Medical Policies - Mental Health


Mental Health Services

Number:PSY301.000

Effective Date:06-15-2018

Coverage:

*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*

NOTE: For information regarding Applied Behavior Analysis (ABA) or Early Intensive Behavioral Intervention (EIBI) please refer to medical policy PSY301.021 Applied Behavior Analysis (ABA) for Autism Spectrum Disorder (ASD) Diagnosis.

Modalities used for the treatment of mental health conditions must be appropriate to the specific mental health disorder(s) of the patient being treated. The degree of impairment should be a factor in determining frequency and duration of therapeutic services.

The following treatment modalities may be considered medically necessary if they are determined to be medically appropriate to the specific mental health condition:

Individual psychotherapy,

Group therapy,

Family counseling,

Pharmacotherapy.

NOTE:

Benefits should be provided on a single provider basis when rendered by co-therapists.

Phone based therapy (mental health counseling or psychotherapy) may be a contract exclusion under mental health contracts.

Services provided at behavioral modification facilities, boot camps, emotional group academies, military schools, therapeutic boarding schools, wilderness programs, halfway houses and group homes may be a contract exclusion under mental health contracts or considered not medically necessary.

The following services are considered not medically necessary:

Services directed toward enhancing one's personality;

Consciousness raising;

Vocational or religious counseling;

Group socialization;

Activities primarily of an educational nature;

Behavioral modification for lifestyle enhancement;

Primal therapy (psychotherapy in which the patient is encouraged to relive his/her early traumatic experiences);

Obesity control therapy;

Rolfing (structural integration): a system of soft tissue manipulation and movement education that theorizes there is a correlation between muscular tensions and pent up emotions;

Bioenergetic therapy;

Sleep therapy (narcosis): a non-specific and reversible depression of function of the central nervous system marked by stupor or insensibility produced by drugs;

Carbon dioxide therapy: form of rarely used shock therapy employed for the treatment of withdrawn psychotic patients, in which unconsciousness is induced by the administration of carbon dioxide gas by inhalation);

Dance therapy;

Music therapy;

Services for psychotherapeutic services concurrently (at the same appointment) by more than one mental health provider;

Services credited toward earning a degree or furtherance of the education or training of the patient;

E-mail, phone, or web-based chat therapy would not be a covered benefit or may be considered not medically necessary (NOTE: Member’s contract benefits and/or plan legislation may apply); and

Any other modalities not provided by a licensed behavioral health professional in accordance with nationally accepted treatment standards.

RELATED MEDICAL POLICIES:

For Repetitive Transcranial Magnetic Stimulation (rTMS) of the brain, SEE Medical Policy PSY301.015.

For cranial electrical stimulation (CES) used for treatment of anxiety disorders, depression, substance abuse and other mental health purposes, SEE Medical Policy MED201.026.

For Electroconvulsive Therapy, SEE Medical Policy PSY301.013.

For Autism Spectrum Disorder, SEE Medical Policy PSY301.014.

For Psychological and Neuropsychological Testing, SEE Medical Policy PSY301.020.

For Neurofeedback, SEE Medical Policy PSY301.011.

For Vagus Nerve Stimulation (VNS), SEE Medical Policy SUR712.021.

Description:

Mental health services are treatment methods directed toward identifying specific behavior pat-terns, factors determining such behavior, and effective goal-oriented therapies. The American Psychiatric Association has published guidelines and practice parameters outlining standard care in the field.

Rationale:

This medical policy was developed in 1990 and has been updated regularly with searches of the MEDLINE database. A search of peer reviewed literature through April 2018 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

The therapies defined under this policy include:

Individual psychotherapy: a form of therapy involving the therapist and a single patient dependent principally on verbal interchange, including crisis intervention, and insight oriented behavior modification.

Group therapy: a form of treatment in which carefully selected patients are placed into a distinct group (minimum of four, maximum of 12), guided by a psychotherapist for the purpose of helping one another effect personality change. By using a variety of technical maneuvers and theoretical constructs, the psychotherapist uses the members' interaction to bring about this change.

Family counseling (conjoint): involves two or more family members and is not intended to be treatment for the relatives but to promote understanding of the patient and more acceptable ways of family functioning.

Pharmacotherapy: involves the prescription of medications, observation or response and regulation of dosage.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90865, 90882, 90885, 90887, 90899, 96150, 96151, 96152, 96153, 96154, 96155

HCPCS Codes

G0410, G0411, S9480, S3005

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder (2004) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 5, 2018).

2. Guideline Watch: Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder (2009) American Psychiatric Association. Available at <http://www.psychiatryonline.com> (accessed April 5, 2018).

3. Treatment of Patients with Alzheimer’s Disease and Other Dementias 2nd edition (2007) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 2016).

4. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder (2007) American Academy of Child and Adolescent Psychiatry. Available at <http://www.aacap.org> (accessed April 5, 2018).

5. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents (2011) American Academy of Pediatrics. Available at <http://pediatrics.aappublications.org> (accessed April 5, 2018).

6. Practice Guideline for the Treatment of Patients with Bipolar Disorder 2nd Edition (2002) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 5, 2018).

7. Guideline Watch: Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd Edition (2005) American Psychiatric Association. Available at <http://www.psychiatryonline.com> (accessed April 5, 2018).

8. Practice Guideline for the Treatment of Patients with Delirium (1999) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 2016).

9. Guideline Watch (August 2004): Practice Guideline for the Treatment of Patients with Delirium (2004) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 5, 2018).

10. Practice Guideline for the Treatment of Patients with Major Depressive Disorder 3rd Edition (2010) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 2016).

11. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders (2007) American Academy of Child and Adolescent Psychiatry. Available at <http://www.aacap.org> (accessed April 5, 2018).

12. Adult Depression in Primary Care Guideline (2013) Institute for Clinical Systems Improvement. Available at <https://www.icsi.org> (accessed April 2016).

13. Practice Guideline for the Treatment of Patients with Eating Disorders 3rd Edition (2006) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 5, 2018).

14. Guideline Watch: Practice Guideline for the Treatment of Patients with Eating Disorders 3rd Edition (2012) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 5, 2018).

15. Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder (2007) American Psychiatric Association. Available at <http://psychiatryonline.org> (April 5, 2018).

16. Guideline Watch: Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder (2013) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 2016).

17. Practice Guideline for the Treatment of Patients with Panic Disorder 2nd Edition (2009) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 5, 2018).

18. Practice Guideline for the Treatment of Patients with Schizophrenia 2nd Edition (2004) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 5, 2018).

19. Guideline Watch (September 2009): Practice Guideline for the Treatment of Patients with Schizophrenia (2009) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 2016).

20. Practice Guideline for the Treatment of Patients with Substance Use Disorders 2nd Edition (2006) American Psychiatric Association. Available at <http://psychiatryonline.org> (accessed April 5, 2018).

21. Guideline Watch (April 2007): Practice Guideline for the Treatment of Patients with Substance Use Disorders 2nd Edition (2007) American Psychiatric Association. Available at <http://www.psychiatryonline.com> (accessed April 5, 2018).

22. Psychotherapy understanding group therapy. American Psychological Association. Available at <http://www.apa.org> (accessed April 16, 2018).

23. What is Psychotherapy? American Psychiatric Association. Available at <http://www.psychiatry.org> (accessed April 16, 2018).

24. Psychotherapies. National Institute of Mental Health. Available at <https://www.nimh.nih.gov> (accessed April 16, 2018).

Policy History:

Date Reason
6/15/2018 Document updated with literature review. Coverage unchanged. References 22-24 were added.
1/1/2017 Document updated with literature review. Coverage has changed. The following service listed under the considered not medically necessary list was changed from: Phone, E-mail, web-based psychotherapy, or telemedicine (NOTE: Member’s contract benefits and/or plan legislation may apply) to: E-mail, phone, or web-based chat therapy would not be a covered benefit or may be considered not medically necessary (NOTE: Member’s contract benefits and/or plan legislation may apply).
2/15/2015 Documented updated with literature review. The following was added to Coverage: Services provided at behavioral modification facilities, boot camps, emotional group academies, military schools, therapeutic boarding schools, wilderness programs, halfway houses and group homes are considered not medically necessary ; in addition, these services may be a contract exclusion under mental health contract. In addition, the following examples were added to the list of services that are considered not medically necessary: 1) Phone, E-mail, web-based psychotherapy, or telemedicine (NOTE: Member’s contract benefits and/or plan legislation may apply). 2) Any other modalities not provided by a licensed behavioral health professional in accordance with nationally accepted treatment standards. In addition, the references were complete updated and revised.
12/1/2013 Document reviewed. No changes.
5/1/2010 No coverage change. Document updated with the following change: Transcranial magnetic stimulation was removed from this policy and placed on new document PSY301.015 Transcranial Magnetic Stimulation (TMS).
6/1/2008 Policy reviewed without literature review; new review date only.
4/1/2007 Revised/Updated Entire Document
7/1/2006 CPT/HCPCS code(s) updated
4/1/2005 New CPT/HCPCS code(s) added
10/24/2003 Revised/Updated Entire Document
5/1/1996 Revised/Updated Entire Document
1/1/1993 Revised/Updated Entire Document
5/1/1990 New Medical Document

Archived Document(s):

Title:Effective Date:End Date:
Mental Health Services01-01-201706-14-2018
Mental Health Services02-15-201512-31-2016
Mental Health Services12-01-201302-14-2015
Mental Health Services05-01-201011-30-2013
Mental Health Services06-01-200804-30-2010
Mental Health Services04-01-200705-31-2008
Mental Health Services10-24-200303-31-2007
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