Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2014 Title: Residential Treatment for Mental Health & Substance Use Disorders
Revision Date: 11/01/2018 Document: BI449:00
CPT Code(s): T2033
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Certain plans provide coverage for residential treatment facilities for the treatment of mental health or substance use disorders; refer to your policy documents

2)    Care in a residential treatment facility for mental health or substance use disorders is covered only when part of a treatment plan that has been preauthorized by QualChoice.

3)    A residential treatment facility for mental health or substance use disorders is a 24-hour facility that is not a hospital. These facilities provide a controlled, structured environment that is designed to improve the effectiveness of therapy.  Residential treatment facilities are not for "providing housing", custodial care, a wilderness center training camp or any other structured environment whose use is simply to change the person’s environment.

4)    CHI members see BI208.

5)    Certain plans may cover cognitive (neurological) rehabilitation; see BI456 for details.

6)    Residential treatment for other services is not covered.


Medical Statement

Mental Health Residential Treatment Center

To qualify, the patient’s symptoms or condition must meet the diagnostic criteria for a DSM Axis I or ICD Diagnosis that is consistent with symptoms and the primary focus of treatment is residential treatment center (RTC) psychiatric care. All services must meet the definition of medical necessity in the patient’s plan document.

Severity of Illness (SI)

The patient must have all of the following to qualify:

1)    The patient 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 or other appropriate outpatient setting; AND

2)    The social environment is characterized by temporary stressors or limitations that would undermine treatment that could potentially be improved with treatment while the patient is in the residential facility; AND

3)    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 patient will be able to return to outpatient treatment.

Intensity of Service (IS)

The patient must have all of the following to qualify:

1)    Residential treatment takes place in a structured facility-based setting; AND

2)    Documentation shows that a blood or urine drug screen was done on admission and during treatment if indicated; AND

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 a registered nurse [RN]  []) with 24 hour medical availability to manage medical problems if medical instability identified as a reason for admission to this level of care; AND

4)    Within 72 hours, a multidisciplinary assessment with an individualized problem-focused treatment plan completed, addressing psychiatric, academic, social, medical, family and substance use needs; AND

5)    A psychiatrist is available 24 hours per day, 7 days per week to assist with crisis intervention and assess and treat medical and psychiatric issues, and prescribe medications as clinically indicated AND

6)    A Comprehensive Treatment Plan is to be completed within 5 days that includes:

a)  A clear focus on the issues leading to the admission and on the symptoms which need to improve to allow treatment to continue at a less restrictive level of care.

b)  If this is a readmission, clarity on what will be done differently during this admission that will likely lead to improvement that has not been achieved previously.

c)  Multidisciplinary assessments of mental health issues, substance use, medical illness(s), personality traits, social supports, education, and living situation.

d)  The treatment plan results in interventions utilizing medication management, social work involvement, individual, group therapies as appropriate.

e)  The goal is to improve symptoms, develop appropriate discharge criteria and a plan that involves coordination with community resources to allow a smooth transition to a less restrictive level of care, family integration, and continuation of the recovery process.

f)   All medical and psychiatric evaluations should include consideration of the possibility of relevant co-morbid conditions.

g)  This plan should:

·         Be developed jointly with the individual and family/significant others

·         Establish specific, measurable goals and objectives

·         Include treatment modalities that are appropriate to the clinical needs of the individual

·         For individuals with a history of multiple re-admissions and treatment episodes, the treatment plan needs to include clear interventions to identify and address the reasons for previous non-adherence/poor response and clear interventions for the reduction of future risks

Note: The Treatment Plan is not based on a pre-established programmed plan or time frames. Medical Necessity and length of stay are to be assessed individually to ensure appropriate treatment for the appropriate length of time rather than based on a pre-determined program

7)    Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual`s PCP, providing treatment to the patient, and where indicated, clinicians providing treatment to other family patients, is documented; AND

8)    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; AND

9)    Skilled nursing care (RN) available on-site twenty four (24) hours daily; AND

10)   Individual treatment with a qualified Psychiatrist as frequently as clinically indicated, but  at least once a week including medication management if indicated; AND

11)   Individual treatment with a licensed behavioral health clinician at least once a week; AND

12)   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 is not geographically accessible. For children and adolescents, this includes at least weekly individual family therapy, unless clinically contraindicated; AND

13)   A discharge plan is completed within one week that includes:  

a)    Where the patient will reside;

b)    Coordination with community resources to facilitate a smooth transition back to home, family, work or school, and appropriate treatment at a less restrictive level of care;

c)    Timely and clinically appropriate aftercare appointments, with at least one appointment within 7 days of discharge;

d)    Prescriptions for any necessary medications, in a quantity sufficient to bridge any gap between discharge and the first scheduled follow-up psychiatric appointment AND

14)   The treatment is individualized and not determined by a programmatic timeframe. It is expected that patients will be prepared to receive the majority of their treatment in a community setting; AND

15)   For a child or adolescent, the patient’s current living environment does not provide support for and access to therapeutic services necessary for recovery; AND

16)   Medication evaluation and documented rationale if no medication is prescribed.

Continued Stay Criteria (CS)

The patient must continue to meet "SI/IS" Criteria and have the following to qualify:

1)    SI criteria are still met and likelihood of benefit and return to outpatient (OP) treatment is shown by adherence to the treatment plan and recommendations by the patient and by progress in treatment; if progress is not occurring than the treatment plan is being amended in a timely and medically appropriate manner with treatment goals still achievable.

Residential Treatment Detoxification for Substance Use Disorder

To qualify, patient’s symptoms or condition must meet the diagnostic criteria for a DSM Axis I or ICD Substance Dependence diagnosis for residential treatment detoxification. All services must meet the definition of medical necessity in the patient’s plan document.

Severity of Illness (SI)

Nature and pattern of use of abused substance (s) (including frequency and duration) predicts the potential for clinically significant withdrawal necessitating 24-hour medical intervention to prevent complications and is not appropriate for a lower level of care (e.g., alcohol and benzodiazepine withdrawal).

Note: Withdrawal from stimulants or marijuana alone generally does not require a medical detoxification and opiate detoxification is generally appropriate for a lower level of care).

·         Detoxification at this level of care is characterized by its emphasis on peer and social support rather than intensive medical and nursing care.

·         Residential Detoxification is only appropriate when substance use withdrawal symptoms are of moderate severity, such that an intensive medically monitored inpatient detoxification is not required.

·         Detoxification in Residential Substance Use Disorders Treatment level of care is NOT appropriate if any of the following circumstances are present:

a)    The individual does not meet the Medical Necessity criteria for Residential Substance Use Disorders Treatment.

b)    Objective medical symptoms and/or a history that indicates a high level of risk for a severe alcohol and/or sedative, hypnotic withdrawal syndrome, or an opiate withdrawal syndrome that is of such severity that the individual is not capable of active participation in the residential treatment program.

c)    An individual who is suffering from symptoms of a severe co-existing mental or physical disorder that is of such severity that the individual is not capable of active participation in the residential treatment program

·         A need for initiation or continuation of detoxification and/or symptoms associated with withdrawal or post-acute withdrawal should not be the primary criteria for admission or continued stay at substance residential level of care.

·         Presence of any of the following may necessitate an acute hospital level of care:

a)    A complicating psychiatric illness that requires inpatient treatment; OR

b)    A withdrawal history of delirium tremens, seizures, hallucinations or acute psychotic reaction secondary to chronic alcohol use and/or polysubstance drug use; OR

c)    An unstable medical illness that requires daily care by a consulting physician; OR

d)    Presence of active withdrawal symptoms that cannot be safely or effectively managed at a lower level of care.

Intensity of Service (IS)

The patient must have all of the following to qualify:

1)    Documentation of blood and/or urine drug screen results upon admission; AND

2)    Multi-disciplinary problem-focused treatment plan that addresses psychological, social (including living situation and support system), medical, substance abuse and rehabilitation needs which is re-evaluated and amended in a timely and medically appropriate manner as indicated; AND

3)    Examination by a qualified physician within 24 hours of admission and physician visits on a daily basis while in detoxification; AND

4)    24 hours skilled nursing (either an RN or LVN) on site. Note: If the patient’s medical symptoms require 24-hour nursing care for assessment, frequent administration of medication, monitoring of vital signs and other services only provided by a nurse, then acute inpatient detoxification is required; AND

5)    Medication management of withdrawal symptoms; AND

6)    Discharge planning is initiated on the day of admission and includes appropriate continuing care plans; AND

7)    Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the patient’s PCP, providing treatment to the patient, and where indicated, clinicians providing treatment to other family members, is documented; AND

8)    Evaluation for medication that may improve the patient`s ability to remain abstinent; document the rationale if no medication is prescribed; AND

9)    All therapeutic services provided by licensed or certified professional in accordance with state laws.

Continued Stay Criteria (CS)

The patient must continue to meet "SI/IS" Criteria and have the following to qualify:

1)    Progress in treatment is being documented and the patient is not stable enough to be treated at a lower level of care.

Residential Treatment Center for Substance Abuse Disorder

To qualify, patient’s symptoms or condition must meet the diagnostic criteria for a DSM Axis I or ICD Substance Abuse and/or Dependence diagnosis for residential treatment center treatment. All services must meet the definition of medical necessity in the Covered Individual`s plan document.

Severity of Illness (SI)

The patient must meet criteria 1 or 2, as well as 3 (and 4, for children and adolescents) to qualify:

1)    Acute psychiatric symptoms that would interfere with:

a)    The patient maintaining abstinence; AND

b)    Recovery outside of a 24 hour structured setting; AND

c)    Represent a deterioration from their usual status; AND

d)    Include either self-injurious or risk taking behaviors that poses risk serious harm to the patient or others and cannot be managed outside of a 24 hour structured setting; OR

2)    Acute medical symptoms that would likely interfere with the patient maintaining abstinence and recovery outside of a 24 hour structured setting; AND

3)    Evidence of major functional impairment in at least 2 domains (work/school, ADL, family/interpersonal, physical health); AND

4)    The individual has a documented diagnosis of a moderate-to-severe substance use disorder, per the most recent version of the Diagnostic and Statistical Manual of Mental Disorders; AND

5)    For individuals under 18 years, the individual’s family is willing to commit to active regular treatment participation; AND

6)    As a result of the interventions provided at this level of care, the symptoms and/or behaviors that led to the admission can be reasonably expected to show improvement such that the individual will be capable of returning to the community and to less restrictive levels of care; AND

7)    The individual is able to function with some independence, so as to be able to participate in structured activities in a group environment; AND

8)    For children and adolescents, the patient’s current living environment does not provide support for and access to therapeutic services necessary for recovery.

Intensity of Service (IS)

The patient must have all of the following to qualify:

1)    Evaluation by a qualified psychiatrist or addictionologist  within 48 hours of admission and weekly visits by a qualified psychiatrist  if dually diagnosed and psychiatric symptoms identified as a reason for admission requiring this level of care; AND

2)    Physical exam and lab tests done within 48 hours if not 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 requiring this level of care; AND

3)    Programming provided will be consistent with the patient’s language, cognitive, speech and/or hearing abilities; AND

4)    Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the patient’s PCP, providing treatment to the patient, and where indicated, clinicians providing treatment to other family members, is documented; AND

5)    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; AND

6)    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; AND

7)    Family supports identified and contacted within 48 hours and family/primary support person participation in treatment at least weekly unless contraindicated. For children and adolescents, this includes at least weekly individual family therapy, unless clinically contraindicated; AND

8)    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; AND

9)    Drug screens used after all off-grounds activities and whenever otherwise indicated; AND

10)   All therapeutic services provided by licensed or certified professionals in accordance with state laws; AND

11)   The treatment is individualized and not determined by a programmatic timeframe. It is expected that patients will be prepared to receive the majority of their rehabilitation in a community setting; AND

12)   Evaluation for medication that may improve the patient`s ability to remain abstinent; document the rationale if no medication is prescribed; AND

13)   All therapeutic services provided by licensed or certified professional in accordance with state laws.

Relapse should not be the sole criterion for managing an individual in a more intensive level of care. When appropriate, an evaluation should be performed to assess the extent of the relapse, its effects on the individual and the family; the risk of danger/ harm to the individual or others; and the reason for the relapse.

A need for initiation or continuation of detoxification and/ or symptoms associated with withdrawal or post-acute withdrawal should not be the primary criteria for admission or continued stay at substance use residential level of care.

Continued Stay Criteria (CS)

The patient must continue to meet "SI/IS" Criteria and have the following to qualify:

1)    Progress toward all goals in the treatment plan must be documented in weekly treatment plan reviews. If progress is not being achieved, then the treatment plan must be revised with achievable treatment goals; AND

2)    The patient is still participating, following recommendations and continuing to show a level of motivation such that treatment goals can be achieved.

Codes Used in This BI:

T2033  Residential Care, per Diem


Limits

Limits

1)    Residential treatment is not covered for the use of foster homes or halfway houses.

2)    Residential treatment is not covered for Wilderness Center training.

3)    No benefits are available for custodial care, situation or environmental change.


Application to Products

1)    This policy applies to those plans that specify coverage of residential treatment for mental health and substance use disorders.  Review your Explanation of Coverage, Certificate of Coverage, or Summary Plan Description to determine if you plan covers these services.

2)    For CHI members, see BI208.

1) This policy applies to those plans that specify coverage of residential treatment for mental health and substance use disorders. Review your Explanation of Coverage, Certificate of Coverage, or Summary Plan Description to determine if you plan covers these services. 2) For CHI members, see BI208.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.