Medically Necessary

Outpatient psychotherapy services are covered for the diagnosis and treatment of mental health and substance use disorders specified in the most recent Diagnostic and Statistical Manual (DSM)™ or with the most recent International Classification of Diseases (ICD). The reported diagnosis should support the current symptom presentation and should be the focus of treatment.

Clinical Guideline Coverage Criteria

The Plan considers outpatient psychotherapy services, delivered by a provider licensed in a recognized discipline, as reasonable and medically necessary when EITHER of the following are met:

1. Must meet either A or B
   • Meet ALL of the following:
     1. When clinical data provide clear evidence of signs and symptoms consistent with a mental health or substance use disorder as defined in the most recent DSM or ICD; and
     2. And when there is a treatment plan, with measurable goals and approaches, that address the signs and symptoms of the patient’s mental health or substance use disorder and that is consistent with current professional practice standards; and
     3. And when there is no less intensive or more appropriate level of service that can be safely and effectively provided;
   • or b. When clinical data indicate that the Member’s condition has stabilized and continued treatment at a less frequent maintenance level is needed to sustain the current level of functioning.

Limitations

The Plan considers outpatient psychotherapy as not reasonable or medically necessary for ANY of the following:

1. Regardless of medical necessity, services listed as exclusions, or not listed as covered benefits, in the Member’s benefit document; or
2. Services that could safely and effectively be provided at a lesser frequency or intensity; or
3. Therapy visits more than once a week except in situations of acute crisis for a brief period of time. For example, situations when there is a risk of hospitalization, severe symptoms and/or severe functional impairments; or
4. When services are not documented in a medical record containing contemporaneous progress notes.

Codes