Appendix

CBHA Medical Necessity Criteria

Mental Illness - Outpatient Treatment

The following criteria will be utilized to determine the medical necessity of continued outpatient treatment for mental illness:

Admission Criteria

1. The member has signs and symptoms consistent with a DSM-IV-TR diagnosis.
2. Symptoms are significant enough to interfere with the member's ability to function in at least one area of life.
3. The individual has the capacity to make significant progress toward treatment goals or therapy is necessary to maintain current functioning.

Review Criteria

1. Member has been diagnosed with a mental illness as described in DSM-IV-TR on Axis I and/or Axis II.
2. The member's symptoms are such that they cause significant impairment in functioning.
3. The member's GAF score is between 40 and 70.
4. The member's CGI score is "Borderline Mentally Ill" or more severe.
5. The member has a severe and persistent mental illness that requires on-going maintenance treatment to maintain symptom relief.
6. Member needs sessions to complete therapy, even though criteria above may not be met.
7. The member does not need a more intensive level of care.

Discharge Criteria

1. Member is absent signs/symptoms of a DSM-IV-TR diagnosis.
2. The member's treatment goals have been mostly met.
3. There is no reasonable expectation of further improvement for the member.
4. GAF above 70.

Mental Illness - 23-Hour Observation

The following criteria will be utilized to determine the medical necessity of 23-hour observation treatment for mental illness:

1. Demonstrated failure to respond to treatment at a less intensive level of care, including medication management if indicated.
2. Documentation of signs and symptoms consistent with DSM (most recently-published edition) diagnosis.
3. There is need for specialized care including complex medication management/monitoring, multiple diagnostic procedures and special risk management.
4. Suicide ideation exists and may be associated with a plan, intent to carry out that plan and the means to carry out the plan or history of a suicide attempt/s.
5. Evidence of significant self-mutilation, serious risk-taking or other self-endangering behavior.

After 23 hours or less of observation it will be determined if the enrollee meets criteria for a full inpatient admission or can be treated at a less intensive level of treatment.

Mental Illness - Inpatient - Initial & Continuation - Adult

The following criteria will be utilized to determine the medical necessity of an initial inpatient stay for a mental illness.

1. Demonstrated failure to respond to treatment at a less intensive level of care, including medication management if indicated.
2. Documentation of signs and symptoms consistent with DSM (most recently-published edition) diagnosis.
3. Documentation of disordered behavior that endangers the welfare of the patient or others, or interferes with activities of daily living.
4. Demonstrated need for specialized care including complex medication management/monitoring, multiple diagnostic procedures or special risk management.
5. Documentation of serious risk of suicide or self-harm.
6. Suicide attempts which are considered by their degree of intent, hopelessness, and impulsivity.
7. Suicide ideation exists and may be associated with a plan, intent to carry out that plan and the means to carry out the plan.
8. Evidence of significant self-mutilation, serious risk-taking or other self-endangering behavior.
9. Documentation of serious risk of harm to others.
10. Assaultive behavior that is a result of a psychiatric condition has occurred and there is a risk of escalation or repetition of this behavior.
11. Destructive behavior toward property, which is a result of a psychiatric condition, possibly threatening other, such as setting fires.

The following criteria will be utilized to determine the medical necessity for continuing inpatient treatment for a mental illness:

1. Documentation of signs and symptoms consistent with DSM (most recently-published edition) diagnosis.
2. Documentation of ongoing disordered behavior in the milieu, which unmonitored would endanger the welfare of the patient or others or interfere with activities of daily living.
3. Documentation of need for ongoing specialized care including complex medication management / monitoring, multiple diagnostic procedures and special risk management.
4. Evidence of the patient's incapacity for reliable attendance within a partial hospital program.
5. Documentation of active and realistic psychiatric evaluation, treatment and discharge planning under way within the shortest possible time frame.

Mental Illness - Inpatient - Initial & Continuation - Child & Adolescent

The following criteria will be utilized to determine the medical necessity for initial inpatient treatment for children and adolescents:

1. Treatment at a less intensive level of care would be ineffective or unsafe.
2. The child/adolescent demonstrates psychiatric signs and symptoms consistent with a DSM (most recently-published edition) mental disorder. The primary diagnosis is not a substance abuse disorder.
3. The child/adolescent demonstrates at least one of the following:
   • Suicide attempt has been made with serious intent,
   • Suicidal ideation exists with intent, a plan and the means to actualize the plan.
4. Documentation shows a recent pattern of self-mutilation or unsafe acts without regard to life threatening potential.
5. Documented assaultive threats or acts toward people or property that endanger others. Escalation or repetition is likely in near future.
6. Psychotic thinking, bizarre behavior, psychomotor retardation, psychomotor agitation or obsessive compulsive rituals create a level of functional impairment that keeps the child/adolescent from functioning at a lower level of care.
7. Memory impairment or disorientation at a lower level of care.

The following criteria will be utilized to determine the medical necessity for continuing inpatient treatment for children and adolescents:

The child/adolescent patient requires at least one of the following:

1. A comprehensive multi-modal treatment plan that requires 24-hour medical supervision and coordination.
2. 24-hour medical supervision and observation are needed to monitor and adjust psychopharmaco therapy.
3. 24-hour supervision is needed to observe and manage physically destructive, self-mutilation or suicidal behavior.
4. Continuous monitoring and treatment of serious medication side effects.
5. Detoxification for demonstrated sign/symptoms of drug withdrawal.

Both of the following are occurring:

1. • The multidisciplinary team is preparing an appropriate discharge plan to transition the patient from inpatient care.
   • The family/guardians are involved intensively in the treatment.

Mental Illness - Partial Hospitalization - Initial & Continuation - Adult

The following criteria will be utilized to determine the medical necessity of initial partial hospitalizations:

1. Evidence of patient capacity for reliable attendance at the partial hospital program.
2. Evidence of compliance with a recommended medication regime.
3. Risk to self, others or property is not so serious as to require 24-hour medical supervision.
4. Documentation of signs and symptoms consistent with DSM (most recently-published edition) diagnosis.
5. Evidence of sufficient impulse control to contract not to harm self.
6. Evidence of sufficient impulse control to contract not to engage in self-mutilating, risk taking or other self-endangering behavior.
7. Evidence of sufficient impulse control to contract not to harm others.
8. Demonstrated need for at least routine medical observation and supervision.
9. Evidence of significant risk for decompensation in the absence of Partial Hospitalization, which would require acute inpatient hospitalization.

The following criteria will be utilized to determine the medical necessity for continuing partial hospitalization:

1. Evidence that in the absence of partial hospitalization there is significant risk for decompensation, which would require acute inpatient hospitalization.
2. Demonstration of need for ongoing medical observation and supervision to effect significant regulation of psychotropic medication.
3. Demonstration of attendance, compliance and progress made with partial hospital programming.
4. Documentation of active and realistic psychiatric evaluation, treatment and discharge planning under way within the shortest possible time frame.

Mental Illness - Partial Hospitalization - Initial & Continuation - Child & Adolescent

The following criteria will be utilized to determine the medical necessity for initial partial hospitalization treatment for children and adolescents:

1. The child/adolescent has a DSM (most recently-published edition) psychiatric disorder and a level of functional impairment that requires treatment in a structured setting.
2. The child/adolescent and parent/guardian show a capacity for attendance at the partial hospitalization program.
3. The child/adolescent also demonstrates at least one of the following:
   1. Suicidal ideation without intent exists and the patient can report suicidal impulses to staff for evaluation and intervention.
   2. Aggressive tendencies toward persons or property do exist but are not serious enough to require 24-hour supervision.
   3. Continued medical supervision is needed to adjust psychotropic medications.
4. Documentation of a mood impairment or thought disorder that interferes with the patient's ability to function at a lesser level of care.
5. Documentation indicates the need for supervision of self-care, nutritional intake or age appropriate functioning in school, family and community.

The following criteria will be utilized to determine the medical necessity for continuing partial hospitalization treatment for children and adolescents:

1. The patient's disorder and functional impairment prevent the patient from functioning at a lower level of care.
2. Continued need for supervision of psychotropic medication therapy.
3. Active discharge planning is occurring.

Mental Illness - Intensive Outpatient Program - Initial and Continuation

The following criteria will be utilized to determine the medical necessity of initial outpatient treatment:

1. Documentation showing evidence of signs and symptoms consistent with DSM (most recently-published edition) diagnosis.
2. Evidence that the patient is experiencing symptoms that have significantly impaired the ability to function in normal activities.
3. Demonstrated failure to respond to treatment at a less intensive level of care, including medication management if indicated.
4. Demonstrated capacity and need to continue regular work schedule.
5. Evidence that in the absence of IOP there is significant risk for decompensation, which would require a higher level of care.

The following criteria will be utilized to determine the medical necessity for continuing IOP treatment:

1. Documentation showing evidence of signs and symptoms consistent with DSM (most recently-published edition) diagnosis.
2. Evidence that the patient is experiencing symptoms that have significantly impaired the ability to function in normal activities.
3. Documentation regarding precipitating factors indicating acute stressors rather than chronic conditions.
4. Demonstration of attendance, compliance and progress made within IOP.
5. Documentation indicating that appropriate psychotherapeutic interventions consistent with the patient's symptoms have been initiated.
6. Documentation indicating that appropriate medical interventions consistent with the patient's symptoms have been initiated.
7. Documentation reflects an appropriate schedule for treatment termination.
8. Evidence that in the absence of IOP there is significant risk for decompensation, which would require a higher level of care.

Chemical Dependency - Detoxification

The following criteria will be utilized to determine the medical necessity for detoxification review:

1. Signs and symptoms are present in which failure to use this level of treatment would be life threatening or cause permanent impairment once substance abuse has stopped.
2. A person must require all of the following services to meet criteria for inpatient detoxification:
   1. Fluids and medication to modify or prevent withdrawal complications that threaten life or bodily functions.
   2. 24-hour nursing care with close and frequent observation and monitoring of vital signs.
   3. Medical therapy, which is supervised and re-evaluated daily, by the attending physician in order to stabilize the patient's physical condition.

Withdrawal Signs and Symptoms:

The patient must exhibit at least two or more of the following symptoms of substance withdrawal:

• Tachycardia
• Hypertension
• Diaphoresis
• Significant increase or decrease in psychomotor activity
• Tremor
• Significantly disturbed sleep pattern
• Nausea/vomiting
• Clouding of consciousness with reduced capacity to shift, focus and sustain attention

Authorization of Continued Stay for Chemical Dependency Detoxification:

1. The patient continues to manifest acute withdrawal symptoms that can be treated only in a 24-hour medical setting with skilled nursing care.
2. The patient experiences medical or neurological complications, which can only be treated in a 24-hour medical setting with skilled nursing care.
3. The patient's condition is expected to improve within a brief time.
4. A standard detox protocol is in use (i.e., the detox of alcohol would not be accomplished with decreasing dosages of alcohol).
5. Patient's medical condition prevents the patient from participating in another level of care.

Chemical Dependency - 23 Hour Observation

The following criteria will be utilized to determine the medical necessity of 23-hour observation for Chemical Dependency:

1. Documentation of a pattern of substance abuse and/or dependence or prior history of withdrawal symptoms necessitating close observation to determine need for medical detoxification.
2. Documentation of at least two signs of substance withdrawal:
   1. Tachycardia
   2. Hypertension
   3. Diaphoresis
   4. Significant increase or decrease in psychomotor activity
   5. Tremor
   6. Significantly disturbed sleep pattern
   7. Nausea/Vomiting
   8. Clouding of consciousness with reduced capacity to shift, focus, and sustain attention
3. Enrollee reports use of chemicals, the amounts and over a period of time, such that sudden cessation could result in imminent withdrawal.

Chemical Dependency - Inpatient - Initial & Continuation

The following criteria will be utilized to determine the medical necessity of an initial inpatient stay for Chemical Dependency:

1. Documentation of signs and symptoms indicating that failure to use this level of treatment would be life threatening or cause permanent impairment once substance abuse has stopped.
2. Documentation of need for all inpatient detoxification services including:
   1. Fluids and medication to modify or prevent withdrawal complications that threaten life or bodily functions.
   2. 24-hour nursing care with close and frequent observation and monitoring of vital signs.
   3. Medical therapy, which is supervised and re-evaluated daily, by the attending physician in order to stabilize the patient's physical condition.
3. Documentation of at least two signs of substance withdrawal:
   1. Tachycardia
   2. Hypertension
   3. Diaphoresis
   4. Significant increase or decrease in psychomotor activity
   5. Tremor
   6. Significantly disturbed sleep pattern
   7. Nausea/Vomiting
   8. Clouding of consciousness with reduced capacity to shift, focus, and sustain attention

The following criteria will be utilized to determine the medical necessity of a continued inpatient stay for Chemical Dependency:

1. The patient continues to manifest acute withdrawal symptoms that can be treated only in a 24-hour medical setting with skilled nursing care.
2. The patient experiences medical or neurological complications, which can only be treated in a 24-hour medical setting with skilled nursing care.
3. The patient's condition is expected to improve within a brief time.
4. A standard detox protocol is in use (i.e., the detox of alcohol would not be accomplished with decreasing dosages of alcohol). CBHA currently promulgates use of a symptom-triggered detoxification protocol, such as CIWA, etc.
5. Patient's medical condition prevents the patient from participating in another level of care.

Chemical Dependency - Partial Hospitalization - Initial & Continuation

The following criteria will be utilized to determine the medical necessity of initial chemical dependency partial hospitalization review criteria:

1. The patient experiences acute withdrawal, medical or neurological complications, which require a medical setting with skilled nursing care, available for the majority of the day.
2. The patient's condition is expected to improve within a brief time.
3. A standard detox protocol is in use (i.e., the detox of alcohol would not be accomplished with decreasing dosages of alcohol).
4. Patient's medical condition prevents the patient from participating in another level of care such as CD rehabilitation, group, etc.

The following criteria will be utilized to determine the medical necessity of continuing chemical dependency partial hospitalization:

1. Demonstration of attendance, active participation and progress made within partial hospital programming.
2. Demonstration of need for ongoing medical observation and supervision to effect significant regulation of psychotropic medication.
3. Demonstration of abstinence from substance abuse.
4. Patient's medical condition prevents the patient from participating in another level of care.
5. Documentation of active and realistic psychiatric evaluation, treatment and discharge planning under way within the shortest possible time frame.

Chemical Dependency - Intensive Outpatient Program - Initial & Continuation

The following criteria will be utilized to determine the medical necessity of initial IOP chemical dependency treatment:

1. Documentation of a pattern of substance abuse and/or dependence, necessitating intensive treatment to effect and sustain remission.
2. Demonstrated capacity and need to continue regular work schedule.
3. Evidence that in the absence of IOP there is significant risk for decompensation, which would require a higher level of care.

The following criteria will be utilized to determine the medical necessity of continuing IOP chemical dependency treatment:

1. Demonstration of attendance, compliance and progress made within IOP.
2. Documentation indicating that appropriate psychotherapeutic interventions consistent with the patient's symptoms have been initiated.
3. Documentation indicating that appropriate medical interventions consistent with the patient's symptoms have been initiated.
4. Documentation reflects an appropriate schedule for treatment termination.
5. Evidence that in the absence of IOP there is significant risk for decompensation, which would require a higher level of care.