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MP 3.01.99 Mental Health and Substance Abuse (MHSA) Coverage Guidelines

Medical Policy    
Section
Mental Health
 
Original Policy Date
10/2009
Last Review Status/Date
Created with literature search/10:2009
Issue
10:2009
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. 


Description

Obtaining prior authorization to establish medical necessity for the services listed below will ensure coverage under the terms of the member’s policy. If you do not obtain prior authorization, we may deny coverage for these services.


MHSA Covered Services

Blue Cross of Idaho will provide benefits for the following MHSA services:

  • Outpatient psychotherapy, which includes individual, group and family therapy
  • Intensive outpatient program (IOP)
  • Partial hospitalization program (PHP)
  • Residential treatment
  • Inpatient hospitalization
  • Psychological/Neuropsychological testing
  • Electroconvulsive therapy (ECT) 

Blue Cross of Idaho MHSA Coverage Exclusions
Specific MHSA Coverage Exclusions 

Blue Cross of Idaho will not cover the following services under the MHSA benefit except for intervention for acute, brief episodes when other diagnoses are present:

  • Mental health conditions as described in ICD-9-CM codes 302.0 through 302.9
  • Tobacco use disorder (ICD-9-CM code 305.1)
  • Other, mixed or unspecified drug abuse (ICD-9-CM codes 305.90 through 305.93)
  • Specific delays in development (ICD-9-CM codes 315.00 through 315.9)
  • Psychic factors associated with diseases classified elsewhere in the ICD-9-CM (ICD-9-CM code 316)
  • Mental retardation (ICD-9-CM codes 317 through 319)
  • Personal history of mental disorder (ICD-9-CM codes V11.0 through V11.9)
  • Psychological trauma (ICD-9-CM code V15.41 through V15.49)
  • Psychiatric condition (ICD-9-CM code V17.0)
  • Other family circumstances and other psychological services (ICD-9-CM codes V61.01 through V62.9)
  • Other persons seeking consultation (ICD-9-CM codes V65.40 through V65.8)
  • Problems related to lifestyle-gambling and betting (ICD-9-CM code V69.3)
  • General psychiatric examination (ICD-9-CM code V70.2)
  • Observation for suspected mental condition (ICD-9-CM code V71.01 through V71.09)
  • Special screening for mental disorders and developmental handicaps (ICD-9-CM codes V79.0 thru V79.9)

General MHSA Coverage Exclusions                                        

Blue Cross of Idaho does not provide mental health or substance abuse benefits for:

  • No benefits are provided for non medically necessary services which include those services that are:
    • Not necessarily directed toward alleviation or prevention of an acute condition and
    • Expected to be of long duration without any reasonably predictable date of termination.
  • Therapies not based on American Psychiatric and American Psychological Association acceptable techniques and theories.
  • Education, socialization, delinquency or custodial care services.
  • Stress reduction classes and pastoral counseling.
  • Acupuncture, acupressure or massage therapy, rolfing, homeopathic or naturopathic remedies.
  • Self-care or self-help training.
  • Inpatient confinement for environmental change or similar treatment.
  • Support therapies, including personal counseling, assertiveness training, dream therapy, music or art therapy, recreational therapy, wilderness programs, adventure therapy and bright light therapy.

Definitions as Related to MHSA Services
Psychiatric Hospital

A facility provider principally engaged in providing diagnostic and therapeutic services and rehabilitation services for the inpatient treatment of mental or nervous conditions, alcoholism or substance abuse or addiction. These services are provided by or under the supervision of a staff of physicians, and continuous nursing services are provided under the supervision of a licensed R.N. A psychiatric hospital provides these services for compensation from and on behalf of its patients.

Residential Treatment Program

A 24 hour level of care that provides insureds with long-term or severe mental disorders or substance abuse related disorders with residential care. Care includes treatment with a range of diagnostic and therapeutic behavioral health services that cannot be provided through existing community programs. Residential care also includes training in the basic skill of living as determined necessary for each insured.

Intensive Outpatient Program (IOP)

Intensive outpatient program (IOP) is a treatment program that includes extended periods of therapy sessions, several times a week for a minimum of three hours per day, a minimum of three days per week and a minimum of nine hours per week. It is an intermediate setting between traditional therapy sessions and partial hospitalization.

Partial Hospitalization Program (PHP)

Partial hospitalization program (PHP) is a treatment program that provides interdisciplinary medical and psychiatric services. Partial hospitalization program involves a prescribed course of psychiatric treatment provided on a predetermined and organized schedule and provided in lieu of hospitalization for a patient who does not require full-time hospitalization.

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is a treatment for severe forms of depression, bipolar disorder, schizophrenia and other serious mental illnesses that uses electrical impulses to induce a convulsive seizure.

Substance Abuse or Addiction

A behavioral or physical disorder manifested by repeated excessive use of a drug or alcohol to the extent that it interferes with an insured’s health, social, or economic functioning.


Policy History
Date Action Reason
10/10/09 Add to Mental Health section New policy
2/04/13 coding update only added new HCPCS/CPT codes