuse: J Research Treatment 21(3):279-307, 2009 Gill R, Raphel S: New hope and help for forgotten youth. J Child Adolescent Nursing 22(2)57-62, 2009 Ikoma PA, Harris-Wyatt G, Doucet G, Rodney HE: Treatment for juveniles who sexually offend in a Southwestern state. J Child Sexual Abuse. 18(6):594-610, 2009 Letourneau EJ, Miner MH: Juvenile sex offenders: a case against the legal and clinical status quo. Sexual Abuse: J Research Treatment 17(3):293-312, 2005 Parks GA, Bard DE: Risk factors for adolescent sex offender recidivism: evaluation of predictive factors and comparison of three groups based upon victim type. Sexual Abuse: J Research Treatment 18(4):319-342, 2006 St Amand A, Bard DE, Silovsky: Meta-analysis of treatment for child sexual behavior problems: practice elements and outcomes. Child Maltreatment 13(2):145-166, 2008 Underwood LA, Robinson SB, Mosholder E, Warren KM: Sex offender care for adolescents in secure care: critical factors and counseling strategies. Clin Psychology Rev 28(6):917-932, 2008

KENTUCKY MEDICAID ADULT THERAPEUTIC REHABILITATION SERVICES ADMISSION CRITERIA: Adults with a serious and persistent mental illness (excluding developmental disabilities and mental retardation) residing in a non-institutional setting are eligible for therapeutic rehabilitation services. These services are provided by a CMHC for the specific purpose of assuring that individuals possess the physical, emotional and intellectual skills to live, learn, and work in their particular environment. Individuals who are referred for therapeutic rehabilitation must have objectively identifiable deficits that impair their ability to function in their environment. These deficits must be amenable to remediation. PROGRAM: REQUIREMENTS: Therapeutic rehabilitation must be provided by a CMHC. At the time of initial referral a treatment plan must be developed that includes specific problem areas to be addressed along with treatments recommended and time frames for completion. A psychiatrist must approve the treatment plan. The treatment plan should be reviewed by the psychiatrist on a monthly basis and updated at least once every three months. The implementation of the treatment plan must be supervised, on-site, on a daily basis by a qualified mental health professional. GLOBAL INDICATORS: 1. The member has been diagnosed as suffering from a severe and persistent mental illness excluding developmental disabilities and mental retardation. 2. The member is in a stable living environment where their routine physical and emotional needs can be met. 3. An objective assessment of the individual s psychosocial situation has identified specific deficits in functioning that compromise their ability to maintain themselves in their particular environment. 4. A time limited training program is reasonably expected to correct the identified deficits. SEVERITY OF ILLNESS Objective professional evaluations of the member s current condition indicate a level of severity that will not require institutional care if they receive rehabilitation services. Impairment in Safety: The individual does not present an imminent significant risk to himself or herself. Confidential and Proprietary 2014 MHNet Behavioral Health

Impairment in Self Care: The member is capable of providing routine self-care. Impairment in Reality Construction: Any impairment is not so severe as to preclude benefit from rehabilitative services. Impairment in Social Functioning: Not applicable. Complicating Conditions: There are no other complicating conditions that preclude benefit from treatment. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: Individuals with serious and persistent mental illnesses may lack personal and social resources necessary to maintain stability in their environment. A major function of therapeutic rehabilitation is to identify and compensate for these deficits. Exclusions: None. INTENSITY OF SERVICE ELEMENTS: The frequency, type, and intensity of service vary depending on the specific needs of the individual. Services can be provided on an individual basis or in a group. Services can range from an hour to 4 hours/day. Services can be provided anywhere from once a day to once a week. All services must be therapeutic in nature. All services must be documented. Services that are strictly related to substance abuse or are recreational, social or physical exercise are not covered. Services must be provided in a setting that meets the following standards: 1. The location must be structured so as to minimize the risk of self-injury. 2. There must be continuous monitoring of the patient at all times. 3. Individuals conducting the monitoring must be certified in the management of individuals with serious mental illnesses. 4. The staff has the capability to obtain emergency care if necessary. CONTINUED STAY CRITERIA: Continued stay is contingent on significant progress towards meeting the treatment plan goals and/or a change in circumstances that necessitates that revision of the treatment plan. DISCHARGE CRITERIA: 1. The client has met the goals of the treatment plan. Confidential and Proprietary 2014 MHNet Behavioral Health

2. The client is repeatedly non-compliant with treatment recommendations. 3. The client has reached a therapeutic plateau where no further improvement is anticipated. In that situation, an alternative plan that includes ongoing supportive maintenance care may be implemented. Confidential and Proprietary 2014 MHNet Behavioral Health

KENTUCKY MEDICAID CHILD THERAPEUTIC REHABILITATION SERVICES ADMISSION CRITERIA: Children with a serious mental illness who require more than intermittent outpatient services to maintain themselves in the community are eligible for therapeutic rehabilitation. These services are provided by a CMHC for the specific purpose of assuring that individuals develop the ability to function in the community. These services are intended to be an adjunct to an outpatient treatment plan that includes individual, group and family therapy along with medication management as appropriate. PROGRAM: REQUIREMENTS: Therapeutic rehabilitation must be provided by a CMHC. At the time of initial referral a treatment plan must be developed that includes specific problem areas to be addressed along with treatments recommended and time frames for completion. A psychiatrist must approve the treatment plan. The treatment plan should be reviewed by the psychiatrist on a monthly basis and updated at least once every three months. The implementation of the treatment plan must be supervised, on-site, on a daily basis by a qualified mental health professional. GLOBAL INDICATORS: 1. The child has been diagnosed as suffering from a severe mental illness excluding developmental disabilities and mental retardation. 2. The child is in a stable living environment where their routine physical and emotional needs can be met. 3. An objective assessment of the child s psychosocial situation has identified specific deficits in functioning that compromise their ability to maintain themselves in their particular environment. 4. A time limited training program is reasonably expected to correct the identified deficits. SEVERITY OF ILLNESS Objective professional evaluations of the child s current condition indicate a level of severity that will not require institutional care if they receive rehabilitation services. Impairment in Safety: The child does not present an imminent significant risk to himself or herself.

Impairment in Self Care: The child is capable of providing routine self-care. Impairment in Reality Construction: Any impairment is not so severe as to preclude benefit from rehabilitative services. Impairment in Social Functioning: Not applicable. Complicating Conditions: There are no other complicating conditions that preclude benefit from treatment. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: Children with serious mental illnesses may lack personal and social resources necessary to maintain stability in their environment. A major function of therapeutic rehabilitation is to identify and compensate for these deficits. Exclusions: None. INTENSITY OF SERVICE ELEMENTS: The frequency, type, and intensity of service vary depending on the specific needs of the individual. Services can be provided on an individual basis or in a group. Services can range from an hour to 4 hours/day. Services are provided on a daily basis until the child is ready for discharge. All services must be therapeutic in nature. The individual providing the service must document all services. In addition there must be a weekly summary note indicating the child s progress towards meeting the goals of the treatment plan. Services that are strictly related to education, recreation, social or physical exercise are not covered. Services must be provided in a setting that meets the following standards: 1. The location must be structured so as to minimize the risk of self-injury. 2. There must be continuous monitoring of the child at all times. 3. Individuals conducting the monitoring must be certified in the management of individuals with serious mental illnesses. 4. The staff has the capability to obtain emergency care if necessary. CONTINUED STAY CRITERIA: Continued stay is contingent on significant progress towards meeting the treatment plan goals and/or a change in circumstances that necessitates that revision of the treatment plan.

DISCHARGE CRITERIA: 1. The child has met the goals of the treatment plan. 2. The child is repeatedly non-compliant with treatment recommendations. 3. The child has reached a therapeutic plateau where no further improvement is anticipated. In that situation, an alternative plan that includes ongoing supportive maintenance care may be implemented.

KENTUCKY TARGETED CASE MANAGEMENT SERVICES ADMISSION CRITERIA: Eligibility for adult targeted case management requires that the member meets Kentucky regulations for a chronic mental illness: currently severely impaired by mental illness other than substance abuse or mental retardation and has been impaired for the previous two years or has had two hospitalizations in the past two years. Eligibility for child/adolescent case management requires that: the client has a severe emotional disability excluding chemical dependency, mental retardation or developmental delay, the severity of the client s condition is expected to be of short duration, and the client has been identified by a regional interagency council (RIAC). PROGRAM AND SERVICE REQUIREMENTS: 1. Must be a regional mental health mental retardation center. 2. Conducts an initial assessment of every client. 3. Participates in the development of the client s service plan. 4. Provides referrals and linkages as needed. 5. Advocates for the client. 6. Monitors clients progress. 7. Reassesses as appropriate. 8. Maintains a case record. 9. Assists with crisis planning. SEVERITY OF ILLNESS An objective professional evaluation of the member s current condition indicates a level of complexity that the members requires coordinated care by multiple service providers and/or advocacy to obtain necessary services. Impairment in Safety: The patient presents a significant risk to himself or herself or they are at risk for significant deterioration if left untreated. Impairment in Self Care: The member may need assistance with self-care. Impairment in Reality Construction: Any impairment can be managed on an outpatient basis. Impairment in Social Functioning: Not applicable.

Complicating Conditions: There are no other complicating conditions that preclude benefit from outpatient treatment. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: By definition members in need of target case management lack personal and social resources necessary for recovery. Exclusions: Any lack in resources is not so severe as to preclude treatment in an outpatient setting. CONTINUED STAY CRITERIA: Continued stay is contingent on the member continuing to suffer from a severe mental illness that requires the coordination of care between multiple providers and/or requires advocacy to obtain necessary services. DISCHARGE CRITERIA: 1. The member is no longer in need of services. 2. Continued case management services are not expected to provide any additional benefit.

KENTUCKY MEDICAID EXTENDED CARE UNITS PROGRAM DESCRIPTION: Extended care units (ECUs) are for individuals under the age of 18 who no longer need inpatient hospitalization or residential care but are unable to return to community based outpatient care either due to placement issues or continued psychological and/or behavioral disturbances that preclude a safe transition to outpatient care. ECUs treat a wide range of psychiatric problems. Therefore the facilities and the staffing must be appropriate for the population being served. Extended care services are transitional in nature. The length of stay is determined by the amount of time necessary to resolve the issue(s) that preclude discharge to a community based out patient setting. Expected lengths of stay are between 1 week and 2 months. Extended care is separate and distinct from custodial care. Once an individual stops making progress towards achieving behavioral control and/or there is no expectation of community placement in the immediate future (i.e. the individual is not able to return home or is not on a waiting list for placement) they are considered to be in custodial care and therefore no longer eligible for extended care services. ADMISSION CRITERIA: 1. The individual is currently being treated in an inpatient, a residential or rehabilitation facility. 2. The individual is less than 18 years of age. 3. Discharge to a community based non-residential setting is not feasible because: a. Placement could not be arranged in a timely fashion b. There continues to be sufficient psychological and or behavioral disturbances as to preclude a safe placement in the community. 4. There is a reasonable expectation that the problem(s) indentified above will be remedied within 2 months. GLOBAL INDICATORS: 1. The member has been diagnosed as suffering from a severe mental illness including pervasive developmental disorders. 2. The member is no longer in need of inpatient, residential rehabilitation or rehabilitation services. 3. The member represents a danger to themselves or others if discharged to the community. 4. Short term behavioral interventions and/or discharge planning will permit the member to be transitioned to community based out patient treatment.

SEVERITY OF ILLNESS An objective professional evaluation of the member s current condition indicates a level of severity that requires continuous monitoring by a caregiver. Impairment in Safety: The patient presents a significant risk to himself or herself if placed in a setting without continuous care. Impairment in Self Care: Any impairment can be met in a community based setting and/or can be remedied by the ECU in the near future. Impairment in Reality Construction: Any impairment is not so severe as to preclude community based outpatient treatment. Impairment in Social Functioning: Any impairment can be remedied in the near future and/or is not so severe as to preclude community based outpatient treatment. Complicating Conditions: There are no other complicating conditions that preclude benefit from treatment. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: Limitations in personal resources are only applicable in as much as they ve delayed placement by the referring facility. Exclusions: Any individual in need of custodial care. INTENSITY OF SERVICE ELEMENTS: The frequency and intensity of service varies according to the population being served. At minimum the following must be met: 1. The location must be structured so as to minimize the risk of self-injury and preclude the possibility of elopement. 2. Trained staff must be available at all times. 3. Individuals providing treatment and discharge planning must be certified in the treatment of individuals with the problems being served. 4. There must be access to education programs for members who are in school. 5. The staff has the capability to distribute medication and obtain emergency care if necessary. 6. Primary care medical staff are available, in house, on a daily basis to address routine medical issues. Acute medical care and specialty medical care is available, as needed with the facility arranging appointments and transportation. BEHAVIORALLY ORIENTED TREATMENT PLAN:

1. By the end of the first week there must be a treatment plan in place that identifies all the barriers to community based outpatient treatment. 2. This treatment plan must delineate specific interventions to address each barrier. 3. For each intervention there must be an expected time frame for intervention. 4. For members in need of placement, there must be a list of possible options. If availability is a concern, the member must be placed on a waiting list along with an expected date for transfer. This list must be updated weekly. CONTINUED STAY CRITERIA: Continued stay is contingent on either: 1. The member making progress towards achieving sufficient behavioral control to permit discharge to a community based outpatient setting, 2. The member has been accepted for placement but is awaiting availability. DISCHARGE CRITERIA: 1. A safe and satisfactory community based placement has been arranged. 2. The member is making no progress towards achieving the goals necessary for discharge to community based outpatient treatment. 3. The member has reached the maximum benefit from this level of care. 4. There is no expectation of discharge to community based outpatient treatment within the next two months.

KENTUCKY CHILD/ADOLESCENT PSYCHIATRIC RESIDENTIAL TREATMENT PROGRAM DEFINITION: The State of Kentucky Medicaid program recognizes a need for unique psychiatric residential treatment facilities (PRTFs) that provide a homelike environment for severely emotionally disabled children and adolescents who do not require an inpatient level of care. These facilities are intended to obviate the need for institutional care or traditional residential care. PRTFs must be free standing, located within a residential community. Residents must undergo a comprehensive assessment upon admission that includes a medical examination, a psychiatric assessment and a social services assessment. These assessments are used to develop a utilization review plan that includes a comprehensive treatment plan and an aftercare plan. PRTFs should have the capability of providing educational, nursing services, medication administration, individual, family and group therapy as well as substance abuse education. The facility must provide psychiatric and behavioral health services at least two (2) times a week. All facilities must be JCAHO accredited and must be located within the State of Kentucky. The State further recognizes the need for two (2) levels of PRTFs. Level I PRTFs are designed for children/adolescents age six (6) to twenty one (21) who have an emotional disability. Level I PRTFs are restricted to 9 beds or less. Level II PRTFs are for children/adolescents who have a severe emotional disability in addition to aggressive behaviors, intellectual disability, sexual acting out behaviors or developmental disability. ADMISSION CRITERIA: 1. The member is Medicaid eligible, between the ages of four (Level II) or six (Level I) and twenty one and has a DSM 5 diagnosable emotional disability that has persisted or is expected to persist for at least one year. 2. The member cannot be managed in their home environment but does not need inpatient care. 3. The member is expected to improve to the point that they no longer need a PRTF. 4. Failure to place the member in a PRTF would result in regression and the need for a higher level of care. Confidential and Proprietary Page 1 of 3 2014 MHNet Behavioral Health

SEVERITY OF ILLNESS: An objective professional evaluation of the patient's current condition indicates a level of severity appropriate to a PRTF as evidenced by the following: Impairment in Safety: Presents a pervasive pattern of poor impulse control and highrisk behavior, assaultive or homicidal behavior and periods when suicide or homicide risk is considered high. Impairment in Self-Care: Presents significant impairment in capacity for self care without being monitored in structured environment. Impairment in Reality Construction: Presents impairment in cognitive and perceptual function and attendant impairment in judgment and problem solving. Impairment in Social Functioning: Presents disturbances in age-appropriate adaptive functioning and interpersonal functioning manifested in the family, at school and other social settings. Complicating Conditions: Physical and psychological complications are not of sufficient severity to preclude safe placement in a PRTF. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: As further evidence for a PRTF, the patient presents with significant limitations in resources to resolve presenting problems as indicated by: Limited Personal Resources: The member does not have the coping skills sufficient to reduce risk without this level of service. Limited Social Resources: Patient does not have the family and/or the social support needed to maintain them in the home environment. INTENSITY OF SERVICE ELEMENTS: Within the PRTF, the patient should be receiving the following services as further justification of the admission: 1. A multidisciplinary assessment of social, psychiatric, psychological, and developmental and biological functioning. 2. A comprehensive medical examination including history, physical examination and laboratory testing. Confidential and Proprietary Page 2 of 3 2014 MHNet Behavioral Health

3. An individualized treatment plan designed to meet the member s specific needs including a time line for eventual discharge. 4. The family system is the subject of assessment, and the family is actively involved in treatment. 5. A structured environment which provides behavioral intervention and systematic feedback. 6. A psychoeducational assessment with any identified needs being addressed in the educational component of the program. 7. Individual, family and `group therapy as appropriate. 8. Treatment plan includes methods and/or goals for addressing crisis management. CONTINUED STAY CRITERIA: In order to justify remaining in a PRTF the patient must continue to manifest symptoms justifying the principal DSM 5 diagnosis and the following: 1. Psychological disturbances continue to significantly impair level of functioning. 2. Progress is evident towards treatment goals. However, more consistency is needed to achieve treatment goals. 3. Continued authorization of PRTF care is necessary to maintain and or improve the current level of functioning. DISCHARGE CRITERIA: The patient is ready for discharge when any of the following are obtained: a) They can be safely transitioned to a private or group home with appropriate support (e.g. foster care, wrap-around services etc.). b) They reach the age of twenty two (22). c) They regress and require inpatient care. Confidential and Proprietary Page 3 of 3 2014 MHNet Behavioral Health

KENTUCKY CASE MANAGEMENT SERVICES PURPOSE: Case management is designed to coordinate the care of individuals with a mental illness or substance related disorder who are receiving services from multiple providers and/or institutions. Case management can be further classified as basic, involving only occasional contact with the client, or intensive, which involves frequent contact to ensure that the client is fully compliant with their treatment plan and all providers are conducting follow-up activities as needed. Case management services are separate and distinct from Targeted Case Management which is designed for individuals who have a serious and persistent mental illness, mental retardation, emotional disability or developmental delay. ADMISSION CRITERIA: Authorization of Case Management must be based on the following Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and an Intensity of Service appropriate to the objectives of Targeted Case Management. GLOBAL INDICATORS: 1. Individual presents with at least one valid DSM-5. 2. Individual s condition must be directly attributable to the designated mental disorder and not to Antisocial Personality or be a part of a pervasive pattern of antisocial conduct. 3. The individual s condition requires active involvement by multiple providers. This may include medical, psychiatric, social, educational, vocational and other services as needed. SPECIFIC CIRCUMSTANCES THAT MAY REQUIRE CASE MANAGEMENT: The following situations are frequently found to benefit from Case Management: 1. Pregnant women whose pregnancy is at risk if their mental illness is not controlled. 2. Individuals with a history of multiple recent inpatient admissions who are at high risk for readmission. 3. Individuals with multiple recent episodes of ambulatory care who are likely to deteriorate and require a higher level of care. 4. Children or adolescents with an active mental health problem who are victims of abuse or neglect.

5. Individuals with a suffering from chronic substance abuse who ve experienced severe withdrawal symptoms or significant medical complications from their abuse. 6. Recently discharged individuals who require intensive community/social support in order to prevent deterioration and readmission. 7. Individuals who have recently made a severe, life-threatening suicide attempt. 8. Individuals who have been recently hospitalized who have a past history of noncompliance with outpatient care and/or Individuals whose guardians have been unsupportive of outpatient care. 9. Individuals with multiple complicating factors (medical, social, financial) that require ongoing assistance in order to avoid deterioration and higher levels of care. PROGRAM AND SERVICES REQUIREMENTS: 1. Case management must be provided by a Community Mental Health Center licensed to provide this service. 2. There must be an initial assessment that identifies the client s needs and identifies appropriate providers along with contact information. 3. If an appropriate provider is not available, case management will arrange a referral. 4. Clients will be designated as needing basic services (HCPCS T1016) or intensive services (HCPCS T1017) depending on the risk of serious deterioration if they do not receive comprehensive, integrated and coordinated care. 5. Case management will serve as an advocate for the client. 6. Case management will monitor the client s progress and will periodically reassess the client s needs. 7. Case management will maintain an on-going record of involvement. 8. Case management will assist in developing a crisis management program. SEVERITY OF ILLNESS: An objective professional evaluation of the individual s current condition indicates a level of severity appropriate to Case Management services as evidenced by one or more of the following: Impairment in Safety: Individual presents levels of risk to self and/or others that can be adequately managed in the home environment and outpatient setting. Impairment in Self Care: Individual can provide for self care or has the ageappropriate assistance in maintaining self care. Impairment in Reality Construction: Individual has adequate grasp of reality and demonstrates capacity for judgment to contain risks outside of a hospital or other

structured setting. Impairment in Social Functioning: Impairment is not so substantial as to require a more restricted setting than what is available in the home environment. Complicating Factors: Multiple agencies and service delivery systems are frequently involved in the care of the individual. Impaired family functioning may contribute substantially to the mental illness/substance abuse of the identified Individual. LIMITATION IN PERSONAL AND/OR SOCIAL RESOURCES: Personal Resources: The individual has adequate age-appropriate coping skills to contribute to treatment success through active participation and the ability to complete assigned tasks between sessions. The family or legal custodian requires help in effectively intervening in the pathological behaviors of the Individual. The client and family may require assistance in identifying available resources. Social Resources: The individual has adequate family and/or social support to provide the successful context for Case Management services. The participation of family members or legal custodian(s) is essential for Case Management services to be successful. INTENSITY OF SERVICE ELEMENTS: When Case Management is being provided, treatment should include the following services as further justification for continued care: 1. An individualized treatment plan with specific goals and attendant plans for interventions. The treatment plan includes the active participation and involvement of the family/legal custodian and identifies collaborative agencies and their roles in the comprehensive treatment of the Individual. 2. Symptoms described correspond to the diagnosis and meet criteria as specified in the DSM-5. 3. Plan includes interventions appropriate to crises as they occur (e.g., 24 hour call capacity). 4. Frequency and duration of contact are appropriate to the plan of care. 5. Multiple agencies are involved in delivering services. Coordination of services will help minimize redundancy as well as ensure a cohesive and efficient treatment planning approach. CONTINUED STAY CRITERIA:

In order to justify continued Case Management services, the client must continue to manifest symptoms justifying the principal DSM-5 diagnosis and one of the following: 1. The individual continues to obtain services from multiple agencies such that the coordination of such care is determined to be essential for the positive outcome of treatment. 2. The individual remains at high risk for multiple hospitalizations or other forms of intensive treatment. 3. The individual and family are compliant with treatment and progress is being made in achieving treatment plan goals. DISCHARGE CRITERIA: Termination or interruption of Case Management is appropriate under the following conditions: a) The individual s condition has improved to the point that treatment can proceed within the scope of traditional outpatient services, or b) The individual and/or family are uncooperative with treatment and further progress seems unlikely, or c) Progress as documented in the record does not justify continuation at this level of care, or d) Another agency assumes responsibility for the care of the individual, or e) The individual declines further case management.

KENTUCKY MOBILE CRISIS INTERVENTION SERVICES PURPOSE: Crisis intervention is a clinical service rendered to individuals with a mental health condition who are at imminent risk of harm to self or others or at risk for significant decompensation if immediate interventions are not taken. Mobile crisis intervention is the provision of services to a client at their current location rather than requiring the client to go to a designated facility. Providers of mobile crisis intervention services must be available to travel to the client s location 24 hours a day, 365 days a year. Crisis intervention specialists must be licensed mental health professionals who have immediate access to a board certified/board eligible psychiatrist at all time. The crisis intervention specialist should be capable of resolving immediate threats to the client s welfare including arranging emergency treatment as appropriate. Appropriate client s for mobile crisis services are those individuals who, by history, lack the insight or ability to access services when their mental health condition deteriorates to the point where they are an imminent danger to themselves or others. Mobile crisis services are not intended to provide on-going, in-home care for individuals who won t participate in outpatient treatment. ADMISSION CRITERIA: To be eligible for mobile crisis services a client must: 1. Be suffering from a significant mental illness that puts them at risk for rapid decompensation in psychological or social functioning. 2. The client s ability to access alternative crisis services is impaired. GLOBAL INDICATORS: 1. Patient presents with at least one valid DSM-5 diagnosis. 2. The client s condition must be directly attributable to the designated mental disorder and not to Antisocial Personality or be a part of a pervasive pattern of antisocial conduct. 3. Prior history indicates that the client is likely to experience severe rapid decompensation and be unable to obtain necessary services without a mobile intervention. PROGRAM AND SERVICES REQUIREMENTS: 1. Mobile crisis services must be provided by a Community Mental Health Center licensed to provide the services.

2. Potential clients must undergo a comprehensive assessment that indicates a potential benefit from mobile crisis services. 3. There must be a mental health professional available at all times to go immediately to the client s location. 4. There must be immediate availability of psychiatric supervision. 5. Ongoing records must be kept of the client s current treatment including names and contact numbers for all providers, names and contact numbers for family and other support individuals, as well as current medications and current medical problems. These records must be continuously updated as the client s circumstances change. 6. An individualized plan for crisis intervention must be designed. 7. Individuals responsible for conducting mobile services must have access to the client s crisis plan as well as their current treatment plan. SEVERITY OF ILLNESS: An objective professional evaluation of the client s current condition indicates a level of severity appropriate to Mobile Crisis Services as evidenced by one or more of the following: Impairment in Safety: The client has a history of being at risk for harm to self and/or others. Impairment in Self Care: The client has a history of being periodically unable to provide for self care due to an exacerbation of their mental illness. Impairment in Reality Construction: The client has a history of psychotic illness that impairs their insight or judgment to the point that they are unable to obtain appropriate care. Impairment in Social Functioning: The client has a history of rapid deterioration in social functioning that impairs their ability to remain in a community setting. LIMITATION IN PERSONAL AND/OR SOCIAL RESOURCES: Personal Resources: During periods of crisis the client has the personal resources to benefit from immediate services and stabilize to the point where hospitalization can be avoided. Social Resources: The client has sufficient social support to continue to reside in the community if Mobile Crisis Intervention is provided.

CONTINUED STAY CRITERIA: In order to justify continued Mobile Crisis Services, the client must continue to manifest symptoms justifying the principal DSM-5 diagnosis and one of the following: 1. The client continues to be at significant risk for harm to self or others or at risk for significant decompensation. 2. The client lacks the insight or ability to obtain services during periods of crisis. The patient and family are compliant with treatment and progress is being made in achieving treatment plan goals. 3. Experience has shown the Mobile Crisis Intervention has been effective in maintaining the client in the community and/or reducing self harm, social or psychological deterioration. DISCHARGE CRITERIA: Termination of Mobile Crisis Services is appropriate under the following conditions: a) The client s condition has improved to the point that they no longer require the services. b) The client is unable to cooperate with the service providers. c) Mobile Crisis Services have been found to be unsuccessful in improving the client s situation during periods of crisis. d) Another agency assumes responsibility for the care of the client. e) The clinic refuses Mobile Crisis Services when they are not in crisis and stable.

KENTUCKY PEER SUPPORT SERVICES PROGRAM DESCRIPTION Peer support services are designed to maintain and improve the level of functioning of individuals with significant impairment in day-to-day personal, social, vocational and educational functioning due to mental illness. Peer support is provided to the adult or adolescent client or their family by individuals under the supervision of a mental health professional. The role of peer support is to provide insight and understanding of the client or family s situation based on the peer s experience with similar situations. The peer is expected to engage in structured and scheduled non-clinical activities that promote socialization, recovery, self advocacy, preservation and enhancement of community living skills. SERVICE ELEMENTS: 1. Peer support services may only be provided by Community Mental Hearth Centers licensed to provide the service. 2. Peer support providers must meet criteria designated by the State of Kentucky (908 KAR 2:220). 3. Every peer support specialist must be supervised by a mental health professional. ADMISSION CRITERIA: Medicaid members currently enrolled in a Community Mental Health Center are eligible for peer support if the client s treatment team determines that they would benefit from peer support and the client is accepting of the service. GLOBAL INDICATORS: 1) A valid DSM-5 diagnosis. 2) Demonstrated inability to function independently or demonstrated inability to maintain independent functioning without support. 3) Ability to participate and benefit from peer support and rehabilitation activity. SEVERITY OF ILLNESS: There must be historical evidence of behavioral or cognitive dysfunction sufficient to prevent functioning independently. Confidential and Proprietary Page 1 of 2 2014 MHNet Behavioral Health

LIMITATIONS IN PERSONAL/SOCIAL RESOURCES: There is a demonstrated lack of resources sufficient to sustain the member in the community without ongoing support. INTENSITY OF SERVICES: Services may range from daily contact in a clubhouse setting to monthly contact on an individual basis. The type, frequency and duration of treatment must be individualized, must be the least restrictive possible and must be reviewed at least every 6 months. CONTINUED STAY CRITERIA: 1. The member is demonstrating significant progress towards skill acquisition and/or, 2. The member s skills would deteriorate leading to an inability to sustain themselves in the community without continued peer support. DISCHARGE CRITERIA: 1. The member is able to sustain themselves in the community without further support. 2. The member refuses to participate in the peer support program. 3. Further peer support is not expected to maintain or improve the member s outcome. Confidential and Proprietary Page 2 of 2 2014 MHNet Behavioral Health

PROGRAM DEFINITION: KENTUCKY CRISIS STABILIZATION The State of Kentucky recognizes the need for crisis stabilization units for individuals who are experiencing an acute emergency that cannot be safely managed in the individual s community. Crisis stabilization units are designed for short term use to stabilize the individual and avoid an inpatient admission. In addition to providing residential facilities, the crisis stabilization units must be capable of providing screening evaluations, bio-psych-social assessments, treatment planning, individual, family and group therapy, psychiatric services and peer support. Daytime staffing and programming should be comparable to an outpatient day treatment program. Crisis stabilization can be used for individuals experiencing a psychiatric emergency as well as individuals needing substance abuse stabilization including non-medically monitored detoxification. Crisis stabilization units must be operated independent of any inpatient or residential treatment facility. Since they are designed strictly for stabilization, ancillary services such as education, vocational training, habilitation, recreation or social activities are not appropriate. ADMISSION CRITERIA: Admission to a crisis stabilization unit must be based on the following Global Indicators, Indicators of Severity of Illness and further justified by Limitations of Personal and/or Social Resources and by Intensity of Services appropriate to partial hospitalization. GLOBAL INDICATORS: 1. The member presents at least one valid DSM-5 diagnosis and a failure to admit to a crisis stabilization unit is likely to result in imminent admission to inpatient care, and 2. The member s condition must be directly attributable to the designated mental disorder and not to Antisocial Personality Disorder, or be a part of a pervasive pattern of antisocial conduct, and 3. The member s symptoms are amenable to brief residential treatment with an expectation that they will return to their community and 4. Treatment in a less restrictive setting is deemed to be inappropriate due to the severity of the member s condition, and 5. Specialized intervention is considered likely to be effective and is essential to contain risks presented and to provide for improvement.

SEVERITY OF ILLNESS: The member must be able to benefit from psychological and behavioral interventions as evidenced by the absence of significant cognitive impairment (i.e. significant dementia). An objective, professional evaluation of the member s current condition indicates an acute level of severity appropriate to crisis stabilization as evidenced by the following: Impairment in Safety: The member may be experiencing suicidal/homicidal ideation with a plan and expressed intent. The member must be able to contract for safety while in the crisis stabilization unit. The suicidal/homicidal ideation is expected to resolve in a few days and/or the member must have a social support system available to support them post-discharge. Impairment in Self-Care: The member may be experiencing noticeable impairment in ADLs (i.e., disheveled clothing, unkempt appearance, and poor personal hygiene). The member may be experiencing significant impairment in their eating and/or sleeping patterns. Impairment in Reality Construction: The member is sufficiently intact to benefit from brief crisis intervention strategies. Impairment in Social Functioning: This level of care is considered appropriate for patients who are unable to function in unmonitored social/occupational settings. The member s acute symptoms disable them from fulfilling occupational roles/responsibilities. The member may be exhibiting/verbalizing a noticeable decrease in personal interactions. The member has the capacity to benefit from continuing involvement with family/social support system. Complicating Conditions: Biomedical complications are minimal, coexisting long term psychological problems will not prevent stabilization and a return to the community. Any complications from pharmacological intervention are considered manageable. Exclusion Medical conditions in and of themselves, are not sufficient justification for admission. Exclusion Unless medically necessary, court-ordered treatment is considered an exclusion. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: The member presents with limitations in resources to resolve presenting problems as indicated by:

Limited Personal Resources The member has adequate cognitive and emotional coping skills to actively participate in care. The member is capable of controlling their behavior and/or has the ability to seek assistance while in the program. Limited Social Resources The member has an adequate social support system, including a suitable environment to support them in the community once the acute crisis is resolved. Exclusion Limitations in resources, in and of themselves, are not sufficient justification for admission. INTENSITY OF SERVICE ELEMENTS: Within the crisis stabilization unit, the following program elements must be provided to satisfy medical necessity criteria: 1. A comprehensive psychiatric evaluation must be conducted and documented on the day of admission. This evaluation must include an initial treatment plan and tentative discharge plan. 2. Structured daily program, including nursing and medical supervision. 3. An individualized treatment plan with specific goals and intervention plans. 4. A structured activities schedule which can include individual, family and group therapy. 5. A plan exists for management of any unanticipated medical or psychiatric deterioration. 6. Linkages with appropriate support groups (e.g., AA or Overeaters Anonymous). 7. A psychiatrist must be available every day of treatment providing daily supervision of care and ongoing medication monitoring and adjustment. CONTINUED STAY CRITERIA: The expected length of stay in a crisis stabilization unit is 1-4 days. In order to justify remaining in a crisis stabilization unit, the member must continue to manifest symptoms related to the principal DSM-5 diagnosis and the following: 1. Admission criteria must be met. 2. Clinical documentation supports the member s active progress toward treatment goals. 3. Clinical documentation shows that a less restrictive level of care would result in exacerbation of the member s condition.

4. The member is cooperating with caregivers and actively involved in care. 5. Family involvement is appropriate to the goal of sustaining the progress that is being made. 6. The member is actively participating in aftercare planning. DISCHARGE CRITERIA: The member is ready for discharge when they satisfy any of the following criteria: a) They complete the treatment plan, or b) The impairment in functioning can be managed in the community without residential care, or c) The member leaves AMA, or d) The member is admitted to a higher level of care, or e) The member s condition is deemed to be chronic and not amenable to crisis intervention.

KENTUCKY THERAPEUTIC FOSTER CARE PURPOSE: Therapeutic foster care is designed to meet the needs of children and adolescents who suffer from a mental illness and/or substance abuse who cannot be managed in a traditional foster care setting. ADMISSION CRITERIA: To be eligible for therapeutic foster care a child or adolescent must: a) Be in the temporary custody of an agency, or at risk of such and, b) Have a diagnosed active mental illness or substance abuse that precludes placement in a traditional foster home and, c) The member s mental health and/or substance abuse needs can be met in a Therapeutic Foster Care setting. GLOBAL INDICATORS: 1. The member presents with at least one active DSM-5 diagnosis. 2. The member s condition must be directly attributable to the designated mental disorder and not to Antisocial Personality or be a part of a pervasive pattern of antisocial conduct. 3. The member is in the temporary custody of a child welfare agency, or at risk of such, and is in need of foster care. 4. The member is expected to improve to the point where they can be transitioned to home-based care within 3 months. PROGRAM AND SERVICES REQUIREMENTS: The foster home is managed by a Therapeutic Foster Parent who is supervised by a child-placing agency and has completed specialty training and annual re-training in accordance with 907 KAR 3:030. Mentoring, counseling, behavioral therapy and crisis intervention services must be available within the therapeutic foster care setting. Family services must also be available for those adolescents and children who are being considered for reunification with their parent(s) or guardian. Individuals assigned to therapeutic foster care must have a Collaborative Service Plan that includes visitation with parents(s) or guardians if reunification is a possibility, a plan for home based therapy services, a behavior management plan, Targeted Case Management, individual therapy, social skills training and a plan for transitioning to home-based services. The expected time to transition to home-based services is 3 months or less.

SEVERITY OF ILLNESS: An objective professional evaluation of the member s current condition indicates a level of severity appropriate to Therapeutic Foster Care as evidenced by one or more of the following: Impairment in Safety: The member has a history of being at risk for harm to self and/or others. Impairment in Self Care: The member has a history of being periodically unable to provide for self care due to an exacerbation of their mental illness or substance abuse. Impairment in Reality Construction: Any impairment is sufficiently mild that it can be managed in a therapeutic foster care setting. Impairment in Social Functioning: Impairments in social functioning can be managed in a therapeutic foster care setting and are amenable to behavioral therapy. LIMITATION IN PERSONAL AND/OR SOCIAL RESOURCES: Personal Resources: The member has sufficient personal resources to benefit from therapeutic foster care. Social Resources: Limitation in social resources per se does not preclude participation in therapeutic foster care. CONTINUED STAY CRITERIA: In order to justify continued therapeutic foster care, the member must continue to manifest symptoms justifying the principal DSM-5 diagnosis and: 1. The member is making progress towards achieving treatment goals or there is an expectation that they will make progress in the immediate future, and 2. There is a comprehensive treatment plan in place that address all of the member s bio-psycho-social needs including active discharge planning, and 3. The treatment plan is expected to result in home-based placement within 3 months of admission. DISCHARGE CRITERIA:

1. The member has been successfully transitioned to home-based care, or 2. The member is transferred to an alternative level of care, or 3. The member is no longer under guardianship with an agency that can authorize foster care, or 4. Improvement to the point where the member can be transitioned to home-based care in the near future is no longer feasible.

MISSOURI MEDICAID RESPITE CARE FOR THE SERIOUSLY MENTALLY ILL Respite care refers to short term assistance provided to a primary caregiver who is temporarily unable to meet the physical or emotional needs of a significantly impaired individual. Under respite care, services are provided to the significantly impaired individual to afford the primary caregiver temporary relief from their usual duties and obligations. ADMISSION CRITERIA: Eligibility for respite care requires that the member meet several criteria: a) they must suffer from a severe mental illness or pervasive developmental disorder that requires continuous monitoring by a caregiver, b) they must be in a stable living situation where the primary caregiver is capable of meeting their needs, c) the primary caregiver has a time limited situation that necessitates assistance in providing continuous care and d) no other means of temporary care exists. Examples of time-limited situations include an acute medical problem, family crisis or need for a break from care. Respite care is not intended as an on-going source of care or support. Respite care may not be used to fill an on-going gap in the capabilities of the primary care giver. GLOBAL INDICATORS: (Must meet all of the following) 1. The member has been diagnosed as suffering from a severe and persistent mental illness including a pervasive developmental disorder. 2. The member is in a stable living environment where their routine physical and emotional needs can be met. 3. There has been a significant change in the primary care giver s ability to meet the needs of the member or the caregiver is in need of short-term relief to maintain their physical and emotional health. 4. Time limited respite care will be sufficient to resolve the primary care giver s situation. SEVERITY OF ILLNESS An objective professional evaluation of the member s current condition indicates a level of severity that requires continuous monitoring by a caregiver. Impairment in Safety: The patient presents a significant risk to himself or herself if left unattended for more than a few minutes. Impairment in Self Care: The member is incapable of providing routine self-care.

Impairment in Reality Construction: Any impairment is not so severe as to preclude the primary caregiver from meeting the member s needs. Complicating Conditions: There are no other complicating conditions that preclude benefit from treatment. LIMITATIONS IN PERSONAL AND/OR SOCIAL RESOURCES: By definition, patients with serious and persistent mental illnesses and pervasive developmental disorders lack personal and social resources necessary for recovery. Exclusions: The inability of the primary care giver of the member to provide for the ongoing routine needs of the member is not sufficient justification for respite care. INTENSITY OF SERVICE ELEMENTS: The frequency and intensity of service can vary between a few hours per day of monitoring in a safe environment by a trained caregiver to several days in a residential setting. Regardless of the treatment setting, the respite care provider must have the following service elements: 1. The location must be structured so as to minimize the risk of self-injury. 2. There must be continuous monitoring of the member at all times. 3. Individuals conducting the monitoring must be certified in the management of individuals with serious mental illnesses and/or pervasive developmental disorders. 4. There must be facilities for bathing, toileting and provision of meals. 5. The staff has the capability to distribute medication and obtain emergency care if necessary. CONTINUED STAY CRITERIA: The expected duration of respite care should be determined at the time of initial authorization. Continued stay is appropriate as long as the acute problem necessitating respite care remains unresolved. In the event that the acute situation is not resolved at the end of the initial authorization, continued respite care can be authorized if, and only if, there is a reasonable expectation that the primary caregiver will be able to meet the needs of the member in the near future. At minimum, the need for continuing respite care must be evaluated every 7 days. DISCHARGE CRITERIA: 1. The primary caregiver is able to meet the needs of the member without the assistance of respite care.

2. The primary caregiver is no longer capable of meeting the needs of the member and alternative placement is required.

TEAM TREATMENT PLANNING WEST VIRGINIA MEDICAID MEMBERS All members receiving services from licensed providers at a Behavioral Health Clinic must receive an individualized service plan. This plan must be developed by a multidisciplinary team. The team will prepare an initial plan within 7 days of starting treatment. A master treatment plan will be developed within 30 days of initiating treatment. The plan must be updated at the time of significant junctures in treatment or every 90 days, whichever is shorter. The treatment team will be comprised of various professional disciplines depending on the needs of the member. Physician participants in the treatment team may bill for the time spent in treatment planning using the procedure code G9008. Psychologists may bill for the time spent using procedure code H0032 AH. All other professional participants in the treatment planning meeting may bill using the procedure code H0032. Only those professionals that are required for the specific member s treatment may bill for participation in the planning meetings. All treatment planning must be documented in accordance with the West Virginia Bureau of Medical Services. ADMISSION CRITERIA: All Medicaid members currently enrolled in treatment at a Behavioral Health Clinic. GLOBAL INDICATORS: 1. Must have a valid DSM-5 psychiatric diagnosis. 2. Condition is responsive to treatment and/or will deteriorate in the absence of treatment. SEVERITY OF ILLNESS: Condition must cause significant impairment in one or more areas of function (social, academic, vocational). LIMITATIONS IN PERSONAL/SOCIAL RESOURCES: Member s resources are insufficient to sustain him/her the community without professional services. INTENSITY OF SERVICES:

The treatment team must be composed of the full range of professional disciplines necessary to ensure that all areas of member need can be addressed. CONTINUED STAY CRITERIA: Member will continue as long as they are receiving active treatment in the Behavioral Health Clinic. DISCHARGE CRITERIA: The Member is no longer receiving active treatment.

CASE CONSULTATION SERVICES WEST VIRGINIA MEDICAID MEMBERS During the course of treatment, a member s treatment team may request the services of a consultant to explain or interpret the results of psychiatric and other medical examinations and procedures to the requesting clinician for the purposes of informing the member, their family or other responsible individual. Consultants chosen for this purpose may not be members of the treatment team. In addition they must have knowledge and expertise that is not available through existing team members. Consultants must document the exact nature of the consultation, their findings and the time spent in performing the consultation. Consultants may bill for their services using procedure code 90887. ADMISSION CRITERIA: Any Medicaid member currently enrolled in a behavioral health clinic whose treatment team requires psychiatric expertise not available in the team members. GLOBAL INDICATORS: Not applicable. SEVERITY OF ILLNESS: The member s condition must be sufficiently severe that the absence of a consultation could result in a significant deficit in treatment. LIMITATIONS IN PERSONAL/SOCIAL RESOURCES: Not applicable. INTENSITY OF SERVICES: Consultation should involve a one time documented evaluation that includes written recommendations. CONTINUED STAY CRITERIA: Not applicable.

DISCHARGE CRITERIA: Member should be discharged once the consultation is complete.

SKILLS TRAINING AND DEVELOPMENT WEST VIRGINIA MEDICAID MEMBERS Skills training is a treatment activity designed to address specific skill deficits in individuals who have failed to develop their expected range of adult skills. These skills may include deficits in personal hygiene, managing their living space, interpersonal/communication ability, social appropriateness, etc. These deficits usually arise from the member being raised in a non-nurturing or abusive environment. Skill training can be provided 1:1 or in small groups of 2-4 individuals. Candidates for skills training and development must have well defined deficits in specific skills. They must have an individualized treatment plan that identifies the specific skill to be acquired, the techniques to be used to acquire the skill and a time frame for skill acquisition. Progress notes must document progress towards skill acquisition. An updated treatment plan must be developed if a member fails to meet their skill acquisition goal and additional treatment is recommended. ADMISSION CRITERIA: Any Medicaid member currently enrolled in a Behavioral Health Clinic with limited skills due to a failure of their environment to adequately nurture their development. GLOBAL INDICATORS: 1. A valid DSM-5 diagnosis. 2. Objective evidence of specific skills deficit(s). 3. Evidence that the individual can respond to skills training. SEVERITY OF ILLNESS: Skills deficit(s) must negatively impact on the individual s ability to function in one or more areas (academic, social, vocational, self care). LIMITATIONS IN PERSONAL/SOCIAL RESOURCES: The member does not have the resources to develop the necessary skills on their own. INTENSITY OF SERVICES: Individual or small group (less than 5 individuals) sessions weekly.

CONTINUED STAY CRITERIA: 1. Member is actively participating in treatment. 2. There is evidence of significant progress in achieving goals. 3. The treatment plan is periodically updated to reflect any changes in treatment approach. 4. Discontinuation of training would result in a significant deterioration in skill functioning. DISCHARGE CRITERIA: 1. Skills have been acquired 2. Further training is not expected to result in further improvement or deterioration. 3. Discontinuation of training will not result in significant regression.

ASSERTIVE COMMUNITY TREATMENT WEST VIRGINIA MEDICAID MEMBERS West Virginia Medicaid members are eligible for specialty services under the provisions of Assertive Community Treatment (ACT). This program is designed for individuals with serious and persistent mental illness who are at high risk for decompensation and hospitalization. To be eligible for admission to the program an individual must have had: a) three or more psychiatric hospitalizations in the previous 12 months, b) five or more psychiatric hospitalizations or admissions to a Community Psychiatric Supportive Treatment Program in the past 24 months c) 180 days of psychiatric hospitalization in the past 12 months. Staff qualifications, team membership, service requirements, case-load and documentation requirements for ACT are defined by the West Virginia Bureau of Medical Services. These services are billed for as an all-inclusive per diem. No other services can be billed for the member while participating in ACT except for Case Consultation, depot antipsychotic injections, and mileage. If a member covered by ACT is hospitalized, no ACT billing can be made during the hospitalization. The ACT team must, however, actively participate in the inpatient treatment planning. Once enrolled in ACT, members will remain in the program until the Bureau of Medical Services determines that they are no longer eligible. However, members who consistently refuse to participate in the program for 6 months may be placed in an inactive status. ADMISSION CRITERIA: Any Medicaid member who is at high risk for hospitalization based on their immediate past psychiatric history. GLOBAL INDICATORS: 1. The member must have a valid DSM-5 diagnosis. 2. The member must have had: a) three or more psychiatric hospitalizations in the previous 12 months, b) five or more psychiatric hospitalizations or admissions to a Community Psychiatric Supportive Treatment Program in the past 24 months c) 180 days of psychiatric hospitalization in the past 12 months.

SEVERITY OF ILLNESS: The member s illness must be of sufficient severity that they are at high risk for deterioration and hospitalization if not provided on-going daily supervision by licensed mental health professionals. LIMITATIONS IN PERSONAL/SOCIAL RESOURCES: Member s resources are insufficient to sustain the member in the community without daily professional supervision. INTENSITY OF SERVICES: The services must meet the criteria for ACT as defined by the West Virginia Bureau of Medical Services. CONTINUED STAY CRITERIA: Member will continue in services as long as they remain at high risk for hospitalization. DISCHARGE CRITERIA: 1) The member is no longer at high risk for hospitalization. 2) The member fails to participate for 6 months. This will result in the member being placed in an inactive status.

COMPREHENSIVE COMMUNITY SUPPORT WEST VIRGINIA MEDICAID MEMBERS Comprehensive community support is designed to maintain and improve the level of functioning among individuals with severe and persistent mental illness. It is specifically designed for individuals who require frequent individualized support but do not require a day treatment program. Comprehensive community support is provided at licensed treatment sites or in the community. Examples of skills training/maintenance include: personal hygiene, interpersonal skills, communication, meal preparation, etc. Comprehensive community support must be an identified need in the member s master treatment plan. The treatment team is responsible for reviewing the comprehensive community support plan and monitoring progress towards treatment goals. Only individuals who are actively participating and shown to be maintaining or improving skills should continue in the community support program. ADMISSION CRITERIA: Medicaid members currently enrolled in a Behavioral Health Clinic who are in need of ongoing support to maintain themselves in the community. GLOBAL INDICATORS: 1) A valid DSM-5 diagnosis. 2) Evidence of serious and persistent mental illness. 3) Demonstrated inability to perform basic activities of daily living. 4) Ability to participate in community support activity. SEVERITY OF ILLNESS: Must have historical evidence of sufficient illness severity to prevent functioning in a community setting. LIMITATIONS IN PERSONAL/SOCIAL RESOURCES: There is a demonstrated lack of resources sufficient to sustain the member in the community without ongoing support. INTENSITY OF SERVICES: Individualized weekly contact with a skills training specialist. CONTINUED STAY CRITERIA:

1. The member is demonstrating significant progress towards skill acquisition. 2. The member s skills would deteriorate leading to an inability to sustain themselves in the community without continued support. DISCHARGE CRITERIA: 1. The member is able to sustain themselves in the community without further support. 2. The member refuses to participate in the community support program. 3. Further treatment is not expected to maintain or improve the member s outcome.

BEHAVIORAL HEALTH CLINIC DAY TREATMENT WEST VIRGINIA MEDICAID MEMBERS Behavioral health clinic day treatment is a program for Medicaid members who suffer from mental retardation or are developmentally disabled. The program is designed to facilitate increased independence and/or maintain current level of functioning. Candidates for treatment in this program must demonstrate the ability to participate and learn from the skills training. They must have an individualized treatment plan that identifies specific areas to be addressed along with the techniques to be used. There must be documentation on a daily basis of participation and specific skills that were addressed. There must be a comprehensive review of the treatment program every 90 days. Members may continue to participate only as long as they demonstrate active involvement in the program. ADMISSION CRITERIA: Medicaid members who would benefit from daily structured activities designed to maintain and improve their ability to function independently. GLOBAL INDICATORS: 1) A valid diagnosis of mental retardation or developmental disability. 2) Demonstrated ability to acquire new skills and/or an expectation that acquired skills will be lost without ongoing reinforcement. 3) Ability to participate in activities with other members. 4) Ability to benefit from daily structured activity. SEVERITY OF ILLNESS: The member s condition must be of sufficient severity to significantly impair self care or interpersonal functioning. LIMITATIONS IN PERSONAL/SOCIAL RESOURCES: The member lacks sufficient resources to obtain the necessary support outside of a day treatment program. INTENSITY OF SERVICES: Daily programming at least 3 hours per day that meets the requirements of the West Virginia Bureau of Medical Services requirements. CONTINUED STAY CRITERIA:

1) The member is actively participating in the program. 2) Treatment goals are being met. 3) Discontinuation of treatment would result in significant loss of functioning. DISCHARGE CRITERIA: 1) The member refuses to participate. 2) There is no expectation of improvement in the member s condition. 3) The member is unlikely to deteriorate if treatment is discontinued.

TREATMENT PLAN DEVELOPMENT AND MODIFICATIOIN FLORIDA MEDICAID All members receiving services from licensed providers at a Behavioral Health Clinic must receive an individualized service plan. This plan must be developed by a multidisciplinary team. The treating practitioner (physician or licensed independent practitioner) is responsible for the plan. The plan must be completed within 45 days of initiating treatment. The plan must be formally reviewed at least every 6 months or whenever significant changes occur. The treatment team will be comprised of various professional disciplines depending on the needs of the member. All treatment planning must be conducted and documented in accordance with the Florida Community Behavioral Health Services Coverage and Limitations Handbook. The plan must include: Goals that are appropriate to the member Measurable objectives and target dates A list of services to be provided along with the designated provider The amount and frequency of each service until the next treatment plan review Names and signatures of all treatment plan members Signature of the member, (unless an exception is noted) For members under the age of 18 the signature of a parent, guardian or legal custodian (unless an exception is noted) A statement by the treating practitioner that all services are medically necessary ADMISSION CRITERIA: All Medicaid members currently enrolled in treatment at a Behavioral Health Clinic. GLOBAL INDICATORS: 1. Must have a valid DSM-5 psychiatric diagnosis. 2. The condition is responsive to treatment and/or will deteriorate in the absence of treatment. SEVERITY OF ILLNESS: Confidential and Proprietary Page 1 of 2 2014 MHNet Behavioral Health

The condition must cause significant impairment in one or more areas of function (social, academic, vocational). LIMITATIONS IN PERSONAL/SOCIAL RESOURCES: Member s resources are insufficient to sustain him/her in the community without professional services. INTENSITY OF SERVICES: The treatment team must be composed of the full range of professional disciplines necessary to ensure that all areas of member need can be addressed. CONTINUED STAY CRITERIA: Member will continue as long as they are receiving active treatment in the Behavioral Health Clinic. DISCHARGE CRITERIA: The Member is no longer receiving active treatment. Confidential and Proprietary Page 2 of 2 2014 MHNet Behavioral Health

COMMUNITY SUPPORT AND REHABILITATIVE SERVICES FLORIDA MEDICAID Community support and rehabilitative services is designed to maintain and improve the level of functioning of individuals with significant impairment in day-to-day personal, social, prevocational and educational functioning due to psychiatric, behavioral, cognitive or addictive disturbances. Community support and rehabilitative services may be provided in a facility, the member s home, other community settings (e.g. workplace or school) as well as a therapeutic clubhouse. Examples of problems to be addressed include: daily living skills, food planning and preparation, money management, maintenance of the environment and training in appropriate use of community services. Participation in a community support and rehabilitation program must be included in the member s treatment plan if they are enrolled in a Behavioral Health Clinic. In the absence of a Behavioral Health Clinic treatment plan, the primary service provider must document the member s specific impairment(s) that are to be addressed, the procedure for addressing each impairment, as well as the frequency and expected duration of the intervention. All services under the community support and rehabilitation must be provided by: A behavioral health technician under the supervision of a bachelor s level practitioner; A bachelor s level practitioner under the supervision of a master s level practitioner; A substance abuse technician; A certified addictions professional. ADMISSION CRITERIA: Medicaid members [currently enrolled in a Behavioral Health Clinic] who have impairments in skills or functioning necessary for independent living who can be reasonably be expected to improve with treatment. GLOBAL INDICATORS: 1) A valid DSM-5 diagnosis. 2) Demonstrated inability to function independently or demonstrated inability to maintain independent functioning without support 3) Ability to participate and benefit from community support and rehabilitation activity. SEVERITY OF ILLNESS: Confidential and Proprietary Page 1 of 2 2014 MHNet Behavioral Health

Must have historical evidence of behavioral or cognitive dysfunction sufficient to prevent functioning independently. LIMITATIONS IN PERSONAL/SOCIAL RESOURCES: There is a demonstrated lack of resources sufficient to sustain the member in the community without ongoing support. INTENSITY OF SERVICES: Services may range from daily contact in a clubhouse setting to monthly contact on an individual basis. The type, frequency and duration of treatment must be individualized, must be the least restrictive possible and must be reviewed at least every 6 months. CONTINUED STAY CRITERIA: 1. The member is demonstrating significant progress towards skill acquisition. 2. The member s skills would deteriorate leading to an inability to sustain themselves in the community without continued support. DISCHARGE CRITERIA: 1. The member is able to sustain themselves in the community without further support. 2. The member refuses to participate in the community support program. 3. Further treatment is not expected to maintain or improve the member s outcome. Confidential and Proprietary Page 2 of 2 2014 MHNet Behavioral Health