OPTUMHEALTH

By United Behavioral Health

COVERAGE DETERMINATION GUIDELINE

Intensive Outpatient Program for Major Depressive Disorder (MDD)

Guideline Number: BHCDG202012 Approval Date: October, 2010 Revised Date: April, 2012 Table of Contents: Instructions for Use Plan Document Language Indications for Coverage Coverage Limitations and Exclusions Definitions References Coding 1 2 2 14 15 15 16 Product: 2001 Generic UnitedHealthcare COC/SPD 2007 Generic UnitedHealthcare COC/SPD 2009 Generic UnitedHealthcare COC/SPD Related Coverage Determination Guidelines: Related Medical Policies: Level of Care Guidelines American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of American Psychiatric Association, Practice Guideline for the Treatment of Patients with Depressive Disorders, 2010 Association for Ambulatory Behavioral Healthcare, Standards and Guidelines for Partial Hospital Programs, 2008 INSTRUCTIONS FOR USE This Coverage Determination Guideline provides assistance in interpreting behavioral health benefit plans that are managed by OptumHealth. This Coverage Determination Guideline is also applicable to behavioral health benefit plans managed by Pacificare Behavioral Health and U.S. Behavioral Health Plan, California (doing business as OptumHealth of California (OptumHealthCA). When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollees document (e.g., Certificates of Coverage (COCs), Schedules of Benefits (SOBs), or Summary Plan Descriptions (SPDs) may differ greatly from the standard benefit plans upon which this guideline is based. In the event that the requested service or procedure is limited or excluded from the benefit, is defined differently, or there is otherwise a conflict between this document and the COC/SPD, the enrollee's specific benefit document supersedes these guidelines. All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements that supersede the COC/SPD and the plan benefit coverage prior to use of this guideline. Other coverage determination guidelines and clinical guideline may apply. OptumHealth reserves the right, in its sole discretion, to modify its coverage determination guidelines and clinical guidelines as necessary. While this Coverage Determination Guideline does reflect OptumHealths understanding of current best practices in care, it does not constitute medical advice.
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PLAN DOCUMENT LANGUAGE Before using this guideline, please check enrollees specific plan document and any federal or state mandates, if applicable. INDICATIONS FOR COVERAGE
Key Points According to the DSM, Major Depressive Disorder (MDD) is a form of Mood Disorder whose essential feature is the presence of a Major Depressive episode of at least two weeks in duration in which there is either depressed mood or the loss of interest or pleasure in nearly all activities. The Mental Health/Substance Use Disorder Designee maintains that Intensive Outpatient treatment for MDD should be consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines. Patients with MDD should be treated in the least restrictive level of care that is most likely to prove safe and effective. Choice of intensive outpatient treatment is driven by symptom severity, the intensity of services required, and current level of functioning. The following should also be considered: o The members psychosocial functioning has become impaired by moderate to severe symptoms of MDD, and treatment cannot be adequately managed in an outpatient setting. The members mental status or cognition has deteriorated to the extent that a higher level of care will likely be needed if IOP treatment is not provided. The patient has an unsupportive living situation creating an environment in which the members MDD is likely to worsen without the intensity and support of an IOP program. The patient is not at imminent risk of serious harm to self or others. Co-occurring conditions, if present, do not compromise treatment and can be safely managed in an IOP setting.

o o

o o

The goal of Intensive Outpatient Treatment for MDD is to improve the presenting signs and symptoms of MDD to the point that the intensity of IOP is no longer required and the patient can safely transition to the next most appropriate level of care. Best practices include the following: o Assessment and Evaluation A comprehensive psychiatric evaluation should be completed within the first 3 treatment days to include an assessment of suicidality. IOP treatment plans should be individually tailored to address the patients acute behavioral symptoms, monitoring response, updating the treatment plan as changes are observed, and engaging the family/support network. Within the first 3 treatment days the provider and, whenever possible, the patient should document clear, reasonable and objective treatment goals and timeframes that stem from the patients diagnosis, and are supported by specific treatment strategies which address the patients acute symptoms and the
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o Treatment Planning

Intensive Outpatient Program for Major Depressive Disorder

precipitant for admission. The treatment plan should be continuously reassessed if new information becomes available or if the patients status changes. The treatment plan should always address co-occurring behavioral and medical conditions including substance use disorders when applicable. Psychotherapy Cognitive Behavioral Therapy or Interpersonal Therapy are considered first line interventions Pharmacotherapy SSRIs, Buproprion, SNRIs, Venlafaxine or Mirtazapine are considered first line agents in addition to any current FDA approved medications for the treatment of MDD. Psychotherapy Combined with Pharmacotherapy Electroconvulsive Therapy Methods of measurement Include tools such as the HAM-D and the PHQ-9 for screening and measuring progress, and algorithms such as the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) should be integrated into the treatment plan. If there has been an exacerbation of symptoms for patients already engaged in treatment, it is important to complete a reassessment to determine the patients response to previous and/or current interventions and to help explain an exacerbation of depressive symptoms. When a patients depressive symptoms have not improved or have worsened as indicated by a thorough reassessment, a change to the diagnosis or modification of the treatment plan may be indicated. The discharge plan is derived from the members response to treatment, prior history of treatment, and availability of services in the members community. The discharge plan should document: The next level of care and recommended modalities of treatment; Linkages with community support services and support groups; The plan to convey pertinent clinical information to the postdischarge provider(s); The plan to ensure that the member has a supply of medication sufficient to bridge the time between discharge and the scheduled follow-up medication management visit; Confirmation that the member or an authorized representative on behalf of the member understands the discharge plan; and A crisis management and safety plan

o Interventions

Treatment Non-Response

Discharge

An intensive outpatient program (IOP) is a freestanding or hospital-based program that maintains hours of service for at least 3 hours per day, 2 or more
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days per week. It may be used as an initial point of entry into care, as a step up from routine outpatient services, or as a step down from acute inpatient, residential care or a partial hospital program. An IOP can be used to treat mental health conditions or can specialize in the treatment of co-occurring mental health and substance use disorders. When supported by the benefit plan, coverage may be available for intensive outpatient programs that are provided with less intensity to members who are recovering from severe and persistent mental health conditions. The requested Intensive Outpatient Treatment service or procedure must be reviewed against the language in the enrollee's benefit document. When the requested Intensive Outpatient Treatment service or procedure is limited or excluded from the enrollees benefit document, or is otherwise defined differently, it is the terms of the enrollee's benefit document that prevails. Benefits include the following services provided in Intensive Outpatient Treatment: Diagnostic evaluations and assessment Treatment planning Referral services Medication management Individual, family, therapeutic group and provider-based case management services Crisis intervention

Indications for coverage for treatment in an intensive outpatient treatment program for Major Depressive Disorder: Patients with MDD should be treated in the least restrictive level of care that is most likely to prove safe and effective. Choice of intensive outpatient treatment is driven by symptom severity, the intensity of services required, and current level of functioning. The following should also be considered: o The members psychosocial functioning has become impaired by moderate to severe symptoms of MDD, and treatment cannot be adequately managed in an outpatient setting. o The members mental status or cognition has deteriorated to the extent that a higher level of care will likely be needed if IOP treatment is not provided.. o The patient has an unsupportive living situation creating an environment in which the members MDD is likely to worsen without the structure and support of an IOP program..
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o The patient is not at imminent risk of serious harm to self or others. o Co-occurring conditions, if present, do not compromise treatment and can be safely managed in an IOP setting. o The goal of Intensive Outpatient Treatment for MDD is to improve the presenting signs and symptoms of MDD to the point that the intensity of IOP is no longer required and the patient can safely transition to the next most appropriate level of care. Best practices for the treatment of Major Depressive Disorder in an intensive outpatient program include the following: Diagnostic Evaluation and Assessment A psychiatric evaluation is to be conducted within the first 3 treatment days in order to determine the precipitants for admission and a thorough assessment of the patients presenting signs and symptoms. All of the following should be included as part of the evaluation: Assessment of Suicidality Patients in IOP treatment for MDD may require ongoing assessment for suicidality. Although IOP treatment is not indicated for patients exhibiting imminent risk, suicidality should be closely monitored as a symptom of MDD. Ongoing evaluation will help determine the patients level of risk, improvement or decompensation of suicidality, and the possible need for acute care. The evaluation of suicidal thoughts or behaviors should be evaluated separately from self-harming behaviors which may involve repetitive selfcutting with a motivation to relieve sadness, anger or loneliness rather than the motivation to end ones life. Consider the following when conducting a psychiatric assessment for suicidality: o The patients current behavioral health condition o The patients symptoms including the degree of their severity o Current level of functioning o Current suicidal ideation, plan, and means o The history of suicidal behavior o The nature of the current crisis or other unique issues that may have precipitated the suicidal behavior o The patients psychosocial situation o The patients medical history o Relevant familial factors such as family history of suicide and mental illness
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o Protective factors If assessed to be at high risk, IOP treatment may not appropriately address acute suicidal symptoms and inpatient, residential or partial hospital treatment may be required to ensure the patients safety. The evaluation should also include an assessment of all of the following: o The presence of any co-occurring conditions, o Current substance use and substance use history, o History of interventions including psychosocial interventions, medications and use of community resources, o Side effects experienced from prescribed and over-the-counter medications, o Laboratory tests should be ordered if indicated, o The history of the onset and progression of symptoms from family members, caregivers, the primary care physician and other medical and/or behavioral health providers if indicated, o Family history of MDD to include any history of suicide attempts or completions. o The patients ability to make informed decisions about their treatment, o The ability of the members family/caregiver to participate in the members treatment, and o The optimal treatment setting and the patients ability to benefit from a different level of care should be reevaluated on an ongoing basis throughout the course of treatment. All relevant general and specialty medical services for the purposes of diagnostic evaluations and assessment are to be available as needed and provided with the urgency that is commensurate with the patients medical need. The clinical presentation of depression in children and adolescents can differ significantly from that of adults and will vary with the childs age. The following should be considered when evaluating children and adolescents: o Younger children may exhibit behavioral problems such as social withdrawal, aggressive behavior, apathy, sleep disruption, and weight loss. o Adolescents may present with somatic complaints, self-esteem problems, rebelliousness, poor performance in school, or a pattern of engaging in risky or aggressive behavior.
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o A variety of informants should be used in evaluating children and adolescents, including parents and teachers. Differential diagnosis should also be conducted as part of the evaluation as many medical and/or psychiatric disorders mimic or overlap with the symptoms of MDD, especially in children and adolescents. o Due to the potential risks of misdiagnosis and differing treatment recommendations for MDD and Bipolar Disorder, careful differential diagnosis will ensure the most appropriate care is delivered (i.e., the correct diagnosis is made and appropriate treatment goals are set) and should be a routine part of the evaluation with the following considerations: Major depressive episodes or recurrent depressive episodes are common in the course of both Bipolar I and II. Acute psychosis, a history of mania or hypomania, and/or a family history of Bipolar Disorder may be indicators of the need for additional evaluation and screening for Bipolar Disorder. When incorrectly prescribed to an individual with Bipolar Disorder, antidepressants may precipitate rapid cycling or mania.

Treatment Planning Within the first 3 treatment days the provider and, whenever possible, the patient should document clear, reasonable and objective treatment goals and timeframes that stem from the patients diagnosis, and are supported by specific treatment strategies which address the patients symptoms and the precipitant for admission. Psychoeducation about MDD and its treatment should be provided to the patient, family members and/or caregivers in order to inform about the causes, symptoms, types and risks associated with treatment; to improve treatment adherence and motivation, to collaborate with the patients support system, and to mitigate the risk of relapse. MDD symptoms as well as the side effects of treatment may impact the patients engagement in intensive outpatient treatment and the transition to outpatient services. The treatment plan should take into account the patients preferences and address the patients readiness to engage in treatment. The treatment plan should also focus on bolstering protective factors such as: o The patients reason(s) to live o Availability of social supports o Activities that provide purpose

Intensive Outpatient Program for Major Depressive Disorder Coverage Determination Guideline Confidential and Proprietary, OptumHealth 2012 OputmHealth is a brand used by United Behavioral Health and its affiliates.

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The treatment plan must include objectives, actions and timeframes to address the following: o Inventorying the members strengths and other psychosocial resilience factors such as the members support network. o Determining whether the member has an advance directive, a recovery plan, and a plan for managing relapse. o How symptom reduction and rapid stabilization will be achieved. o How co-occurring substance use disorders and medical conditions will be managed. o How the members ability to manage their condition will be improved such as by providing health education, and linking the member with peer services and other community resources. o How risk issues related to the members presenting condition, cooccurring substance use disorders, or co-occurring medical conditions will be managed including how the members motivation will be maintained/enhanced, provision of close supervision of behavior, addressing medication effects or possible side effects, and collaborating with the member to develop/revise the advance directive or relapse prevention plan.

The patients outpatient provider should be contacted with the patients documented consent to obtain information about the patients presenting condition and response to treatment. IOP programs should have affiliations with other levels of care to assist the patient with access to services in other higher or lower levels of care and linkages to services such as vocational training or transportation when indicated. The provider and, whenever possible, the patient should update the treatment plan at least every 3-5 treatment days in response to changes in the patients condition, or provide compelling evidence that continued IOP treatment is required to prevent deterioration or exacerbation of the patients current condition. For children and adolescents, family involvement is imperative in order to successfully treat the patient. Family and/or caregiver interventions should be included in the therapeutic process and treatment plan as family members are vital to the successful treatment, transition and/or discharge to the next most appropriate level of care. Participation in treatment should be at least 1 time per week unless clinically contraindicated.

Treatment planning considerations for children and adolescents:

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A child or adolescent patient may require IOP in addition to a non-treatment out-of-home placement such as a group home or foster home placement. The appropriate custodian/guardian should be included in the treatment plan where appropriate. Treatment interventions and modalities should be tailored to engage adolescents who are at varying levels of developmental maturity which may require linkages or referrals to other service providers (i.e., educational testing, family therapy, juvenile justice, foster care, or other social service interventions) For children and adolescents, an individualized education plan may be necessary to address the patients academic difficulties as a result of depressive symptoms as well as comorbid conditions. Any school-based services to address MDD should also be reflected in the treatment plan. Psychosocial and pharmacological interventions should be implemented in the IOP setting and continue at the next most appropriate level of care after the patients discharge. Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are recommended forms of psychotherapy for the treatment of MDD. Buproprion, Venlafaxine, or Mirtazapine and SSRI and SNRI class medications are first line agents for the treatment of MDD. Consider combining a SSRI with an antipsychotic agent for MDD with psychotic features. Consider tricyclic antidepressants for patients who have a history of poor response to standard first line agents, and who have been successfully treated with tricyclic antidepressants agents. Consider combining pharmacotherapy with psychotherapy for the following: o Patients with moderate to severe MDD if psychosocial issues are important. o Patients who dont respond to monotherapy.

Interventions

Except for lower initial doses to avoid unwanted effects, the doses of the antidepressants in children and adolescents are similar to those used for adult patients.

Intensive Outpatient Program for Major Depressive Disorder Coverage Determination Guideline Confidential and Proprietary, OptumHealth 2012 OputmHealth is a brand used by United Behavioral Health and its affiliates.

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Consider Electroconvulsive Therapy when there is significant risk to management on an outpatient basis including the following: o Patients who are imminent risk for suicide o Patients who evidence signs/symptoms of psychosis o Patients who evidence substantial cognitive impairment o Patients who are otherwise severely incapacitated Measurement Tools and Algorithms Tailoring the treatment plan requires ongoing and systematic assessment of the patients needs. This can be facilitated by integrating clinician and/or patient administered rating scale measurements into initial and ongoing evaluation. Commonly used tools include: o Inventory of Depressive Symptoms (IDS), which is available in clinician-rated and self-rated versions o Clinician-rated Hamilton Rating Scale for Depression (HAM-D) o Clinician-rated Montgomery Asberg Depression Rating Scale (MADRS) o Self-rated Patient Health Questionnaire (PHQ-9) o The Beck Depression Inventory (BDI, BDI-II), copyrighted, 21-question multiple-choice self-rated instrument. Consider Sequenced Treatment Alternatives to Relieve Depression (STAR*D) particularly to augment or change the course of treatment for patients who have not responded to initial treatment of Depression with an antidepressant. o The purpose of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) is to determine the most effective treatment for people with Major Depressive Disorder (MDD) who have not responded to initial treatment with an antidepressant. o STAR*D aims at defining which subsequent treatment strategies, in what order or sequence, and in what combination(s) are both acceptable to patients and provide the best clinical results with the least side effects. o The STAR*D algorithm provides a four-level sequence of treatments designed to increase adherence and remission rates in a measurable way. o The primary goal of each level is to determine if the treatment used during that level can adequately treat patients major depressive
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disorder (MDD). Those who do not become symptom-free can proceed to the next level of treatment. o The chart of treatment options throughout STAR*D can be accessed here: http://www.nimh.nih.gov/trials/practical/stard/stard-treatmentflowchart.pdf Addressing Treatment Non-Response If the patient has been participating in outpatient treatment prior to an IOP program, the patients response to treatment interventions should be determined to help explain an exacerbation of depressive symptoms that may have led to the current episode of care. If the patients depressive symptoms have not improved or have worsened prior to, or while participating in an IOP, a reassessment may be indicated to stabilize the members current symptoms and modify the overall course of treatment. As part of the reassessment, the treating provider should verify: o Patient adherence and confirmation that an adequate dose of medication has been given for an adequate duration (generally 4-6 weeks); and o That psychotherapy has been or is being skillfully executed and conducted over an appropriate period of time with an adequate frequency of visits (to be reassessed every 3-4 months). If it is determined through the process of reassessment that the patient has not adequately responded to prior or current treatment efforts leading to an exacerbation of symptoms, the following should be considered: o The patient has been misdiagnosed; o The treatment plan is not appropriately addressing the patients needs o The patient may not be adhering to prescribed medication or an inappropriate medication or dosage has been prescribed; and/or o The patient is not engaged in or is only partially engaged in treatment. After a complete reassessment, strategies to address non-response may include the following: o Augmenting initial treatments by increasing the intensity or frequency of psychotherapy or increasing medication to the upper limit in consideration of efficacy, side effects and adherence. o Changing to a different antidepressant medication (either from one in the same class or to one of a different class) using STAR*D secondstep treatment recommendations. o Combining psychotherapy with medication treatment for patients not responding to medication treatment alone.
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o Considering Electroconvulsive Therapy which continues to be one of the most effective treatments when there has been no response. o Consider implementation of motivational enhancement interventions in order to help the patient engage into the treatment process. Discharge Planning and Referral Management The optimal treatment setting and the patients ability to benefit from a different level of care should be reevaluated throughout the course of treatment. Patients ready for discharge from IOP may no longer require monitoring to ensure stability, have decreased moderate symptomotology, and have increased functioning as evidenced by the ability to reintegrate into community life. The patient, the patients family and/or caregivers and providers should begin collaboratively planning for discharge, the next level of care and aftercare from the time of admission. The provider and, whenever possible, the patient should update the plan for discharge ultimately ensuring that an appropriate and final discharge plan is in place prior to discharge. With the patients documented consent, discharge planning will include the active involvement of the patients family and outpatient provider. The discharge plan should include: o The anticipated discharge date. o The next level of care and the rationale for the referral, the date and time of the first appointment, and the providers location. The first appointment should be within 7 days of discharge. o The name(s) of the provider(s) responsible for post-discharge care. o The recommended modalities of post-discharge care including the following: Recommended frequency of each modality. The names, dosages and frequencies of each medication and a schedule for appropriate lab tests if pharmacotherapy is a modality of post-discharge care.

o The plan to communicate all pertinent clinical information to the provider(s) responsible for post-discharge care, as well as to the patients primary care provider as appropriate.

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o The plan to coordinate discharge with agencies and programs such as the school or court system with which the patient has been involved when appropriate and with the patients documented consent. o The plan to ensure that the patient has a supply of medication sufficient to bridge the time between discharge and the scheduled follow-up psychiatric assessment if applicable. o The plan to address crisis and safety management. o Confirmation that the patient understands the discharge plan. o Confirmation that the patient was provided with written instruction for what to do in the event that a crisis arises prior to the first postdischarge appointment. In Some Situations OptumHealth May Offer: Peer Review: OptumHealth will offer a peer review to the provider when services do not appear to conform to this guideline. The purpose of a peer review is to allow the provider the opportunity to share additional or new information about the case to assist the Peer Reviewer in making a determination including, when necessary, to clarify a diagnosis. Second Opinion Evaluation: OptumHealth facilitates obtaining a second opinion evaluation when requested by an enrollee, provider, or when OptumHealth otherwise determines that a second opinion is necessary to make a determination, clarify a diagnosis or improve treatment planning and care for the enrollee. Referral Assistance: OptumHealth provides assistance with accessing care when the provider and/or enrollee determine that there is not an appropriate match with the enrollees clinical needs and goals, or if additional providers should be involved in delivering treatment. Intensive Outpatient Treatment for MDD requires pre-service notification. Notification of a scheduled admission must occur at least five (5) business days before admission or as soon as is reasonably possible. Notification of an unscheduled admission (including Emergency admissions) should occur as soon as is reasonably possible. In the event that the Mental Health/Substance Use Disorder Designee is not notified of an intensive outpatient admission, benefits may be reduced. Check the members specific benefit plan document for the applicable penalty and provision for a grace period before applying a penalty for failure to notify the Mental Health/Substance Use Disorder Designee as required. Covered Health Service(s) UnitedHealthcare 2001 Those health services provided for the purpose of preventing, diagnosing or treating a sickness, injury, mental illness, substance abuse, or their symptoms. A Covered Health Service is a health care service or supply described in Section 1:
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What's Covered--Benefits as a Covered Health Service, which is not excluded under Section 2: What's Not Covered--Exclusions. Covered Health Service(s) UnitedHealthcare 2007 and 2009 Those health services, including services, supplies, or Pharmaceutical Products, which we determine to be all of the following: Provided for the purpose of preventing, diagnosing or treating a Sickness, Injury, mental illness, substance abuse, or their symptoms. Consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines as described below. Not provided for the convenience of the Covered Person, Physician, facility or any other person. Described in this Certificate of Coverage under Section 1: Covered Health Services and in the Schedule of Benefits. Not otherwise excluded in this Certificate of Coverage under Section 2: Exclusions and Limitations.

COVERAGE LIMITATIONS AND EXCLUSIONS Inconsistent or Inappropriate Services or Supplies 2001, 2007, 2009 Services or supplies for the diagnosis or treatment of Mental Illness that, in the reasonable judgment of the Mental Health/Substance Use Disorder Designee, are any of the following: Not consistent with generally accepted standards of medical practice for the treatment of such conditions. Not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and are therefore considered experimental. Not consistent with the Mental Health/Substance Use Disorder Designees level of care guidelines or best practice guidelines as modified from time to time. Not clinically appropriate for the patients Mental Illness or condition based on generally accepted standards of medical practice and benchmarks.

Additional Information: The lack of a specific exclusion that excludes coverage for a service does not imply that the service is covered. The following are examples of services that are inconsistent with the Level of Care Guidelines and Best Practice Guidelines (not an all inclusive list). Services that deviate from the indications for coverage summarized in the previous section.
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Intensive Outpatient Program for Major Depressive Disorder

Admission to intensive outpatient treatment without appropriate management of acute symptoms. Admission to intensive outpatient treatment solely as a substitute for an available lower level of care, an intensified schedule of ambulatory care, or a broadened treatment plan. Admission to intensive outpatient treatment that does not provide an adequate program of treatment. Treatment used solely a substitute for an available lower level of care, an intensified schedule of ambulatory care, or a broadened treatment plan

Please refer to the enrollees benefit document for ASO plans with benefit language other than the generic benefit document language. {INCLUDE FOR ASO ONLY: For ASO plans with SPD language other than 2001 and 2007 Generic COC language, Please refer to the enrollees plan specific SPD for coverage.

DEFINITIONS Co-Occurring Conditions Formerly known as dual diagnosis or dual disorder, co-occurring disorders describe the presence of two or more disorders at the same time. For example, a person may suffer substance abuse as well as bipolar disorder. Cognitive Behavioral Therapy (CBT) A classification of therapies that are predicated on the idea that behavior and feelings are caused by thoughts. Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) A manual produced by the American Psychiatric Association which provides the diagnostic criteria for mental health and substance use disorders, and other problems that may be the focus of clinical attention. Unless otherwise noted, the current edition of the DSM applies. Dual Diagnosis Refers to the patient who has signs and symptoms of concurrent substance use and mental disorders. Co-occurring disorders is another term that is often used interchangeably. Intensive Outpatient Treatment Program An intensive outpatient program (IOP) is a freestanding or hospital-based program that includes half-day (i.e., <4 hours/day) programs. IOPs provide services for at least 3 hours per day, 2 or more days per week, and can be used to treat MDD or can specialize in the treatment of co-occurring mental health conditions and substance use disorders REFERENCES
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1. Generic UnitedHealthcare Certificate of Coverage, 2001 2. Generic UnitedHealthcare Certificate of Coverage, 2007 3. Generic UnitedHealthcare Certificate of Coverage, 2009 4. Level of Care Guidelines Intensive Outpatient Program, 2011 5. American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents With Depressive Disorders, 2005, http://www.aacap.org/galleries/PracticeParameters/JAACAP%2005.pdf 6. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Depressive Disorders, 2006, http://www.psychiatryonline.com/Practice%20Guideline/ 7. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Depressive Disorders, 2010, http://www.psychiatryonline.com/pracGuide/PracticePDFs/SUDwatch041307. pdf 8. Association for Ambulatory Behavioral Healthcare, Standards and Guidelines for Partial Hospital Programs, 2008. CODING
The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this guideline are for reference purposes only. Listing of a service code in this guideline does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document. Limited to specific CPT and HCPCS codes? S9480 H0015 YES NO Intensive outpatient psychiatric services, per diem Intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapy YES NO Major Depressive Disorder, Single Episode, Mild Major Depressive Disorder, Single Episode, Moderate Major Depressive Disorder, Single Episode, Severe, Without Psychotic Features Major Depressive Disorder, Single Episode, Severe, With Psychotic Features Major Depressive Disorder, Single Episode, In Partial Remission
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Limited to specific diagnosis codes? 296.2 296.2 296.2 296.2 296.2

Intensive Outpatient Program for Major Depressive Disorder

Coverage Determination Guideline Confidential and Proprietary, OptumHealth 2012 OputmHealth is a brand used by United Behavioral Health and its affiliates.

296.2 296.2 296.3 296.3 296.3 296.3 296.3 296.3 296.3

Major Depressive Disorder, Single Episode, In Full Remission Major Depressive Disorder, Single Episode, Unspecified Major Depressive Disorder, Recurrent, Mild Major Depressive Disorder, Recurrent, Moderate Major Depressive Disorder, Recurrent, Without Psychotic Features Major Depressive Disorder, Recurrent, With Psychotic Features Major Depressive Disorder, Recurrent, In Partial Remission Major Depressive Disorder, Recurrent, In Full Remission Major Depressive Disorder, Recurrent, Unspecified

Limited to place of service (POS)?

YES NO Intensive Outpatient Treatment

Limited to specific provider type?

YES

NO

Limited to specific revenue codes? 905

YES NO Intensive Outpatient-Psychiatric

HISTORY
Revision Date 4/10/12 Name L. Urban Revision Notes Version 2-Final

The enrollee's specific benefit documents supersede these guidelines and are used to make coverage determinations. These Coverage Determination Guidelines are believed to be current as of the date noted.

Intensive Outpatient Program for Major Depressive Disorder Coverage Determination Guideline Confidential and Proprietary, OptumHealth 2012 OputmHealth is a brand used by United Behavioral Health and its affiliates.

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