Coverage Policies

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)    Mental health and substance use (MH/SU) therapy services must be prescribed by a physician. Services provided in the office requires development of a treatment plan by the treating healthcare provider as normal practice. QualChoice may choose to review the treatment plan to evaluate the medical necessity of the services.

2)    MH/SU therapy does not require a prior authorization. Initial therapy should be started after a physician evaluation and with physician orders. After initial 15 visits, subsequent therapy visits can only be performed with an individualized written treatment plan signed by a psychiatrist, psychiatric APRN or (if neither of these is available) a primary care physician. QualChoice may review medical records at any time. Initial therapy started without a physician order, or subsequent therapy performed after initial 15 visits by a practice without an individualized written treatment plan signed by a psychiatrist, psychiatric APRN or (if neither of these is available) a primary care physician or the services not meeting medical necessity criteria as described in the Medical Policy Statement section, will be denied retrospectively.

3)    Psychological testing is addressed in BI174.

4)    Neuropsychological testing is addressed in BI005.

5)    Inpatient, partial hospitalization, intensive outpatient, and residential therapies are not considered in this BI. 

6)    Group/family therapy is only covered for certain plans; please review your plan documents to determine if you have this coverage.

7)    See also BI431 for guidance on billing for these services.

Outpatient Behavioral Therapy:

A.   Initial therapy or therapy after mental health admission require a physician order and is considered medically necessary:

i)     If a treatment plan demonstrates the continued care is for treatment of crisis leading to symptoms amenable to therapy per applicable MCG Care Guideline®. All treatment plans must be available for review by Care Management if requested.

ii)    Updated treatment plans must demonstrate the following to be considered medically necessary:

a)    Documented improvement during previous sessions; and

b)    Capacity for continued significant improvement; and

c)    There has been full co-operation by the member with treatment.

B.   Therapy after Inpatient discharge from detoxification is considered medically necessary when after initial visit:

i)     A treatment plan demonstrates member has completed the first 7 steps of recovery with a sponsor. The initial treatment plan must be available for review by Care Management if requested.

a)    Updated treatment plans must demonstrate the following to be considered medically necessary: Documented improvement during previous sessions; and

b)    Capacity for continued significant improvement; and

c)    There has been full co-operation with treatment.

ii)   Outpatient psychiatric diagnostic evaluations are covered once per provider, every 12 months. More frequent evaluations per provider within 12 months require pre-authorization.

Codes Used In This BI:

1)    Services which are not considered medically necessary, and are not eligible for coverage under mental health or medical benefits, include but are not limited to:

1)    Career counseling

2)    Pre-adoption counseling

3)    Sex therapy

4)    Classical long term psychoanalysis

5)    Family therapy or family counseling as relational treatment

6)    Individual psychohysiotherapy with biofeedback (CPT 90875-90876)

7)     

2)    Services provided by non-licensed providers, such as pastoral counselors, are not covered.

3)    Narcosynthesis (e.g., Amytal interview) is considered experimental/investigational.

4)    Group/family therapy are generally not covered
except for:

1)    Autism coverage.  See BI184.

2)    Metallic small group and individual plans:  90853 is covered.

5)    Interpretation or explanation of results to family, is considered incidental to psychiatric treatment and is not separately payable.

6)    A provider visit solely with the member’s family (except for the legal guardian) is not covered.

7)    MH/SU therapy does not require a prior authorization. Initial therapy should be started after a physician evaluation and with physician orders. After initial 15 visits, subsequent therapy visits can only be perfomed withan individualized written treatment plan signed by a psychiatrist psychiatric APRN or (if neither of these is available) a primary care physician. QualChoice may review medical records at any time. Initial therapy started without a physician order, or subsequent therapy performed after initial 15 visits by a practice without an individualized written treatment plan by a psychiatrist, psychiatric APRN or (if neither of these is available) a primary care physician or the services not meeting medical necessity criteria as described in the Medical Policy Statement section, will be denied retrospectively.

8)    See BI184 for Autism coverage.

Outpatient mental health or substance abuse therapy treatment consists of a prescribed program to relieve symptoms, improve function and prevent further impairment for individuals disabled or impaired by chronic or acute mental health or substance abuse problems. Treatment may include cognitive behavior therapy, gestalt therapy, interpersonal psychotherapy, behavior therapy, or other modalities, depending on patient characteristics and therapist training. 

As with any other therapy, mental health therapies need to be supported by a valid diagnosis, an evidence-based treatment plan, periodic re-evaluation of whether or not the treatment is achieving desired outcomes and adjustments in the treatment plan based on efficacy of the interventions. Historically, many mental health therapies have been provided without a valid diagnosis, without a formal treatment plan and without any monitoring of efficacy. Rather than mental health therapies continuing to be provided in isolation—without any coordination, collaboration or oversight—there is an increasing emphasis on the need to integrate mental health therapies with medical services. An integrated model is more likely to optimize outcomes by promoting appropriate use of evidence-based interventions. A team approach that treats the whole person is highly desirable and can only be realized with coordination, collaboration and oversight.

A concern with requiring psychiatrist oversight or monitoring of mental health therapies is that there are not enough psychiatrists in practice to meet the demand—particularly in smaller or rural communities. In some cases, psychiatrist oversight can be provided through the use of telemedicine. If no direct psychiatric evaluation or telemedicine psychiatric evaluation is available, a psychiatric APRN (with a collaborative practice agreement with a psychiatrist) can fulfill this role.  If neither a psychiatrist nor a psychiatric APRN is available, a primary care physician would be acceptable. The practical reality, for decades, has been that primary care physicians make most of the mental health diagnoses and prescribe most of the medicines for these diagnoses. When there are documented gaps in access to psychiatric services (as with any other specialty service), it’s reasonable, when possible, for primary care physicians to help fill in those gaps.

Mental health parity is often used to promote equivalent coverage for both mental health and medical therapies. We do a tremendous disservice to patients if we pretend mental health disorders are less important than medical disorders and therefore not as worthy of coverage. For any given patient, a mental health disorder may have a greater impact on his/her quality of life than medical diagnoses. In many cases outcomes with medical diagnoses are compromised due to not addressing mental health disorders. However, the two-edged sword of mental health parity is that equivalent coverage also means equivalent accountability and oversight. Without accountability and oversight of mental health therapies (valid diagnosis, an evidence-based treatment plan and periodic re-evaluation) there is no mental health parity.

Medically necessary therapy services must be restorative or for the purpose of designing and teaching maintenance program to assist the patient in coping with their psychological problems. The services must also relate to a written treatment plan and be of a level of complexity that requires the judgment, knowledge and skills of a licensed therapist to perform the services. The frequency and duration of the therapy services must be reasonable, the services must be considered appropriate and needed for the treatment of the disabling or impairing condition, and services must not be palliative or Habilitative in nature. 

1)    National Mental health information center; Evidence-Based Practices: Shaping Mental Health Services toward Recovery located at: http://mentalhealth.samhsa.gov/cmhs/CommunitySupport/toolkits/illness/goi/scale.asp.

2)    New York State, Office of Mental Health; Mental Health Clinic Standards of Care for Adults- Interpretive Guidelines. Located at : http://www.omh.state.ny.us/omhweb/clinic_restructuring/appendix1.html

3)    Los Angeles County Commission on HIV, Standards of Care, mental health/psychotherapy. Located at: http://hivcommission-la.info/cms1_044407.pdf

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.