CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria — Mental Health Services: Level-of-Care (Inpatient, Residential, PHP, IOP, Outpatient)

Defines Kaiser Permanente Washington clinical review criteria and medical necessity review process for mental health services across levels of care (inpatient, residential, partial hospitalization, intensive outpatient, outpatient, eating disorders) for plan members and providers.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria — Mental Health Services: Level-of-Care

Policy CodePolicy N/A

Change TypeMaterial: psychoanalysis NMNLOCUS/MCG adoption noted

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionUse the Pre-authorization Code Check and submit clinical notes (up to 6 months) showing need and progress when requesting authorization under adopted LOC criteria.

SourceLink

POLICY UPDATE CHANGES

Psychoanalysis (CPT 90845) is considered not medically necessary due to insufficient evidence.

Adopted MCG or LOCUS-based level-of-care criteria at various times and announced future transition to LOCUS/CALOCUS for determinations.

Merged all Mental Health Services for all levels of care into one policy.

All major LOCsLevels of care governed

Effective 1/1/2026Non‑Medicare criteria timeframe

NMNPsychoanalysis status

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Coverage and Medical Necessity Criteria

Level-of-care authorization

Covered when utilization criteria from the adopted level‑of‑care system are met and supporting documentation demonstrates medical necessity.

General LOC-based authorization: Authorization requires submission of documentation and meeting the adopted level‑of‑care (LOC) admission criteria (MCG historically; LOCUS/CALOCUS adopted per Washington statute).

Specific numeric or symptom thresholds are contained in the referenced MCG or LOCUS/CALOCUS documents; providers may request the specific criteria used for individual determinations by contacting Kaiser Permanente Clinical Review staff.

Documentation for review: Clinical documentation supporting the request must address the need for services, progress to date, and cover the episode of care (records up to 6 months may be requested).up to 6 months

Submit records and clinical notes as specified in the policy and via the Pre‑authorization Code Check process when applicable.

Admission and continued stay determinations: Admission, continued stay, and discharge decisions are determined by whether the member meets the adopted LOC admission and continued‑stay criteria (MCG guidelines used historically; LOCUS/CALOCUS to be implemented per timeline).

MCG are proprietary; individual MCG criteria used for a determination can be requested from Kaiser Permanente Clinical Review staff.

Not medically necessary

Not covered when the policy explicitly finds insufficient evidence or when contract exclusions apply.

Psychoanalysis not medically necessary: Psychoanalysis (CPT 90845) is considered not medically necessary due to insufficient evidence per the Medical Technology Assessment Committee (MTAC) review.

Clinical reviewers will not authorize psychoanalysis for treatment of mental disorders under this policy.

Contract exclusions and denial triggers: Services will not be authorized if member contract exclusion criteria are met or if documentation does not support medical necessity.

Providers should verify member benefits and exclusions; use Pre‑authorization Code Check to confirm authorization requirements by plan type.

Services will not be authorized if the member's contract includes exclusion criteria applicable to the requested level of care. This restriction applies to partial hospital, outpatient, and residential psychiatric services when the specific exclusion language in the member's coverage contract is met. Mental health services are subject to post-service review for medical necessity and require submission of supporting documentation to facilitate that review.

Psychoanalysis (CPT 90845) is considered not medically necessary based on the Medical Technology Assessment Committee (MTAC) conclusion that there is insufficient evidence to evaluate its effectiveness and safety for mental disorders. Clinical reviewers will not authorize psychoanalysis under this policy.

Codes and Documentation Window

Not covered / Not medically necessaryCPTNot Covered

90845

Psychoanalysis (CPT 90845)

Applicable Codes (policy references)HCPCS

J0101

Listed in Applicable Codes section (J-code referenced)

Documentation window

Required record timeframeClinical records should encompass the entire episode of care, up to 6 months.

Types of documentationClinical notes from the requesting provider and/or specialist must be submitted.

Content expectationsDocumentation must address the need for services and the progress made during the episode of care.

Reference for more guidanceSee Kaiser Permanente Provider Manual sections on medical records and documentation standards, obtaining outpatient mental health care, and post-service claims review.

Prior Authorization, Documentation, and Utilization Review

Prior Authorization

Prior authorization and applicable codes

Use the Pre-authorization Code Check to verify whether prior authorization is required for a specific CPT/HCPCS code and the member's plan type before scheduling services.

Use the Pre-authorization Code Check for plan-specific authorization requirements
Applicable CPT/HCPCS codes listed in the policy should be checked prior to service

Note

Level-of-care criteria for utilization review

Level-of-care determinations for utilization review are based on the specified criteria adopted by Kaiser Permanente. Historically this has included MCG criteria and KP hybrid adaptations; LOCUS/Calocus (LOCUS/ CALOCUS) criteria may be used per the most recent committee approvals. Providers should submit documentation that aligns with the chosen level-of-care framework for the requested service (e.g., outpatient, intensive outpatient, partial hospital, residential) to support medical necessity review.

MCG or KP hybrid criteria have been used historically for adult and child/adolescent outpatient and IOP levels of care

Policy Background and Level-of-Care Systems

Kaiser Permanente uses structured level-of-care utilization systems to determine medical necessity for mental health services across all levels of care. Historically, determinations have relied on MCG-based guidance; per Washington State legislation the organization has elected to adopt age-appropriate LOC criteria (the LOCUS/CALOCUS systems) effective January 1, 2026. Providers should follow the adopted LOC criteria when requesting authorization for inpatient, residential, partial hospitalization, intensive outpatient, and outpatient services.

Terminology and Level-of-Care Systems

LOCUS / CALOCUS (per WA statute)

DefinitionLevel of Care Utilization System (LOCUS) / Child Adolescent Level of Care Utilization System (CALOCUS): age-appropriate placement criteria for psychiatric and addiction services as required by Washington State legislation.

Effective date referencedPolicy notes adoption per statute effective January 1, 2026.

Scope of LOCUS/CALOCUSProvides multi-level placement categories (e.g., recovery/maintenance, low/high intensity community-based services, medically monitored non-residential, and residential/medically managed levels).

PurposeUsed to align review criteria with generally accepted standards of mental health and substance use disorder care for age-appropriate placement decisions.

Criteria by Level of Care

Inpatient/Residential/PHP/IOP/Outpatient

Authorization for the following levels of care requires meeting the adopted LOC admission criteria and supporting documentation demonstrating medical necessity.

Inpatient / Residential / Partial Hospitalization (PHP): Admission to Inpatient, Residential, or Partial Hospitalization requires meeting the adopted LOC admission criteria (MCG historically; LOCUS/CALOCUS adopted per statute) and submitting supporting documentation demonstrating medical necessity.

Continued stay and discharge decisions are based on continued‑stay LOC criteria per the adopted guideline.

Intensive Outpatient Program (IOP): Admission to IOP requires meeting the adopted LOC admission criteria and documentation that outpatient resources are insufficient to meet the member's clinical needs.

MCG/LOCUS criteria specify required symptom severity, functional impairment, and treatment intensity thresholds.

Outpatient Services: Outpatient behavioral health services require documentation of clinical need; utilization that meets higher LOC thresholds (IOP, PHP, Residential, or Inpatient) should be authorized at that level when LOC criteria are met.

Specific Treatment Modalities

Psychotherapy / Psychoanalysis

Psychotherapy modalities are covered when clinically indicated; psychoanalysis is specifically not authorized under this policy.

Psychotherapy clinical use: Psychotherapy is an important component of treatment and may be authorized when clinically indicated and supported by documentation of need and progress.

Frequency and intensity should be clinically justified; evidence indicates very frequent psychotherapy has not demonstrated improved outcomes.

Psychoanalysis exclusion: Psychoanalysis (CPT 90845) is considered not medically necessary due to insufficient evidence and will not be authorized for treatment of mental disorders under this policy.

This non‑coverage stance follows MTAC's evidence conclusion that available studies are insufficient to establish effectiveness and safety for psychoanalysis.

Visit Frequency and Limits

Psychotherapy frequency note

Evidence summaryVery frequent utilization of psychotherapy has not been shown to improve outcomes per referenced literature (Lee et al.).

Clinical implicationPsychotherapy frequency should be clinically justified rather than routinely very frequent.

Supporting referenceLee AA et al., Psychotherapy and depressive symptom trajectories among VA patients: Comparing dose-effect and good-enough level models.

Policy applicationFrequency of psychotherapy visits may be reviewed for medical necessity based on demonstrated clinical progress and justification.

Policy Changes and Effective Dates

2016-11-01adoption

MPC approved adoption of MCG 20th Edition for Acute Outpatient Behavioral Health Level of Care (adult and child/adolescent).

2017-09-05adoption

MPC approved adoption of KP hybrid criteria for Outpatient Services and Intensive Outpatient Services.

2021-07-06adoption

MPC approved adoption of MCG 25th Edition with modifications (KP hybrid) for outpatient and intensive outpatient behavioral health levels of care (60-day notice; effective 2021-12-01).