CurrentAnthemPolicy N/A

Multisystemic Therapy (MST) — Initial Authorization Coverage Criteria

Authorization and clinical admission requirements for Multisystemic Therapy (MST) for youth, including the information providers must submit for initial service authorization and discharge planning. Affects providers requesting MST services for Medicaid/Anthem members.

Policy Summary

PayerAnthem

PolicyMultisystemic Therapy (MST) — Initial Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDecember 2021

Next Review DateN/A

Key ActionSubmit the Initial Service Authorization Request Form with the Comprehensive Needs Assessment, Background Information, Strengths and Needs Assessment, and weekly case summaries as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7pages

11-18age range

30 daysrisk window

1-7criteria items

Coverage Criteria for Multisystemic Therapy (MST)

inv-01: Initial Admission Criteria

Covered when ALL of the following are met:

MST admission criteria

1) Age: youth typically 11-18 years; if outside this range provide justification and explain appropriateness of service.
2) Primary diagnosis: primary DSM diagnosis must be in disruptive behavior, mood, substance use, or traumatic stress; document current symptoms (frequency, intensity, duration) and areas of functional impairment.
3) Recent risk indicators (within past 30 calendar days). At least ONE of the following must be present:
- 3A: Persistent and deliberate attempts to intentionally inflict serious injury on another person (provide details and dates when feasible).

Policy Summary

PayerAnthem

PolicyMultisystemic Therapy (MST) — Initial Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDecember 2021

Next Review DateN/A

SourceLink

On This Page

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3B: Ongoing dangerous or destructive behavior (repeated occurrences that endanger self/others, are difficult to control, cause distress, or negatively affect health).

3C: Increasing and persistent symptoms of depression or anxiety combined with externalizing behaviors contributing to decreased community functioning (describe change over the last 30 days).

3D: Ongoing substance use or dependency that interferes with interpersonal relationships and community functioning (identify substances, use patterns, and impacts).

3E: The youth is returning home from an out-of-home placement and MST is needed as a step-down service (provide placement name, reason for admission, behavioral health treatment received, and response).

4) Rationale: Description of how successful reintegration/maintenance depends on an integrated, intensive family/caregiver treatment approach and why MST is the best fit for the youth's problem behaviors.

5) Family/caregiver participation: Identify family member(s)/caregiver(s) available to participate in MST services with the youth.

6) Supervision and safety: Describe home/community supervision arrangements that will ensure reasonable safety for participation; attach or cite an existing safety plan if available.

7) Clinical attestation: An LMHP (or LMHP-R/S/RP) must review psychiatric history, complete the appropriate assessment or addendum, attest that the assessment indicates medical necessity, and provide assessment date and signature.

Note: All items 1–7 are required (AND). Within item 3, the subcriteria 3A–3E are OR-related — at least one of those must be present within the past 30 calendar days.

The policy does not list any explicit exclusions for Multisystemic Therapy (MST).

Authorization for MST is contingent on meeting ALL numbered admission criteria (1–7). Failure to document that the youth meets every required criterion — including age, a qualifying primary DSM diagnosis, and at least one qualifying risk indicator within the past 30 calendar days — will render the request unsupported and may lead to denial.

Key Coding and Time-window Details

inv-04: Risk behavior time window

Risk behavior time windowWithin the past 30 calendar days

Context for assessmentAdmission criterion #3 requires documentation that at least one risk indicator occurred within this 30-day window

Examples of qualifying indicatorsPersistent deliberate attempts to inflict serious injury; ongoing dangerous/destructive behavior; increasing/persistent depression or anxiety with externalizing behaviors; ongoing substance use/dependency

inv-05: Youth age range

Youth age range11 to 18 years

Out-of-range guidanceIf the youth is outside 11–18, provide justification for the need and appropriateness of MST

Role in admission decisionAge is criterion #1 and must be documented as part of meeting ALL admission criteria

Provider Submission and Authorization Requirements

Prior Authorization

Initial authorization submission

Initial prior authorization requires submission of the Service Authorization Request Form including proposed service dates and whether the request is for a retro review. Providers must include proposed start and end dates and indicate if the member is currently receiving the service.

Include proposed From (date) and To (date) and total units/duration requested
Indicate if Retro Review Request: Yes/No
If member currently receiving service, include actual start date of service

Step Therapy

Step therapy

No step therapy rules specified for this service.

Documentation Required

Required submission documents

Providers must submit the Initial Service Authorization Request Form with required provider and member information, documentation of prior treatment and outcomes, proposed service dates, and supporting clinical documentation addressing all admission criteria. Relevant MST documentation (Comprehensive Needs Assessment, Background Information and Strengths and Needs Assessment, Weekly Case Summary Form) should be attached when available.

Completed Initial Service Authorization Request Form
Provider information: organization name, Group NPI, Provider Tax ID, phone, fax, email, address, clinical contact name and credentials
Member information: name, DOB, gender, Medicaid #, Plan ID #, address, phone, legal guardian contact if applicable
Primary and secondary ICD-10 diagnoses and corresponding DSM diagnosis
History of prior MST treatment in past 12 months (providers, dates of service/intervention, outcomes)
Documentation of other medical/behavioral health concerns (including substance use, personality disorders, dementia, cognitive impairments) that could impact services
Proposed/Requested Service Information (dates, total units/duration)
If applicable, safety plan or supervision arrangements for home/community
Attach CNA, Background Information and Strengths and Needs Assessment, and Weekly Case Summary Form (serves as ISP) as available

Denial Risk

Admission criteria not met/documented

Failure to document that the youth meets ALL admission criteria #1-7 (including age range, primary DSM diagnosis in disruptive behavior/mood/substance use/traumatic stress, evidence within past 30 days of risk for out-of-home placement, need for integrated family/caregiver approach, identified family/caregivers to participate, and supervision/safety arrangements) may result in denial of the request.

Document youth's age and rationale if outside 11–18 years
Clearly specify primary DSM diagnosis and corresponding ICD-10 code
Provide details and dates demonstrating at least one risk factor in past 30 days (persistent intentional harm, ongoing dangerous/destructive behavior, increasing/persistent internalizing with externalizing behaviors, ongoing substance use, or step-down from out-of-home placement)
Explain why MST is the best fit and how reintegration/maintenance depends on intensive family/caregiver partnership
Identify family/caregiver participants and describe supervision/safety arrangements

Eligibility and Admission Definitions

inv-11: Eligibility/admission criteria

Admission logicYouth must meet ALL numbered criteria (1–7) to qualify for MST authorization

Criterion 1 (Age)Typically 11–18 years; justify if outside range

Criterion 2 (Diagnosis)Primary DSM diagnosis must be disruptive behavior, mood, substance use, or traumatic stress; document current symptoms and functional impairment

Criterion 3 (Recent risk)Within past 30 days, at least one risk indicator placing youth at risk of out-of-home placement (see sub-items A–E)

Criterion 4–6 (Care/family/safety)Describe why MST is best fit, identify family/caregivers available to participate, and describe home/community supervision and attach safety plan if applicable

Criterion 7 (LMHP attestation)LMHP review of psychiatric history and attestation that assessment indicates medical necessity, including assessment date and signature (implied in documentation requirements)

Outpatient-Intensive / MST Level-of-Care

Multisystemic Therapy (MST) Treatment Modality

inv-13: Multisystemic Therapy (MST)

MST fidelity and documentation: Weekly Case Summary Form will serve as the Individualized Service Plan; maintain adherence to the MST model and fidelity through supervision/consultation to support recovery planning and discharge; completion of Background Information Form and Initial Strengths and Needs Assessment may demonstrate progress planning.

Background on MST

Multisystemic Therapy (MST) is described as an intensive family- and community-based treatment for youth with serious behavioral problems who are at risk of out-of-home placement. The policy frames MST as an intervention for youth typically aged 11 to 18 years (with justification required if outside this range) and specifies that the youth must demonstrate at least one recent risk behavior within the past 30 calendar days that places them at risk of removal from the home, such as persistent deliberate attempts to inflict serious injury, ongoing dangerous or destructive behavior, increasing/persistent depression or anxiety combined with externalizing behaviors, or ongoing substance use/dependency affecting functioning.