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California Medical Necessity Criteria Guidelines

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California Medical Necessity Criteria Guidelines California Medical Necessity Criteria Guidelines Version 2.0 Effective Date: January 1, 2016 Created: October 12, 2015 Updated: November 11, 2015 ABA Criteria Updated: March 3, 2016 California Medical Necessity Criteria Guidelines © 2007-2016 Magellan Health, Inc. © 2007-2016 Magellan Health, Inc. Table of Contents Table of Contents ......................................................................................................................................................................... ii Preamble - Principles of Medical Necessity Determinations ................................................................................... i Medical Necessity Definition ................................................................................................................................................. iii Levels of Care & Service Definitions .................................................................................................................................. iv Term Definitions ...................................................................................................................................................................... viii Hospitalization, Psychiatric, Adult .................................................................................................................................... 10 Hospitalization, Psychiatric, Child and Adolescent .................................................................................................. 13 Hospitalization, Psychiatric, Geriatric ............................................................................................................................. 17 Hospitalization, Eating Disorders ..................................................................................................................................... 21 Hospitalization, Substance Use Disorders, Detoxification .................................................................................... 25 Hospitalization Substance Use Disorders, Rehabilitation Treatment, Adult and Geriatric .................. 27 Hospitalization, Substance Use Disorders, Rehabilitation Treatment, Child and Adolescent ............. 31 Subacute Hospitalization, Psychiatric, Adult ............................................................................................................... 35 Subacute Hospitalization, Psychiatric, Geriatric ........................................................................................................ 38 Subacute Hospitalization, Psychiatric, Child and Adolescent .............................................................................. 41 23-Hour Observation .............................................................................................................................................................. 44 Residential Treatment, Psychiatric, Adult and Geriatric ....................................................................................... 46 Residential Treatment, Psychiatric, Child and Adolescent ................................................................................... 49 Residential Treatment, Eating Disorders ...................................................................................................................... 52 Residential Treatment, Substance Use Disorders, Detoxification ..................................................................... 56 Residential Treatment, Substance Use Disorders, Rehabilitation, Adult and Geriatric .......................... 58 Residential Treatment, Substance Use Disorders, Rehabilitation, Child and Adolescent ..................... 61 Residential Treatment, Sexual Offender, Child and Adolescent ......................................................................... 64 Supervised Living, Psychiatric, Adult and Geriatric ................................................................................................. 68 Supervised Living, Psychiatric, Child and Adolescent ............................................................................................. 71 Supervised Living, Substance Use Disorders, Rehabilitation, Adult and Geriatric ................................... 73 Supervised Living, Substance Use Disorders, Rehabilitation, Child and Adolescent ............................... 77 Partial Hospitalization, Psychiatric, Adult and Geriatric ....................................................................................... 80 Partial Hospitalization, Psychiatric, Child and Adolescent ................................................................................... 83 Partial Hospitalization, Eating Disorders ...................................................................................................................... 86 Partial Hospitalization, Substance Use Disorders, Rehabilitation Adult and Geriatric ........................... 89 ii © 2007-2016 Magellan Health, Inc. Partial Hospitalization, Substance Use Disorders, Rehabilitation, Child and Adolescent ..................... 92 Intensive Outpatient Treatment, Psychiatric, Adult and Geriatric ................................................................... 95 Intensive Outpatient Treatment, Psychiatric, Child and Adolescent ............................................................... 98 Intensive Outpatient Treatment, Eating Disorders ............................................................................................... 101 Intensive Outpatient Treatment, Substance Use Disorders, Rehabilitation, Adult and Geriatric ... 104 Intensive Outpatient Treatment, Substance Use Disorders, Rehabilitation, Child and Adolescent107 Ambulatory, Substance Use Disorders, Detoxification ........................................................................................ 110 Ambulatory, Substance Use Disorders, Buprenorphine Maintenance ........................................................ 112 Ambulatory, Substance Use Disorders, Laboratory Screening of Drugs/Substances of Abuse ...... 115 Outpatient Treatment, Psychiatric and Substance Use Disorders, Rehabilitation................................. 117 Outpatient Applied Behavior Analysis ........................................................................................................................ 121 Psychological Testing ........................................................................................................................................................... 126 Therapeutic Leave of Absence Documentation ...................................................................................................... 128 Outpatient Electroconvulsive Therapy ....................................................................................................................... 129 Inpatient Electroconvulsive Therapy ........................................................................................................................... 133 Transcranial Magnetic Stimulation Treatment ....................................................................................................... 137 Bibliography ............................................................................................................................................................................. 141 Appendix – Outpatient Applied Behavior Analysis ............................................................................................... 177 iii © 2007-2016 Magellan Health, Inc. Preamble - Principles of Medical Necessity Determinations Individualized, Needs-Based, Least-Restrictive Treatment Magellan1 is committed to the philosophy of providing treatment at the most appropriate, least-restrictive level of care necessary to provide safe and effective treatment and meet the individual patient’s biopsychosocial needs. We see the continuum of care as a fluid treatment pathway, where patients may enter treatment at any level and be moved to more or less-intensive settings or levels of care as their changing clinical needs dictate. At any level of care, such treatment is individualized, active and takes into consideration the patient’s stage of readiness to change/readiness to participate in treatment. The level of care criteria that follow are guidelines for determining medical necessity for the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5™) disorders. Individuals may at times seek admission to clinical services for reasons other than medical necessity, e.g., to comply with a court order, to obtain shelter, to deter antisocial behavior, to deter runaway/truant behavior, to achieve family respite, etc. However, these factors do not alone determine a medical necessity decision. Further, coverage for services is subject to the limitations and conditions of the member benefit plan. Specific information in the member’s contract and the benefit design for the plan dictate which medical necessity criteria are applicable. Although these Medical Necessity Criteria Guidelines are divided into “psychiatric” and “substance-related” sets to address the patient’s primary problem requiring each level of care, psychiatric and substance-related disorders are often co-morbid. Thus, it is very important for all treatment facilities and providers to be able to assess these co-morbidities and address them along with the primary problem. Clinical Judgment and Exceptions The Magellan Medical Necessity Criteria Guidelines direct both providers and reviewers to the most appropriate level of care for a patient. While these
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