BH Day Treatment Form

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Behavioral Health Day Treatment Medical Policy
Updated Revision Effective: 10/1/2025 Policy Number: UM369POL

Approval Date: 8/14/2025

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Psychiatric Day Treatment Program: A planned combination of diagnostic, treatment, and rehabilitative and recovery-oriented services provided to individuals with mental or emotional disabilities who need more active or inclusive treatment than is typically available through a weekly visit to a mental health center or hospital outpatient department, but who do not need full-time hospitalization or institutionalization. Such a program utilizes multiple, intensive, and focused activities in a supportive environment to enable such persons to acquire skills to live an independent life in the community.

Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
Medical necessity review is performed by the Massachusetts Behavioral Health Partnership (MBHP).

Medicare:
This policy does not apply

Policy

I. Criteria for Approval
A. The member is unable to regain a prior, higher level of functioning outside the treatment program due to a mental health disorder as evidenced by:

1. Psychiatric symptoms that require clinical stabilization, such as depression, anxiety, neurovegetative symptoms, or thoughts of self-harm; AND,

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2. Significant interference in at least one functional area (social, vocational, educational, self-care or care of a minor or disabled dependent); AND,
3. The member’s condition cannot be stabilized at a less intensive level of care; AND,
4. The member is actively participating in treatment and attending at least 80% of scheduled sessions, AND,
5. A short-term, intensive treatment setting may reasonably be expected to affect a substantial improvement in the member’s condition; AND,
6. There is an individualized treatment plan developed by a licensed clinician with specific, objective treatment goals and timelines for achieving those goals.
   II. What is Not Covered:
7. The individual can be safely maintained and effectively treated at a less intensive level of care; OR,
8. The individual’s condition is chronic and/or it is not reasonable to expect that a higher level of functioning can be affected by participation in a short-term, intensive treatment setting; OR,
9. The primary problem is social or economic (i.e. housing, family conflict, lack of daily structure or socialization outlets, etc.) or one of physical health without a concurrent major behavioral health disorder.
10. Vocational Rehabilitative or Educational services
11. Functional maintenance program,
12. Research and experimental treatment,
13. Meals
14. Services provided when in an inpatient setting,

15. Group therapy as a separate service

    Coding Guidance

    Code Description PA H2012 Behavioral health day treatment, per hour Yes

    References

    Guy W, Gross M, Hogarty GE, Dennis H. A controlled evaluation of day hospital effectiveness. Arch Gen Psychiatry. 1969 Mar;20(3):329-38. doi: 10.1001/archpsyc.1969.01740150073011. PMID: 5764573. Tyrer PJ, Remington M. Controlled comparison of day-hospital and outpatient treatment for neurotic disorders. Lancet. 1979 May 12;1(8124):1014-6. doi: 10.1016/s0140-6736(79)92764-8. PMID: 86727.

    https://www.mass.gov/doc/bulletin-2015-05-access-to-services-to-treat-substance-use-disorders-issued-73115- 0/download#:~:text=Medically%20monitored%20intensive%20inpatient%20detoxification,week%20nursing%20 and%20medical%20supervision.

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Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 6/2010 Initial policy effective date 8/2023 New template. No substantive changes to policy language. Policy language clarified.
1/2024 Added Line of Business section 3/2024 Reviewed with no changes 7/2025 Reviewed with no changes

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.