Description
Treatment for behavioral health conditions is reimbursed according to the patient’s specific contract benefit language. Behavioral health services are
treatment methods directed toward identifying specific behavior patterns, factors determining such behavior, and effective goal-oriented therapies. The American Psychiatric Association and other recognized, national organizations have published guidelines and practice parameters outlining standard
care in the field.

Definitions:

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, 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.

Behavioral health services: all mental health services and/or substance use disorder services performed by a qualified behavioral health clinician.

Behavioral health clinician: a clinician who renders mental health services and/or substance use disorder services.  

Licensed practitioner of the healing arts (LPHA): an individual who, within the scope of state law, has the ability and appropriate state licensure to independently make a clinical assessment, certify a diagnosis and recommend treatment for individuals with a mental illness.

Rehabilitative behavioral health services (RBHS): are medical or remedial services that have been recommended by a physician or other LPHA with the scope of their practice under South Carolina state law and as further determined by the South Carolina Department of Health and Human Services (SCDHHS) for maximum reduction of physical or mental disability and restoration of a beneficiary to their best possible functional level.  

The term clinician does not include interns, residents or behavioral health clinicians outside the scope of his or her training of his or her license.

Contract: *CAREFULLY CHECK STATE REGULATIONS, THE MEMBER CONTRACT AND/OR FEHBP RULES (IF APPLICABLE).*

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 clinicians 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.

Policy:
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

The following services are excluded services, as not medically necessary, not in accordance with generally accepted standards of medical practice, and/or investigational. In making this determination, the same processes, strategies, evidentiary standards, or other factors were considered in a comparable manner as, and applied no more stringently than, in determining which medical/surgical services are excluded as not medically necessary, not in accordance with generally accepted standards of medical practice, and/or investigational: 

• Psychotherapy for the following diagnoses: tic disorders, mental disorders due to a general medical condition, medication-induced movement disorder and nicotine dependence
• Group socialization
• Primal therapy (psychotherapy in which the patient is encouraged to relive his/her early traumatic experiences)
• Holding therapy
• Movement therapy art therapy
• Dance therapy music therapy
• Animal-assisted therapy
• Sexual conversion therapy (may also be known as conversion or reparative therapy)
• Cranial electrical stimulation (CES) used for treatment of anxiety disorders, depression, substance abuse and other mental health purposes
• Teaching, expanding, appreciating, collaborating, cooperating and holistic (TEACCH) programs
• Higashi schools/daily life
• Facilitated communication
• Floor time
• Developmental individual-difference relationship-based model (DIR)
• Relationship development intervention (RDI)

The following services are excluded services due to being deemed primarily for educational or occupational purposes rather than the provision of medical care. In making this determination, the same processes, strategies, evidentiary standards or other factors were considered in a comparable manner as, and applied no more stringently than, in determining which medical/surgical services are excluded due to being deemed primarily for educational or occupational purposes rather than the provision of medical care: 

•   Activities primarily of an educational nature
•   Services credited toward earning a degree or in furtherance of the education or training of the patient or to see if a learning disorder exits

All services for the following disorders are excluded services unless otherwise provided under the applicable plan document(s), contract(s) and/or state law:

•   Intellectual disabilities, learning disorders, communication disorders, motor skills disorders and relational problems (V codes)

The following facilities and programs are excluded due to (a) being custodial in nature, (b) variability of state licensure requirements, and/or (c) high incidents of fraud and abuse. In making this determination, the same processes, strategies, evidentiary standards or other factors were considered in a comparable manner as, and applied no more stringently than, in determining which medical/surgical services are excluded due to being custodial in nature, variability of state licensure requirements, and/or high incidents of fraud and abuse. See CAM 157HB (Medical Policy Development and Review):

•  Services provided at behavioral modification facilities, boot camps, emotional group academies, military schools, therapeutic boarding schools, wilderness programs, halfway houses and group homes

Otherwise covered services that are merely furnished in any of the above facilities or settings are not excluded under this section, subject to the terms and conditions of the coverage.

References

1. American Academy of Child and Adolescent Psychiatry (AACAP) Policy Statement: Conversion Therapy (2018).
2. American Medical Association / GLMA: Health Professionals Advancing LGBTQ Equality Issue Brief: LGBTQ change efforts (“conversion therapy”) (Approved 1997;Amended & Reaffirmed pending final GLMA Board approval 2018).
3. Attention Deficit Hyperactivity Diagnosis and Management (2018) National Institute for Health and Care Excellence (NICE).
4. Autism Spectrum Disorder: Consensus Guidelines on Assessment, Treatment and Research (2017) British Association for Psychopharmacology.
5. Clinical Guidelines for the Management of Adults with Major Depressive Disorder (2016) Canadian Network for Mood and Anxiety Treatments (CANMAT).
6. Clinical Practice Guidelines for the Treatment of Panic Disorder, Social Anxiety Disorder and Generalized Anxiety Disorder (2018) Royal Australian and New Zealand College of Psychiatrists.
7. Cohen, D. and Maxwell, E. Music Therapy for Depression. American Family Physician 2020, Mar 1; 101(5): 273-274.
8. Eating Disorders: Recognition and Treatment (2017) National Institute for Health and Care Excellence (NICE).
9. Guideline Watch: Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder (2009) American Psychiatric Association.
10. Guideline Watch (October 2014): Practice Guideline for the Treatment of Patients with Alzheimer’s Disease and Other Dementias. American Psychiatric Association.
11. Guideline Watch: Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd Edition (2005) American Psychiatric Association.
12. Guideline Watch (August 2004): Practice Guideline for the Treatment of Patients with Delirium (2004) American Psychiatric Association.
13. Guideline Watch: Practice Guideline for the Treatment of Patients with Eating Disorders 3rd Edition (2012) American Psychiatric Association
14. Guideline Watch: Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder (2013) American Psychiatric Association.
15. Guideline Watch (September 2009): Practice Guideline for the Treatment of Patients with Schizophrenia (2009) American Psychiatric Association.
16. Guideline Watch (April 2007): Practice Guideline for the Treatment of Patients with Substance Use Disorders 2nd Edition (2007) American Psychiatric Association.
17. Guidelines for the Management of Patients with Bipolar Disorder (2018) Canadian Network for Mood and Anxiety Treatments (CANMAT).
18. Guidelines for the Pharmacotherapy of Schizophrenia in Adults (2017) Canadian Psychiatric Association.
19. Hediger, K.; Meisser, A.; Zinsstag, J. A One Health Research Framework for Animal-Assisted Interventions. Int. J. Environ. Res. Public Health 2019, 16, 640.
20. Identification, Evaluation and Management of Children with Autism Spectrum Disorder (2020) American Academy of Pediatrics (AAP).
21. Jones MG, Rice SM, Cotton SM (2019) Incorporating animal-assisted therapy in mental health treatments for adolescents: A systematic review of canine assisted psychotherapy. PLoS ONE 14(1): e0210761.
22. Koch, S. C., Riege, R., Tisborn, K., Biondo, J., Martin, L., & Beelmann, A. (2019). Effects of Dance Movement Therapy and Dance on Health- Related Psychological Outcomes. A Meta-Analysis Update. Frontiers in psychology, 10, 1806. https://doi.org/10.3389/fpsyg.2019.01806
23. Obsessive-Compulsive Disorder: Diagnosis and Management (2015) American Association of Family Physicians.
24. Post-traumatic Stress Disorder (2018) National Institute for Health and Care Excellence (NICE).
25. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders (2007) American Academy of Child and Adolescent Psychiatry.
26. Practice Guideline for the Management of Substance Use Disorders (2015) Veterans Administration/Department of Defense.
27. Practice Guideline for the Pharmacological Treatment of Patients with Alcohol Use Disorder (2018) American Psychiatric Association.
28. Practice Guideline for the Psychiatric Evaluation of Adults (2015) American Psychiatric Association.
29. Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder (2004) American Psychiatric Association.
30. Practice Guideline for the Treatment of Patients with Bipolar Disorder 2nd Edition (2002) American Psychiatric Association.
31. Practice Guideline for the Treatment of Patients with Delirium (1999) American Psychiatric Association.
32. Practice Guideline for the Treatment of Patients with Eating Disorders 3rd Edition (2006) American Psychiatric Association.
33. Practice Guideline for the Treatment of Patients with Major Depressive Disorder 3rd Edition (2010) American Psychiatric Association.
34. Practice Guideline for the Treatment of Patients with Obsessive- Compulsive Disorder (2007) American Psychiatric Association.
35. Practice Guideline for the Treatment of Patients with Panic Disorder 2nd Edition (2009) American Psychiatric Association.
36. Practice Guideline for the Treatment of Patients with Schizophrenia 2nd Edition (2004) American Psychiatric Association.
37. Practice Guideline for the Treatment of Patients with Substance Use Disorders 2nd Edition (2006) American Psychiatric Association.
38. Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia (2016) American Psychiatric Association.
39. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder (2007) American Academy of Child and Adolescent Psychiatry.
40. Psychotherapies. National Institute of Mental Health.
41. Psychotherapy understanding group therapy. American Psychological Association.
42. Screening and Diagnosis of Autism (2014) American Academy of Neurology (AAN) and the Child Neurology Society (CNS).
43. Trangle M, Gursky J, Haight R. et al. Institute for Clinical systems Improvement. Adult Depression in Primary Care. Updated March 2016.
44. Treatment of Patients with Alzheimer’s Disease and Other Dementias 2nd edition (2007) American Psychiatric Association.
45. Turban JL, Beckwith N, Reisner SL, et al. Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults. JAMA Psychiatry. 2019 Sep 11:1-9. PMID 31509158.
46. What is Psychotherapy? American Psychiatric Association.
47. Wijker, C., Leontjevas, R., Spek, A. et al. Effects of Dog Assisted Therapy for Adults with Autism Spectrum Disorder: An Exploratory Randomized Controlled Trial. J Autism Dev Disord 50, 2153–2163 (2020). https://doi.org/10.1007/s10803-019-03971-9
48. Wolraich ML, Hagan JF, Allan C. et al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents (2019) American Academy of Pediatrics. Pediatrics. 2019 Oct; 144(4). PMID    31570645
49. Uttley L, Scope A, Stevenson M, Rawdin A, Taylor Buck E, Sutton A, et al. Art therapy for people with non-psychotic mental disorders. Health Technol Assess 2015;19(18)

Coding Section

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.
 
This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community,
U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved"

History From 2024 Forward

07/01/2024 New Policy