Category III Current Procedural Terminology (CPT®) codes

PURPOSE Administrative Policies are intended to provide further information about the administration of standard Cigna benefit plans. In the event of a conflict, a customer’s benefit plan document always supersedes the information in an . Coverage determinations require consideration of 1) the terms of the applicable benefit plan document; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Administrative Policies and; 4) the specific facts of the particular situation.

Administrative Policies relate exclusively to the administration of health benefit plans. Administrative Policies are not recommendations for treatment and should never be used as treatment guidelines.

Coverage for behavioral health coaching and peer support services for individuals with mental health or substance use disorders is subject to the terms, conditions and limitations of the applicable benefit plan and may be subject to state regulations.

Cigna covers outpatient behavioral health coaching and peer support services for individuals with mental health or substance use disorders when provided by a Licensed/Certified coach acting within the scope of license or certification under the applicable state law.

General Background

Peer Support Services

Peer support services are provided when therapeutically helpful. Peer support services are specialized therapeutic interactions that are performed by individuals who are current or past recipients of behavioral health services. These individuals are trained and certified to provide support and assistance to individuals in their recovery and integration into the community. The goal is to provide understanding and coping skills and empowerment through mentoring and other supports so that individuals with severe and persistent mental health or substance use disorders can cope with stress and achieve personal wellness (American Medical Association [AMA] Current Procedural Terminology (CPT®) guidelines).

Peer support workers practice in a range of settings, including peer-run organizations, recovery community centers, drug courts, recovery residences and other criminal justice settings, hospital emergency departments,

: A015 child welfare agencies, homeless shelters, and behavioral health and primary care settings. Peer support workers may be referred to by different names depending upon the setting in which they practice. Common titles include: peer specialists, peer recovery coaches, peer advocates, and peer recovery support specialists (SAMHSA, 2022).

The role of a peer support worker complements, but does not duplicate or replace, the roles of members of a treatment team. Peer support workers bring their own personal knowledge of what it is like to live and thrive with mental health conditions and substance use disorders. They support people’s progress towards recovery and self-determined lives by sharing vital experiential information and real examples of the power of recovery (Davidson, et al. 2012).

The Substance Abuse and Mental Health Services Administration (SAMHSA) states that emerging research shows that peer support is effective for supporting recovery from behavioral health conditions.

Benefits of peer support may include the following (SAMHSA, 2022):

• increased sense that treatment is responsive and inclusive of needs
• increased engagement in self-care and wellness
• increased self-esteem and confidence
• increased sense of hope and inspiration
• increased sense of control and ability to bring about changes in their lives
• increased empathy and acceptance (camaraderie)
• increased social support and social functioning
• raised empowerment scores
• decreased psychotic symptoms
• decreased substance use and depression

Behavioral Health Coaching

Behavioral health coaching is a patient-centered approach wherein patients determine their goals, use self-discovery or active learning processes together with content education to work toward their goals, and self-monitor behaviors to increase accountability, all within the context of an interpersonal relationship with a coach. Coaches have an advanced degree in a psychology related field and/or a coaching certification issued by an accredited training program. Coaches receive training in behavioral change theory, motivational strategies, communication techniques, and health promotion theories which are used to assist patients in developing the motivation and skills needs to create sustainable change for improved health and well-being.

Coaches are overseen by licensed medical professionals and deliver care as a part of a clinical practice. Coaching services are often provided as an initial intervention for patients with low acuity concerns, delivered in addition to clinical care, or utilized as a step-down support once a patient completes therapy (American Medical Association [AMA] Current Procedural Terminology (CPT®) guidelines; National Board for Health & Wellness Coaching (NBHWC); National Commission for Health Education Credentialing, Inc. Training).

The American Medical Association (AMA) defines a coach as a non-physician health care professional certified by National Board for Health and Wellness Coaching (NBHWC) or National Commission for Health Education Credentialing, Inc. (NCHEC).

There is low to moderate quality evidence indicating that involving peer support workers and coaching in mental health teams results in psychosocial, mental health symptom and service use outcomes for clients that are no better or worse than those achieved by professionals employed in similar roles. There is no difference in client satisfaction with services. There is no evidence of harm associated with involving peer support workers and coaching in mental health teams (Pitt, et al., 2013).