Coverage Determination

Transcription

COVERAGE
DETERMINATION
GUIDELINE
OPTUM™
By United Behavioral Health
Treatment of Dissociative Identity Disorder
Guideline Number: BHCDG822014
Product:
Effective Date: September, 2013
2001 Generic UnitedHealthcare COC/SPD
Revision Date: October, 2014
Table of Contents:
Instructions for Use………………………2
Key Points………………………………...2
Benefits…………………………………….2
Clinical Best Practices…………………...5
Level of Care Criteria…………………...11
Additional Resources…………………...18
Definitions………………………………..19
Related Coverage Determination
Guidelines:
Related Medical Policies:
Level of Care Guidelines
International Society for Study of Trauma &
Dissociation, Guidelines for Treating
Dissociative Identity Disorder in Adults, 2011
Optum Behavioral Health Sciences
Literature Review, Dissociative Identity
Disorder, 2013
References……………………………....19
Coding…………………………………....20
History…………………………………….22
INSTRUCTIONS FOR USE
This Coverage Determination Guideline provides assistance in interpreting behavioral health
benefit plans that are managed by Optum. This Coverage Determination Guideline is also
applicable to behavioral health benefit plans managed by Pacificare Behavioral Health and U.S.
Behavioral Health Plan, California (doing business as Optum California (“Optum-CA”). When
deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee’s
document (e.g., Certificates of Coverage (COCs), Schedules of Benefits (SOBs), or Summary
Plan Descriptions (SPDs) may differ greatly from the standard benefit plans upon which this
guideline is based. In the event that the requested service or procedure is limited or excluded
from the benefit, is defined differently, or there is otherwise a conflict between this document and
the COC/SPD, the enrollee's specific benefit document supersedes these guidelines.
All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements
that supersede the COC/SPD and the plan benefit coverage prior to use of this guideline. Other
coverage determination guidelines and clinical guideline may apply.
Optum reserves the right, in its sole discretion, to modify its coverage determination guidelines
and clinical guidelines as necessary.
While this Coverage Determination Guideline does reflect Optum’s understanding of current best
practices in care, it does not constitute medical advice.
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Coverage Determination Guideline
Confidential and Proprietary, © Optum 2014
Optum is a brand used by United Behavioral Health and its affiliates.
Key Points

Dissociative Identity Disorder (DID) is characterized by the presence of two or more distinct
identities or personality states, each with its own relatively enduring pattern of perceiving,
relating to, and thinking about the environment and self, that recurrently take control of the
individual’s behavior, with the inability to recall personal information that cannot be explained
by ordinary forgetfulness. The disturbance is not due to the effects of substance use or due
th
to a medical (Diagnostic and Statistical Manual of Mental Disorders, 5 ed.; DSM-5;
American Psychiatric Association, 2013).

Benefits are available for covered services that are not otherwise limited or excluded.

Pre-notification is required for inpatient, residential treatment, partial hospital/day treatment,
intensive outpatient treatment programs and home-based outpatient treatment.

Services should be consistent with evidence-based interventions and clinical best practices
as described in Part II, and should be of sufficient intensity to address the member's needs
(Certificate of Coverage, 2007, 2009 & 2011).
PART I: BENEFITS
Before using this guideline, please check enrollee’s specific plan document and
any federal or state mandates, if applicable.
Benefits
Benefits include the following services:

Diagnostic evaluation and assessment

Treatment planning

Referral services

Medication management

Individual, family, therapeutic group and provider-based case
management services

Crisis intervention
Covered Services
Covered Health Service(s) – 2001
Those health services provided for the purpose of preventing, diagnosing or
treating a sickness, injury, mental illness, substance abuse, or their
symptoms.
A Covered Health Service is a health care service or supply described in
Section 1: What's Covered--Benefits as a Covered Health Service, which is
not excluded under Section 2: What's Not Covered--Exclusions.
Covered Health Service(s) – 2007, 2009
Those health services, including services, supplies, or Pharmaceutical
Products, which we determine to be all of the following:
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
Provided for the purpose of preventing, diagnosing or treating a
sickness, injury, mental illness, substance abuse, or their symptoms.

Consistent with nationally recognized scientific evidence as available,
and prevailing medical standards and clinical guidelines as described
below.

Not provided for the convenience of the Covered Person, Physician,
facility or any other person.

Described in this Certificate of Coverage under Section 1: Covered
Health Services and in the Schedule of Benefits.

Not otherwise excluded in this Certificate of Coverage under Section 2:
Exclusions and Limitations.
In applying the above definition, "scientific evidence" and "prevailing medical
standards" shall have the following meanings:

"Scientific evidence" means the results of controlled clinical trials or
other studies published in peer-reviewed, medical literature generally
recognized by the relevant medical specialty community.

"Prevailing medical standards and clinical guidelines" means nationally
recognized professional standards of care including, but not limited to,
national consensus statements, nationally recognized clinical
guidelines, and national specialty society guidelines.
Pre-Service Notification
Admissions to an inpatient, residential treatment center, or a partial hospital/day
treatment program require pre-service notification. Notification of a scheduled
admission must occur at least five (5) business days before admission.
Notification of an unscheduled admission (including Emergency admissions)
should occur as soon as is reasonably possible. Benefits may be reduced if
Optum is not notified of an admission to these levels of care. Check the
member’s specific benefit plan document for the applicable penalty and provision
for a grace period before applying a penalty for failure to notify Optum as
required.
Limitations and Exclusions
The requested service or procedure for the treatment of a mental health condition
must be reviewed against the language in the enrollee's benefit document. When
the requested service or procedure is limited or excluded from the enrollee’s
benefit document, or is otherwise defined differently, it is the terms of the
enrollee's benefit document that prevails.
Inconsistent or Inappropriate Services or Supplies – 2001, 2007, 2009 &
2011
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Services or supplies for the diagnosis or treatment of Mental Illness that, in
the reasonable judgment of the Mental Health/Substance Use Disorder
Designee, are any of the following:

Not consistent with generally accepted standards of medical practice
for the treatment of such conditions.

Not consistent with services backed by credible research soundly
demonstrating that the services or supplies will have a measurable and
beneficial health outcome, and are therefore considered experimental.

Not consistent with the Mental Health/Substance Use Disorder
Designee’s level of care guidelines or best practice guidelines as
modified from time to time.

Not clinically appropriate for the member’s Mental Illness or condition
based on generally accepted standards of medical practice and
benchmarks.
Additional Information
The lack of a specific exclusion that excludes coverage for a service does not
imply that the service is covered.
The following are examples of services that are inconsistent with the Level of
Care Guidelines and Best Practice Guidelines (not an all inclusive list):

Services that deviate from the indications for coverage summarized
earlier in this document.

Admission to an inpatient, residential treatment, partial hospital/day
treatment program or intensive outpatient program without evidencebased treatment of acute symptoms.

treatment program or intensive outpatient program for the sole purpose
of awaiting placement in a long-term facility.

treatment program or intensive outpatient program that does not
provide adequate nursing care and monitoring, or physician coverage.
Please refer to the enrollee’s benefit document for ASO plans with benefit
language other than the generic benefit document language.
PART II: CLINICAL BEST PRACTICES
Evaluation and Treatment Planning
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An evaluation is completed to identify the “why now” factors that precipitated the
need for service (e.g., changes in the member’s signs and symptoms,
psychosocial and environmental factors, or level of functioning) and supports the
choice of the most appropriate treatment setting and formulation of the treatment
plan (LOCGs, 2014). All of the following should be included as part of the
evaluation:
Standard Evaluation
The provider collects information from the member and other sources, and
completes an initial evaluation of the following (LOCGs, 2014):

The member’s chief complaint,

A description of the acute condition or exacerbation of a chronic
condition;

The “why now” factors;

The member’s psychiatric and medical histories including the histories
of substance use, abuse and trauma;

The member’s history of treatment;

Psychosocial and environmental problems;

Mental status examination;

Physical examination (when appropriate);

Risk factors including those related to harm to self or others, as well as
risk stemming from co-occurring behavioral health or medical
conditions;

Assessment of the member’s use of coping strategies;

The member’s readiness for change;

The member’s instructions for treatment or appointment of an agent to
make decisions about mental health treatment; and

The member’s recovery and resiliency goals.
Evaluation of Dissociative Symptoms

Assessment of dissociative symptoms should include the following
(ISSD, 2011):
o Comprehensive clinician-administered structured interviews
(Structured Clinical Interview for Dissociative Disorders-SCID-DR; Dissociative Disorders Interview Schedule-DDIS)
o Comprehensive self-report instruments (Multidimensional
Inventory of Dissociation-MID)
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o Brief self-report screening instruments (Dissociative
Experiences Scale-DES; Dissociation Questionnaire-DIS-Q;
Somatoform Dissociation Questionnaire-SDQ-20)
o Other psychological tests when indicated and according to the
Optum Psychological Testing Guidelines (MMPI, MCMI-III)
o A detailed history of member’s trauma(s) and pattern of
dissociation.
Differential Diagnosis

To ascertain that the full DID criteria have been met, careful differential
diagnosis will ensure the most appropriate care is delivered and
appropriate treatment goals are developed.

Differential diagnosis should identify common conditions that mimic or
overlap with the symptoms of DID (i.e., PTSD, Affective Disorders,
Substance Use Disorders, Psychotic Disorders, Borderline Personality
Disorder, medical conditions, and Dissociative Disorder NOS) (ISSD,
2011).

During the course of a DID differential diagnosis, the five most
commonly missed diagnoses include Bipolar Disorder, Affective
Disorders, Psychotic Disorders, Seizures and Borderline Personality
Disorder (ISSD, 2011).

Dissociative Identity Disorder is most often misdiagnosed when (ISSD,
2011):
o Clinicians who specialize in DID fail to identify nondissociative disorders where dissociative symptoms are
present (PTSD, Somatization Disorder, and Panic Disorder).
o Clinicians assume that amnesia or identity fragmentation
equates to a DID diagnosis.
o Clinicians mistake identity problems common in individuals
with personality disorders as symptoms of DID.
o Mood changes in individuals with Bipolar Disorder are
confused with symptoms DID.
o Delusions associated with Psychotic Disorders are mistaken
for DID symptoms (e.g., being inhabited by other people)
o Dissociative symptoms are present with a non-dissociative
primary diagnosis (e.g., Personality Disorder with
dissociative symptoms and identity disturbances)
o The clinician is not alert to the possibility of factitious or
malingering presentations of DID especially when legal
matters exist.
Treatment Planning
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At the time treatment begins (within 24 hours for inpatient, residential and partial
hospital settings; and within 3 treatment days for intensive outpatient and
outpatient settings) the provider and, whenever possible, the member use the
findings of the initial evaluation and the diagnosis to develop a treatment plan.
The treatment plan should address (LOCGs, 2014):

Specific treatments including the type, amount, frequency and duration
of each treatment;

The expected outcome for each problem to be addressed expressed in
terms that are measurable, functional, time-framed and directly related
to the “why now” factors; and

How the member’s family and other natural resources will participate in
treatment when clinically indicated; and

How treatment will be coordinated with other providers as well as with
agencies or programs with which the member is involved.

As needed, the treatment plan also includes interventions that further
engage the member in treatment, that promote the member’s
participation in care, promote informed decisions, and support the
member’s broader recovery and resiliency goals.

Examples include psychoeducation, motivational interviewing,
recovery and resiliency planning, advance directive planning,
and facilitating involvement with self-help and wraparound
services.

Treatment focuses on addressing the “why now” factors to the point
that the member’s condition can be safely, efficiently and effectively
treated in a less intensive level of care, or treatment is no longer
required.

The provider informs the member of safe and effective treatment
alternatives, potential risks and benefits, and the member gives
informed consent. In providing informed consent, the member
acknowledges willingness and ability to participate in treatment
including any safety precautions; and

A change in the member’s condition prompts a reassessment of the
treatment plan and re-evaluation of level of care. When the member’s
condition has not improved or it has worsened, the reassessment
should determine whether the diagnosis is accurate, the treatment plan
should be modified, or the member’s condition should be treated in
another level of care.
Psychotherapy
There is minimal evidence as to the effectiveness of any one approach for the
treatment of DID. The literature includes the following recommendations (Optum
DID Literature Review, 2013):
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
The goal of treatment for individuals diagnosed with DID is to improve
the member’s overall level of functioning and reduce comorbid
symptoms (e.g., depression and PTSD) (ISSD, 2011).

Treatment should first and foremost address the member’s functional
impairments, and secondarily help the member to address their
experience of dissociation and trauma. A realistic long-term outcome
for some members may be to attain a sufficient level of functioning
although they may continue to experience some dissociative
symptoms (ISSD, 2011).

DID is commonly treated as a trauma-based disorder such as PTSD,
with the use of Dialectical Behavior Therapy and Cognitive Behavioral
approaches, where phased treatment targeting modulation of affect,
impulse control, stabilization from crises, and improving interpersonal
skills results in better treatment outcomes and lower dropout rates
(Optum DID Literature Review, 2013).

Therapy that incorporates or modifies techniques such as Cognitive
Behavioral Therapy (CBT), Eye-Movement Desensitization and
Reprocessing (EMDR), Dialectical Behavior Therapy (DBT) and
Sensorimotor Psychotherapy are most commonly adapted into the
phased approach to treatment (ISSD, 2011).

A phase-oriented treatment approach may include the following
components (ISSD, 2011):
o Phase 1: Establishing safety, stabilization, and symptom
reduction for daily life functioning:

The focus is on establishing the therapeutic alliance,
educating the member about the diagnosis, helping
the member maintain personal safety, control
symptoms, build stress tolerance and enhance basic
life functioning (ISSD, 2011).
o Phase 2: Confronting, working through, and integrating
traumatic memories:

The focus is on addressing the member’s trauma(s).
This includes helping the member remember,
tolerate, process and integrate overwhelming past
events, including cognitive reframing and
strengthening adaptive responses of exposure to
traumatic memories (ISSD, 2011). Full awareness
that one has experienced the trauma and that trauma
is in the past should be accomplished in phase 2
(ISSD, 2011).
o Phase 3: Rehabilitation for overall life adaptation and
coping:
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
The focus is on making additional gains in coping
skills, decreasing remaining comorbid symptoms,
and improving quality of life. There should be
achievement of a more solid and stable sense of self
and of relating to others (ISSD, 2011). In phase 3,
the member is better able to focus less on past
traumas and deal more effectively with current
problems (SSD, 2011).

Treatment of DID and comorbid symptoms (e.g., Depression and
PTSD) with a phase-oriented DBT approach can be used as a standalone treatment model (Optum DID Literature Review, 2013).

Experts caution against addressing alternative identities which may
be harmful due to the suggestion or reinforcement of alternate
personalities (Optum DID Literature Review, 2013). It is suggested
that clinicians focus on the feelings associated with the dissociation
the member is experiencing and its use as a short-term coping
mechanism that is not effective in the long-term (Optum DID
Literature Review, 2013).

There is currently no evidence to suggest that integration of
personality states is a pre-requisite for a successful treatment
outcome. For members with an improvement of symptoms,
regardless of whether the member has had an integration experience
or not, overall improvements were comparable (Optum DID Literature
Review, 2013).

With the use of a phased approach to treatment, common treatment
outcomes depending on the stage include; improved coping skills,
decrease of impulsive and self-injurious behavior, decrease in suicide
attempts, decrease in hospitalizations, decrease of co-occurring
symptoms (e.g., dissociation, PTSD, depression), and an increase in
level of adaptive functioning (Optum DID Literature Review, 2013).
Frequency and Duration of Psychotherapy

For most members, one 45-50 minute weekly outpatient session is
often enough to address DID symptoms (ISSD, 2011).

When CBT and DBT approaches of therapy are implemented, the
typical duration is 4-20 sessions or up to 6 months (Brand, Classen,
McNary, & Zaveri, 2009).

The need for an increase of sessions or the need for a higher level of
care may be limited to circumstances where the member is exhibiting
self-destructive or severely dysfunctional behavior (ISSD, 2011).
Periods of increases in the frequency or length of sessions should be
brief to avoid regression or overdependence on the therapist (ISSD,
2011).
Page 9 of 21

If weekly sessions do not appear to address the member’s
symptoms, the provider should evaluate whether the current level of
care and appropriateness of therapeutic modality and/or interventions
are addressing the severity of the member’s symptoms; and whether
the diagnosis is correct (LOCGs, 2014).
Pharmacotherapy

There are no medications that primarily treat DID. If medications are
used adjunctive to psychotherapy, they should target the presenting
symptoms (e.g., hyperarousal and intrusive symptoms associated with
PTSD) or any symptoms related to a co-occurring condition (e.g.,
Depression, Anxiety, etc.) (ISSD, 2011).
Discharge Planning

During admission/initiation of treatment, the provider and, whenever
possible, the member update the initial discharge plan in response to
changes in the member’s condition ensuring that:
o An appropriate discharge plan is in place prior to discharge;
o The discharge plan is designed to mitigate the risk that the
“why now” factors which precipitated admission will reoccur;
and
o The member agrees with the discharge plan.

The discharge plan includes:
o The date treatment will end;
o Recommended self-help and community support services;
o Information about what the member should do in the event of
a crisis, or to resume services.
o The provider shares the discharge plan and all pertinent
clinical information with the provider(s) at the next level of
care prior to discharge.
o The provider shares the discharge plan with the Care
Advocate to ensure coverage and that necessary prior
authorization or notifications are completed prior to
discharge.
o Notification of the Care Advocate that the member is
discontinuing treatment also serves to trigger outreach and
assistance to the member.
o The provider coordinates discharge with agencies and
programs such as the school or court system with which the
member has been involved as appropriate
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
If the member refuses further treatment or repeatedly
does not adhere with recommended treatment despite
attempts to enhance the member’s engagement, the
provider explains the risk of discontinuing treatment to
the member.
PART III: LEVEL OF CARE CRITERIA
Choice of the most appropriate treatment setting should take into consideration
all of the following (LOCGs, 2014):

The member is eligible for benefits.
- AND -

The member’s current condition cannot be safely, efficiently and
effectively assessed and/or treated in a less intensive setting due to
changes in the member’s signs and symptoms, level of functioning,
and/or psychosocial and environmental factors (i.e., the “why now”
factors leading to admission).
o Failure of treatment in a lower level of care is not a prerequisite
for authorizing coverage.
- AND -

The member’s condition and proposed services are covered under the
benefit plan.
- AND -

Services are within the scope of the provider’s professional training
and licensure.
- AND -

Services are:
o Consistent with generally accepted standards of clinical
practice.
o Consistent with services backed by credible research soundly
demonstrating that the services will have a measurable and
beneficial health outcome, and are therefore not considered
experimental.
o Consistent with Optum’s clinical best practice guidelines.
o Clinically appropriate for the member’s behavioral health
condition based on generally accepted standards of clinical
practice and benchmarks.
- AND -
Page 11 of 21

There is a reasonable expectation that services will improve the
member’s presenting problems within a reasonable period of time.
Improvement of the member’s condition is indicated by the reduction or
control of the acute signs and symptoms that necessitated treatment in
a level of care.
o Improvement in this context is measured by weighing the
effectiveness of treatment against evidence that the member’s
signs and symptoms will deteriorate if treatment in the current
level of care ends. Improvement must also be understood within
the broader framework of the member’s recovery and resiliency
goals.
- AND -

Treatment is not primarily for the purpose of providing social, custodial,
recreational, or respite care.
Outpatient
Admission Criteria

The member presents with symptoms of a behavioral health condition.
- OR -

The member’s psychosocial functioning is impaired or is deteriorating
due to a behavioral health condition.
- OR -

The member has a behavioral health condition which requires
pharmacological treatment.
- AND -

The member is not at imminent risk for harm to self or others.
- AND -

The member exhibits adequate behavioral control to be treated in this
setting.
- AND -

Co-occurring substance use disorders, if present, are stable and are
unlikely to undermine treatment of the mental health condition at this
level of care.
Additional Outpatient considerations include:
Page 12 of 21

The frequency and duration of outpatient visits should allow for safe
and timely achievement of treatment goals, and support the member’s
recovery/resiliency. Multiple factors may impact frequency and duration
of treatment including the goals of treatment, the member’s
preferences, and best practice evidence to support frequency and
duration, and the degree of intensity needed to monitor and address
imminent risk to the member.

Initially, the frequency of outpatient visits generally varies from weekly
in routine cases to as often as several times a week. As the member’s
functional status improves, the frequency of visits should decrease to
meet the member’s current needs in achieving those goals.

Some patients may undergo a course of treatment which increases
their level of functioning, but then reach a point where further
significant increase is not expected. When stability can be maintained
without further treatment or with less intensive treatment, the services
are no longer necessary (Centers for Medicare and Medicaid Benefits
Policy Manual, 2013).

If a patient reaches a point in his/her treatment where further
improvement does not appear to be indicated, and there is no
reasonable expectation of improvement, outpatient services are no
longer considered reasonable or necessary (Centers for Medicare and
Medicaid, Local Coverage Determination (LCD), 2013).
Intensive Outpatient Program
Admission Criteria

Moderate symptoms of a mental health condition cannot be managed
in a less intensive level of care and/or a higher level of care may be
required if an Intensive Outpatient Program is not provided.
- OR -

Moderate impairment in the member’s psychological, social,
occupational, educational, or other area of functioning has impacted
the member’s ability to perform regular daily activities as compared to
baseline.
- OR -

The member requires the support of a structured environment to
complete treatment goals and develop a plan for post-discharge
services in a less intensive setting.
- AND -

The member is not at imminent risk of serious harm to self or others.
- AND -
Page 13 of 21

The member’s co-occurring medical, mental health or substance use
conditions can be safely managed in an intensive outpatient program.
- AND -

The member and/or his/her family/social support system understands
and can comply with the requirements of an intensive outpatient
program.
Partial Hospital/Day Treatment Program
Admission Criteria

The member’s psychosocial functioning has become impaired by
severe symptoms of a mental health condition, and treatment cannot
be adequately managed in a less intensive level of care.
- OR -

The member’s mood, affect or cognition has deteriorated to the extent
that a higher level of care will likely be needed if treatment in Partial
Hospital/Day Treatment Program is not provided.
- OR -

The member has a non-supportive living situation creating an
environment in which the member’s mental health condition is likely to
worsen without the structure and support of Partial Hospital/Day
Treatment Program.
- OR -

The member has completed Acute Inpatient or Residential Treatment
Center, and requires the structure and monitoring available in Partial
Hospital/Day Treatment Program.
- AND -

- AND -

Co-occurring medical conditions, if present, can be safely managed in
an outpatient setting.
- AND -

Co-occurring substance use disorders, if present, can be treated in a
dual diagnosis program, or can be safely managed at this level of care.
o The member is not at risk for severe withdrawal or delirium
tremens.
- AND -
Page 14 of 21

The member or his/her support system understands and can comply
with the requirements of a Partial Hospital/Day Treatment Program, or
the member is likely to participate in treatment with the structure and
supervision afforded by a Partial Hospital/Day Treatment Program.
Residential Treatment Program
Admission Criteria

The member is experiencing a disturbance in mood, affect or cognition
resulting in behavior that cannot be safely managed in a less restrictive
setting.
- OR -

There is an imminent risk that severe, multiple and/or complex
psychosocial stressors will produce significant enough distress or
impairment in psychological, social, occupational/educational, or other
important areas of functioning to undermine treatment in a lower level
of care.
- OR -

The member has a co-occurring medical disorder or substance use
disorder which complicates treatment of the presenting mental health
condition to the extent that treatment in a Residential Treatment Center
is necessary.
- AND -

Inpatient
Admission Criteria

The symptoms of a mental health condition require immediate care
and treatment to avoid jeopardy to life or health. Examples include the
following:

The member is at imminent risk of harm to self or others as
evidenced by, for example:

The member has made a recent and serious suicide
attempt;

The member is exhibiting current suicidal ideation
with intent, realistic plan and/or available means, or
other serious life threatening, self-injurious
behavior(s);

The member has recently exhibited self-mutilation
that is medically significant and/or potentially
dangerous;
Page 15 of 21

The member has made recent and seriously
physically destructive acts that indicate a high risk for
recurrence and serious injury to self of others;
- OR -

There has been a deterioration in the member’s psychological, social,
occupational/educational, or other important area of functioning, and
the member is unable to safely and adequately care for him/herself;
- OR -

There is an imminent risk that severe, multiple and/or complex
psychosocial stressors will produce enough distress or impairment in
psychological, social, occupational/educational, or another important
area of functioning to undermine treatment at a lower level of care;
- OR -

The member has a co-occurring medical disorder or substance use
disorder which complicates treatment of the presenting mental health
condition to the extent that 24-hour management is necessary.
Continued Stay Criteria for All Levels of Care

The admission criteria is still met and the member is making progress
in addressing the admission criteria (LOCGs, 2014);
- AND -

The “Why Now” for the current episode of care is being addressed and
integrated into the discharge plan (LOCGs, 2014);
- AND -

The discharge plan is being updated in response to changes in the
member’s condition, the member’s preferences and goals, the
understanding of the “why now” for the current episode of care, and the
availability of services at the next level of care (LOCGs, 2014);
- AND -

The provider is administering evidence-based interventions and clinical
best practices described above of sufficient intensity to address the
member’s treatment needs (LOCGs, 2014);
- AND -

The member’s family/social supports are being engaged to actively
participate in the member’s treatment and recovery/resiliency as
clinically indicated (LOCGs, 2014).
Discharge Criteria for All Levels of Care

The criterion for admission is no longer met when, for example
(LOCGs, 2014):
Page 16 of 21
o The goals for the current episode of care have been
accomplished;
- OR o The member requires primarily social, custodial, recreational or
respite care;
- OR o The member’s symptoms are a result of a diagnosis that
requires transfer to a medical/surgical setting for appropriate
treatment;
- OR o The member is unwilling or unable to participate in treatment
and involuntary treatment or guardianship is not being pursued;
- OR o In the case of inpatient treatment, there is no imminent risk, the
member does not wish further treatment and the member has
an established and engaged family/support system to support
the member’s recovery/resiliency and transition to a less
intensive level of care;
- OR o In RTC, PHP, IOP or outpatient levels of care, the member’s
condition has worsened, requiring a more intensive level of
care.
PART IV: ADDITIONAL RESOURCES
Clinical Protocols
Optum maintains clinical protocols that include the Level of Care Guidelines and
Best Practice Guidelines which describe the scientific evidence, prevailing
medical standards and clinical guidelines supporting our determinations
regarding treatment. These clinical protocols are available to Covered Persons
upon request, and to Physicians and other behavioral health care professionals
on ubhonline
Peer Review
Optum will offer a peer review to the provider when services do not appear to
conform to this guideline. The purpose of a peer review is to allow the provider
the opportunity to share additional or new information about the case to assist
the Peer Reviewer in making a determination including, when necessary, to
clarify a diagnosis
Second Opinion Evaluations
Page 17 of 21
Optum facilitates obtaining a second opinion evaluation when requested by an
enrollee, provider, or when Optum otherwise determines that a second opinion is
necessary to make a determination, clarify a diagnosis or improve treatment
planning and care for the member.
Referral Assistance
Optum provides assistance with accessing care when the provider and/or
enrollee determine that there is not an appropriate match with the enrollee’s
clinical needs and goals, or if additional providers should be involved in delivering
treatment.
PART V: DEFINITIONS
Cognitive Behavioral Therapy (CBT) A classification of therapies that are
predicated on the idea that behavior and feelings are caused by thoughts.
Diagnostic and Statistical Manual of the American Psychiatric Association
(DSM) A manual produced by the American Psychiatric Association which
provides the diagnostic criteria for mental health and substance use disorders,
and other problems that may be the focus of clinical attention. Unless otherwise
noted, the current edition of the DSM applies.
Inpatient A secured and structured hospital-based service that provides 24-hour
nursing care and monitoring, assessment and diagnostic services, treatment, and
specialty medical consultation services with an urgency that is commensurate
with the member’s current clinical need.
Integration Integration is a broad, longitudinal process referring to all work on
dissociated mental processes throughout the course of treatment.
Intensive Outpatient Program A freestanding or hospital-based program that
maintains hours of service for at least 3 hours per day, 2 or more days per week.
It may be used as an initial point of entry into care, as a step up from routine
outpatient services, or as a step down.
Mental Illness Those mental health or psychiatric diagnostic categories that are
listed in the current Diagnostic and Statistical Manual of the American Psychiatric
Association, unless those services are specifically excluded under the Policy.
Outpatient Visits provided in an ambulatory setting.
Partial Hospital/Day Treatment Program A freestanding or hospital-based
program that maintains hours of service for at least 20 hours per week, and may
also include half-day programs that provide services for less than 4 hours per
day. A partial hospital/day treatment program may be used as a step up from a
less intensive level of care, or as a step down from a more intensive level of care.
Prevailing Medical Standards and Clinical Guidelines means nationally
recognized professional standards of care including, but not limited to, national
consensus statements, nationally recognized clinical guidelines, and national
specialty society guidelines.
Page 18 of 21
Residential Treatment Center A facility-based or freestanding program that
provides overnight services to members who do not require 24-hour nursing care
and monitoring offered in an acute inpatient setting but who do require 24-hour
structure.
Scientific Evidence means the results of controlled clinical trials or other studies
published in peer-reviewed, medical literature generally recognized by the
relevant medical specialty community.
PART VI: REFERENCES
1. American Psychiatric Association: Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric
Association, 2013.
2. Association for Ambulatory Behavioral Healthcare, Standards and Guidelines
for Partial Hospital Programs, 2008.
3. Brand, B. L., Classen, C. C., McNary, S. W., & Zaveri, P. (2009). A review of
dissociative disorders treatment studies. Journal of Nervous and Mental
Disease, 197(9), 646-654. doi:
http://dx.doi.org/10.1097/NMD.0b013e3181b3afaa
4. Center for Medicaid and Medicare Local Coverage Determination, Psychiatric
Inpatient Hospitalization, 2012. http://www.cms.gov/medicare-coveragedatabase/indexes/lcd-alphabetical-index.aspx?bc=AgAAAAAAAAAA&
5. Center for Medicaid and Medicare Local Coverage Determination for
Psychiatric Partial Hospitalization Program, 2013.
http://www.cms.gov/medicare-coverage-database/indexes/lcd-alphabeticalindex.aspx?bc=AgAAAAAAAAAA&
6. Generic UnitedHealthcare Certificate of Coverage, 2001.
10. International Society for Study of Dissociation, Guidelines for Treating
Dissociative Identity Disorder in Adults, 2011..
11. Optum Behavioral Health Sciences Literature Review, Dissociative Identity
Disorder, 2013.
12. Optum Level of Care Guidelines, 2014.
PART VII: CODING
The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this guideline are
for reference purposes only. Listing of a service code in this guideline does not imply that the
service described by this code is a covered or non-covered health service. Coverage is
determined by the benefit document.
Limited to specific CPT and HCPCS codes?
90791
X Yes  No
Psychiatric diagnostic evaluation
Page 19 of 21
90791 plus interactive add-on code (90785)
90832
90832 plus pharmacological add-on code
(90863)
90834
(90863)
90837
(90863)
90839
90846
90847
90849
90853
G0410
G0411
H0015
H0035
S0201
S9480
Psychiatric diagnostic evaluation (interactive)
Psychotherapy, 30 minutes with patient and/or
family
family (interactive)
family (pharmacological management)
family member
family member (interactive)
family member (pharmacological management)
family member
family member (interactive)
family member (pharmacological management)
Psychotherapy for crisis, first 60 minutes
Psychotherapy for crisis, first 60 minutes
(interactive)
Family psychotherapy without the patient
present
Family psychotherapy, conjoint psychotherapy
with the patient present
Multiple-family group psychotherapy
Group psychotherapy (other than of a multiplefamily group)
Group psychotherapy (other than of a multiplefamily group) (interactive)
Group psychotherapy other than of a multiple
family group, in a partial hospitalization setting,
approximately 45 to 50 minutes
Interactive group psychotherapy, in a partial
hospitalization setting, approximately 45 to 50
minutes
Intensive outpatient (treatment program that
operates at least 3 hours/day and at least 3
days/week and is based on an individualized
treatment plan), including assessment,
counseling; crisis intervention, and activity
therapy
Mental health partial hospitalization, treatment,
less than 24 hours
Partial hospitalization services, less than 24
Intensive outpatient psychiatric services, per
die
Limited to specific diagnosis codes?
300.14
300.15
X Yes  No
Dissociative Identity Disorder
Other Specified Dissociative Identity Disorder
Limited to place of service (POS)?
 Yes X No
Page 20 of 21
Limited to specific provider type?
 Yes X No
Limited to specific revenue codes?
100-160
X Yes  No
(Range describes various all-inclusive inpatient
services)
(Range describes various unbundled
behavioral health treatments/services)
(Range describes various sites that provider
24-hour services)
900-919
1000-1005
PART VIII: HISTORY
Revision Date
05/2014
10/2014
Name
L. Urban
L. Urban
Revision Notes
Version 2-Final
DSM-5 Version 2-Final
Page 21 of 21

Coverage Determination

Transcription

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