Welcome to the Medical Necessity Criteria Page

 

Medical Necessity Criteria – 23-Hour observation – Mental Illness

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-IV 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.

 

Medical Necessity Criteria – Initial/Continuation – Inpatient – Mental Illness

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 IV 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 which 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 of a continued inpatient stay for a mental illness.

  1. Documentation of signs and symptoms consistent with DSM-IV 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.

 

Medical Necessity Criteria - Psychiatric-Adult Initial & Continuation Residential Treatment

In order to qualify for coverage for psychiatric residential level of care, a facility's program must meet the following criteria:

  1. Residential treatment takes place in a structured, facility-based setting. Wilderness programs, therapeutic boarding schools, group homes and other supportive living arrangements are not considered residential treatment.
  2. Documentation shows that a blood or urine drug screen was done on admission and during treatment, if indicated.
  3. Evaluation by a qualified physician done within 48 hours and physical exam and lab tests unless done prior to admission, and eight (8) hour on-site nursing (by either an RN or LVN/LPN) with 24-hour medical availability to manage medical problems if medical instability identified as a reason for admission to this level of care.
  4. Within 72 hours, a multidisciplinary assessment with an individual problem-focused treatment plan completed, addressing psychiatric, academic, social, medical, family and substance use needs.
  5. Coordination of care with other clinicians providing treatment to the member, such as the outpatient psychiatrist, therapist and the member's PCP, and, where indicated, the clinicians providing treatment to other family members, is documented.
  6. Treatment would include the following at least once a day and each lasting 60-90 minutes: community/milieu group therapy, group psychotherapy and activity group therapy.
  7. Skilled nursing care (either an RN or LVN/LPN) available on-site at least eight (8) hours daily with 24-hour availability.
  8. Individual treatment with a qualified physician at least once a week including medication management, if indicated.
  9. Individual treatment with a licensed behavioral health clinician at least once a week.
  10. Unless contraindicated, family members participate in development of the treatment plan, participate in family program and groups and receive family therapy at least once a week, including in-person family therapy at least once a month if the provider in not geographically accessible. For adolescents, this includes weekly individual family therapy, unless clinically contraindicated.
  11. A discharge plan is completed within one week that includes who the outpatient providers will be and where the member will reside.
  12. The treatment is individualized and not determined by a programmatic timeframe. It is expected that the member will be prepared to receive the majority of their treatment in a community setting.
  13. Medication evaluation and documented rationale if no medication is prescribed.

The following criteria will be utilized to determine the medical necessity of an initial residential stay for Psychiatric Conditions in an Adult:

  1. Documentation of signs and symptoms of a current DSM or ICD diagnosis with primary focus on psychiatric care. All services must meet the definition of medical necessity in the members plan document.
  2. The member is manifesting symptoms and behaviors which represent a deterioration from their usual status and include either self-injurious or risk taking behaviors that risk serious harm and cannot be managed outside of a 24 hour structured setting.
  3. The social environment is characterized by temporary stressors or limitations that would undermine treatment that could potentially be improved with treatment while the member is in the residential
  4. There should be a reasonable expectation that the illness, condition or level of functioning will be stabilized and improved and that a short term, sub-acute residential treatment service will have a likely benefit on the behaviors/symptoms that required this level of care, and that the member will be able to return to outpatient treatment.

The following criteria will be utilized to determine the medical necessity of a continued residential stay for Psychiatric Conditions in an Adult:

  1. The member continues to meet all basic elements of medical necessity.
  2. One or more of the following must be met:
    • The treatment provided is leading to measurable clinical improvements in acute symptoms and a progression toward discharge from the present level of care, but the individual is not sufficiently stabilized so that he/she can be safely and effectively treated at a less restrictive level of care.
    • If the treatment plan implemented is not leading to measurable clinical improvements in acute symptoms and a progression towards discharge from the present level of care, there must be ongoing reassessment and modification to the treatment plan, when clinically indicated.
    • The member has developed new symptoms and/or behaviors that require this intensity of service for safe and effective treatment.
  3. All of the following must be met:
    • the individual and family are involved to the best of their ability in the treatment and discharge planning process, unless there is a documented clinical contraindication.
    • Continued stay is NOT primarily for the purpose of providing a safe and structured environment.
    • Continued stay is NOT primarily due to a lack of external supports.

 

Medical Necessity Criteria – Psychiatric Child/Adolescent Initial & Continuation Residential

In order to qualify for coverage for psychiatric residential level of care, a facility’s program must meet the following criteria:

  1. Residential treatment takes place in a structured facility-based setting. Wilderness programs, therapeutic boarding schools, group homes and other supportive living arrangements are not considered residential treatment.
  2. Documentation shows that a blood or urine drug screen was done on admission and during treatment, if indicated.
  3. Evaluation by a qualified physician done within 48 hours and physical exam and lab tests unless done prior to admission. The physician should be a psychiatrist who is board certified in child/adolescent psychiatry or shows equivalent competence in this area.
  4. Within 72 hours, a multidisciplinary assessment with an individual problem-focused treatment plan completed, addressing psychiatric, academic, social, medical, family and substance use needs.
  5. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist and the member’s PCP, providing treatment to the member and where indicated, the clinicians providing treatment to other family members, is documented.
  6. There is coordination with community resources with the goal of returning the patient to his/her regular social environment as soon as possible, unless contraindicated. School contact should address the Individualized Educational Plan as appropriate.
  7. Treatment would include the following at least once a day and each lasting 60-90 minutes: community/milieu group therapy, group psychotherapy and activity group therapy.
  8. Care includes evidence based treatment as part of the facility’s program.
  9. The facility has evidence that it can handle special populations, such as autism, reactive attachment disorder, etc or that they specifically screen out for these populations.
  10. The facility has a registered nurse (RN) on site that is in charge of patient care along with one or more RN’s or licensed practical nurses (LPN’s) on site at all times (24 hours per day, 7 days per week).
  11. Individual treatment with a qualified physician at least once a week including medication management if indicated.
  12. The patient is seen daily by a licensed behavioral health practitioner, with appropriate documentation for each contact.
  13. Unless contraindicated, family members participate in development of the treatment plan, participate in family program and groups and receive family therapy at least once a week, including in-person family therapy at least once a month if the provider in not geographically accessible. For adolescents, this includes weekly individual family therapy, unless clinically contraindicated.
  14. A discharge plan is completed within one week that includes who the outpatient providers will be and where the member will reside.
  15. The treatment is individualized and not determined by a programmatic timeframe. It is expected that the member will be prepared to receive the majority of their treatment in a community setting.
  16. Medication evaluation and documented rationale if no medication is prescribed.
  17. The facility maintains permanent and full-time facilities for bed care of resident patients.

The following criteria will be utilized to determine the medical necessity of an initial residential stay for Psychiatric Conditions in a Child or Adolescent:

  1. Documentation of signs and symptoms of a current DSM or ICD diagnosis with primary focus on psychiatric care. All services must meet the definition of medical necessity in the member’s plan document.
  2. The member is manifesting symptoms and behaviors which represent a deterioration from their usual status and include either self-injurious or risk taking behaviors that risk serious harm and cannot be managed outside of a 24 hour structured setting.
  3. The social environment is characterized by temporary stressors or limitations that would undermine treatment that could potentially be improved with treatment while the member is in the residential facility.
  4. There should be a reasonable expectation that the illness, condition or level of functioning will be stabilized and improved and that a short term, sub-acute residential treatment service will have a likely benefit on the behaviors/symptoms that required this level of care, and that the member will be able to return to outpatient treatment.

The following criteria will be utilized to determine the medical necessity of a continued residential stay for Psychiatric Conditions in a Child or Adolescent:

  1. The member continues to meet all basic elements of medical necessity.
  2. One or more of the following must be met:
    • The treatment provided is leading to measurable clinical improvements in acute symptoms and a progression toward discharge from the present level of care, but the individual is not sufficiently stabilized so that he/she can be safely and effectively treated at a less restrictive level of care.
    • If the treatment plan implemented is not leading to measurable clinical improvements in acute symptoms and a progression towards discharge from the present level of care, there must be ongoing reassessment and modification to the treatment plan, when clinically indicated.
    • The member has developed new symptoms and/or behaviors that require this intensity of service for safe and effective treatment.
  3. All of the following must be met:
    • the individual and family are involved to the best of their ability in the treatment and discharge planning process, unless there is a documented clinical contraindication.
    • Continued stay is NOT primarily for the purpose of providing a safe and structured environment.
    • Continued stay is NOT primarily due to a lack of external supports.

 

Medical Necessity Criteria – Initial/Continuation Partial Hospitalization – Mental Illness

The following criteria will be utilized to determine the medical necessity of 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 IV 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 of a continued 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.

 

Medical Necessity Criteria – Intensive Outpatient Program – Mental Illness

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-IV diagnosis.
  2. Evidence that the patient is experiencing symptoms which 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-IV diagnosis.
  2. Evidence that the patient is experiencing symptoms which 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.

 

Medical Necessity Criteria - Outpatient Treatment

Admission Criteria:

  1. The member has signs and symptoms consistent with a DSM-5 diagnosis.
  2. Symptoms are significant enough to interfere with the members 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-5.
  2. The members symptoms are such that they cause significant impairment in functioning.
  3. The members CG1 score is "Borderline Mentally Ill" or more severe.
  4. The member has a severe and persistent mental illness that requires on-going maintenance treatment to maintain symptom relief.
  5. Member needs sessions to complete therapy, even though criteria above may not be met.
  6. The member does not need a more intensive level of care.

Discharge criteria:

  1. The member's treatment goals have been mostly met.
  2. There is no reasonable expectation of further improvement for the member.

 

Medical Necessity Criteria - 23-Hour Observation - Chemical Dependency

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, which can be attributed to a particular substance that is characteristic of its 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
  3. Enrollee reports use of chemicals, the amounts and over a period of time, such that sudden cessation could result in imminent withdrawal.

 

Medical Necessity Criteria — CD Initial & Continuation Inpatient

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:
    • Fluids and medication to modify or prevent withdrawal complications that threaten life or bodily functions.
    • 24-hour nursing care with close and frequent observation and monitoring of vital signs.
    • 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, which can be attributed to a particular substance that is characteristic of its 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

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.

 

Medical Necessity Criteria — Substance Abuse Initial & Continuation Residential

In order to qualify for coverage under substance abuse residential, a facility's program must meet the following criteria:

  1. Evaluation by a qualified physician within 48 hours of admission and weekly visits by a qualified physician if dually diagnosed and psychiatric symptoms identified as a reason for admission requiring this level of care.
  2. Physical exam and lab tests done within 48 hours if not done prior to admission and eight (8) hours on-site nursing (by either an RN of LVN/LPN) with 24 hour medical availability to manage medical problems if medical instability identifies as a reason for admission requiring this level of care.
  3. Programming provided will be consistent with the member's language, cognitive, speech and/or hearing abilities.
  4. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans.
  5. Coordination of care with other clinicians providing treatment to the member, such as the outpatient psychiatrist, therapist and the member's PCP, and, where indicated, clinicians providing treatment to other family members, is documented.
  6. Within 48 hours, an individualized, problem-focused treatment plan is done, based on completion of a detailed personal substance use history, including identification of consequences of use and identifying individual relapse triggers as goals.
  7. The treatment would include the following at least once per day, and each lasting 60-90 minutes: community/milieu group therapy, group psychotherapy and activity group therapy.
  8. Family supports identified and contacted within 48 hours and family/primary support person participation in treatment at least weekly unless contraindicated. For adolescents, this includes weekly individual family therapy, unless clinically contraindicated.
  9. Discharge planning completed within one (1) week of admission including identification of community/family resources, sober supports, connection or re-establishment of connection to community based recovery programs and professional aftercare treatment.
  10. Drug screens used after all off-grounds activities and whenever otherwise indicated.
  11. All therapeutic services provided by licensed or certified professional in accordance with state laws.
  12. The treatment is individualized and not determined by a programmatic timeframe.' It is expected that members will be prepared to receive the majority of their rehabilitation in a community setting.
  13. Evaluation for medication that may improve the members ability to remain abstinent; document the rationale if no medication is prescribed.

The following criteria will be utilized to determine the medical necessity of an initial residential admission for Substance Abuse:

Documentation of signs and symptoms of a Substance Use Disorder as defined in the most current DSM or lCD system. Must meet criteria 1 or 2, as well as 3 to qualify:

  1. Acute psychiatric symptoms that would interfere with:
    • The member maintaining abstinence and
    • Recovery outside of a 24 hour structured setting and
    • Represent a deterioration from their usual status and
    • Include either self-injurious or risk taking behaviors that poses a risk of serious harm to the member or others and cannot be managed outside of a 24 hour structured setting.
  2. Acute medical symptoms that would likely interfere with the member maintaining abstinence and recovery outside of a 24 hour structured setting.
  3. Evidence of major functional impairment in at least 2 domains (work/school, ADL, family/interpersonal, physical health).

The following criteria will be utilized to determine the medical necessity of a continued residential stay for Substance Abuse:

  1. The member continues to meet all basic elements of medical necessity.
  2. One or more of the following must be met:
    • The treatment provided is leading to measurable clinical improvements in acute symptoms and a progression toward discharge from the present level of care, but the individual is not sufficiently stabilized so that he/she can be safely and effectively treated at a less restrictive level of care.
    • If the treatment plan implemented is not leading to measurable clinical improvements in acute symptoms and a progression towards discharge from the present level of care, there must be ongoing reassessment and modification to the treatment plan, when clinically indicated.
    • The member has developed new symptoms and/or behaviors that require this intensity of service for safe and effective treatment.
  3. All of the following must be met:
    • the individual and family are involved to the best of their ability in the treatment and discharge planning process, unless there is a documented clinical contraindication.
    • Continued stay is NOT primarily for the purpose of providing a safe and structured environment.
    • Continued stay is NOT primarily due to a lack of external supports.

 

Medical Necessity Criteria - Substance Abuse Initial & Continuation Rehabilitation

In order to qualify for coverage for substance abuse rehabilitation services, a facility's program must meet the following criteria:

  1. Provide 24-hour skilled nursing care (by either an RN or LVN/LPN).
  2. Physician visits at least daily, seven (7) days a week.
  3. Programming provided will be consistent with the member's language, cognitive, speech and/or hearing abilities.
  4. Implementation of individualize, problem-focused treatment plan, which includes, but is not limited to:
    • Completion of personal substance abuse history with acknowledgment of consequences of use.
    • Program has provisions for member to access psychiatric treatment as needed for a dual diagnosis
    • Initiation or continuation of relapse/recovery program with identification of relapse triggers.
    • Supervised attendance at community-based recovery programs when appropriate and available.
    • Drug screens as clinically appropriate and at random.
    • Family program and involvement in treatment, as appropriate. For adolescents, this includes weekly individual family therapy, unless clinically contraindicated.
  5. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans. An outpatient visit within one week of discharge is expected, if the member is not stepping down to a more intensive level of care.
  6. Coordination of care with other clinicians providing treatment to the member, such as the outpatient psychiatrist, therapist and the member's PCP, and, where indicated, clinicians providing treatment to other family members, is documented.
  7. All therapeutic services provided by licensed or certified professional in accordance with state laws.
  8. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed.

The member must meet all of the following criteria in order to be considered to have medical necessity for an initial rehabilitation stay for Substance Abuse:

  1. Documentation of signs and symptoms of a Substance Use Disorder as defined in the most current DSM or lCD system.
  2. Member no longer meets detoxification severity of illness criteria.
  3. Member has a severe co-morbid medical or psychiatric disorder, which requires 24-hour acute hospital care.
  4. There is evidence of major life impairments in at least two (2) areas of functioning (work/school, family, ADL's, interpersonal).
  5. The member has expressed an interest or desire to work towards the goals of treatment and recovery, at the time of admission or shortly thereafter.

The following criteria will be utilized to determine the medical necessity of a continued rehabilitation stay for Substance Abuse:

  1. The member continues to meet all basic elements of medical necessity.
  2. One or more of the following must be met:
    • The treatment provided is leading to measurable clinical improvements in acute symptoms and a progression toward discharge from the present level of care, but the individual is not sufficiently stabilized so that he/she can be safely and effectively treated at a less restrictive level of care.
    • If the treatment plan implemented is not leading to measurable clinical improvements in acute symptoms and a progression towards discharge from the present level of care, there must be ongoing reassessment and modification to the treatment plan, when clinically indicated.
    • The member has developed new symptoms and/or behaviors that require this intensity of service for safe and effective treatment.
  3. All of the following must be met:
    • the individual and family are involved to the best of their ability in the treatment and discharge planning process, unless there is a documented clinical contraindication.
    • Continued stay is NOT primarily for the purpose of providing a safe and structured environment.
    • Continued stay is NOT primarily due to a lack of external supports.

 

Medical Necessity Criteria — CD Initial & Continuation Partial Hospitalization

The following criteria will be utilized to determine the medical necessity of Chemical Dependency partial hospitalization review criteria:

  1. The patient experiences acute withdrawal, medical or neurological complications, which requires a medical selling 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.

 

Medical Necessity Criteria CD - Initial & Continuation - Intensive Outpatient Program

The following criteria will be utilized to determine the medical necessity of initial 10P 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 10P 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 lOP chemical dependency treatment:

  1. Demonstration of attendance, compliance and progress made within 10P.
  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 10P there is significant risk for decompensation, which would require a higher level of care.

 

Medical Necessity Criteria — Eating Disorder Initial & Continuation Residential

In order to qualify for coverage for eating disorder residential care, a facility's program must meet the following criteria:

  1. Evaluation by a qualified physician or equivalent professional within 72 hours of admission and at least once weekly visits documented.
  2. Physical exam and lab tests done within 72 hours if not done prior to admission and 24 hour on site nursing and medical availability to manage medical problems if risk for medical instability identified as a reason for admission to this level of care.
  3. Programming provided will be consistent with the member's language, cognitive, speech and/or hearing abilities.
  4. Within seven (7) days, an individualized problem focused treatment plan completed, including nutritional, psychological, social, medical and substance abuse needs to be developed based on a complex bio-psychosocial evaluation. This needs to be reviewed at least once a week for progress.
  5. Coordination of care with other clinicians providing treatment to the member, such as the outpatient psychiatrist, therapist and the member's PCP, and, where indicated, clinicians providing treatment to other family members, is documented.
  6. Treatment would include the following at [east once per week and each lasting 60-90 minutes: community/milieu group therapy, group psychotherapy and activity group therapy plus at least once weekly individual therapy with a properly licensed provider.
  7. Family supports identified and contacted within 72 hours and family/primary support person participation at least weekly for adults, twice weekly for children and adolescents, unless contraindicated.
  8. Discharge planning initiated within one (1) week of admission including identification of community/family resources, connection or re-establishment of connection to an outpatient treatment team and coordination with that team.
  9. The treatment is individualized and not determined by a programmatic time frame. It is expected that the member will be prepared to receive the majority of their treatment in a community setting.
  10. Medication evaluation and documented rationale, if no medication is prescribed.

The following criteria will be utilized to determine the medical necessity of an initial residential admission for an Eating Disorder:

  1. If Anorexia Nervosa and weight restoration is the goal, BMI between 15-18 or weight between 75­85% of estimated ideal weight range and no signs or symptoms of acute medical instability that would require daily physician evaluation.
  2. Comorbid psychiatric disorders are controlled or stable enough for the primary focus of treatment to be the eating disorder.
  3. For Anorexia Nervosa, continued restricting and purging is leading to weight loss that is likely to lead to medical instability and need for inpatient treatment with the likelihood that residential treatment will result in improvement; for Bulimia Nervosa, continued purging or excessive exercising is likely to cause medical instability or dehydration that would need inpatient treatment;or for either condition, the member has had multiple inpatient admissions within the past six (6) months with a failure to stabilize with outpatient aftercare.
  4. Significant functional disruption from usual/baseline status in at least two domains (school/work, family, activities, ADL's) related to the eating disorder.
  5. Based on past treatment history, usual level of functioning and comorbid psychiatric disorders, there is a reasonable expectation that the member will benefit from this level of care.
  6. Living environment and support are characterized by either significant deficits or significant conflict or problems that would undermine goals of treatment such that treatment at a lower level of care is unlikely to be successful and this can potentially be improved with treatment.

The following criteria will be utilized to determine the medical necessity of a continued residential stay for an Eating Disorder:

  1. The member continues to meet all basic elements of medical necessity.
  2. One or more of the following must be met:
    • The treatment provided is leading to measurable clinical improvements in acute symptoms and a progression toward discharge from the present level of care, but the individual is not sufficiently stabilized so that he/she can be safely and effectively treated at a less restrictive level of care.
    • If the treatment plan implemented is not leading to measurable clinical improvements in acute symptoms and a progression towards discharge from the present level of care, there must be ongoing reassessment and modification to the treatment plan, when clinically indicated.
    • The member has developed new symptoms and/or behaviors that require this intensity of service for safe and effective treatment,
  3. All of the following must be met:
    • the individual and family are involved to the best of their ability in the treatment and discharge planning process, unless there is a documented clinical contraindication.
    • Continued stay is NOT primarily for the purpose of providing a safe and structured environment.
    • Continued stay is NOT primarily due to a lack of external supports.
Contact Us