CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria — Mental Health Services (Level of Care; Psychoanalysis non-coverage)

Defines medical necessity, level-of-care criteria, documentation and coding guidance for inpatient, residential, partial hospitalization/day treatment, intensive outpatient, and outpatient mental health services (including eating disorders) for Kaiser Foundation Health Plan of Washington members.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria — Mental Health Services

Policy CodePolicy N/A

Change TypeMaterial updates and consolidation

Effective DateN/A

Next Review DateN/A

Key ActionSubmit clinical notes covering up to 6 months of the episode of care to support medical necessity and authorization reviews.

SourceLink

POLICY UPDATE CHANGES

Non-coverage (not medically necessary) policy for Psychoanalysis (CPT 90845).

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

Adopted LOCUS FT/CALOCUS for level-of-care determinations and discontinued use of MCG criteria effective 01/01/2026.

Added explicit language clarifying the need to submit supporting documentation to clinical reviewers.

6levels of care listed

LOCUS/CALOCUSadopted level-of-care tools

90845not medically necessary

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Coverage Criteria and Service Scope

Covered levels of care

Covered mental health services by level of care for non‑Medicare members when medical necessity per LOCUS FT/CALOCUS is met:

Levels of care: Inpatient, Residential, Partial Hospitalization & Day Treatment, Intensive Outpatient, Outpatient; includes eating disorders (anorexia nervosa, bulimia, binge eating)

Placement and medical necessity determined using LOCUS FT for adults and CALOCUS for children/adolescents; effective 01/01/2026 per MPC approval

Not medically necessary services

Not medically necessary:

Psychoanalysis (CPT 90845) is considered not medically necessary due to insufficient evidence compared to evidence‑based therapies (CBT, DBT, EMDR, MI).

MTAC evidence review (08/21/2024) concluded insufficient evidence; MPC approved non‑coverage

Outpatient, partial hospital, and residential mental health services may be excluded from authorization or reimbursement when the member's coverage contract contains specific exclusion criteria. For outpatient services: authorization or reimbursement may be denied if any contract exclusions apply. For partial hospitalization and residential psychiatric services: these levels will not be authorized if exclusion criteria referenced in the member's contract are met. All mental health services are subject to post-service review; providers must submit supporting documentation of services performed to enable a thorough review.

Psychoanalysis (CPT 90845) has been evaluated by the Medical Technology Assessment Committee (MTAC). The MTAC evidence review concluded there is insufficient evidence to demonstrate the effectiveness and safety of psychoanalysis compared to evidence-based therapies (for example, CBT, DBT, EMDR, MI). As a result, psychoanalysis is designated not medically necessary and not covered. Providers should note that authorization requirements vary by plan and that CPT 90845 will not be authorized when billed for psychoanalysis under this policy.

Level-of-Care Determinations (LOCUS/CALOCUS)

Coding and Coverage Status

Not covered / Not medically necessary CPT codesCPTNot Covered

90845

Psychoanalysis

Provider Requirements, Prior Authorization, and Denial Risks

Prior Authorization

Prior authorization & Non-coverage for Psychoanalysis

Psychoanalysis for mental health disorders requires prior authorization and, per Kaiser Permanente MTAC decision, is a non-covered service under this policy. To verify authorization requirements for specific procedure or CPT codes by plan type, use the Pre-authorization Code Check. Authorization rules vary by plan; some plans may deny coverage for psychoanalysis entirely while others may require preauthorization before services are rendered.

Use the Pre-authorization Code Check to verify code-level authorization requirements by plan.
MTAC/Policy decision: Psychoanalysis for Mental Health Disorders designated non-coverage (see MTAC review and revision history).
Authorization requirements and coverage may vary by member contract and plan type.

Step Therapy

Step therapy

There are no step therapy rules documented in this policy for psychoanalysis or other outpatient mental health services.

Specific Treatment Modalities

Psychoanalysis — modality status

Psychoanalysis modality status: Psychoanalysis (CPT 90845) — evaluated by MTAC and found to have insufficient evidence to support its effectiveness and safety compared with evidence‑based therapies; designated not medically necessary.

Resulted in non‑coverage recommendation

Visit Frequency and Limits

Visit limits — psychotherapy frequency

SummaryVery frequent psychotherapy has not been shown to improve outcomes; the policy notes this evidence but does not set a numeric visit limit.

Supporting citationReferences a 2021 J Consult Clin Psychol study comparing psychotherapy dose-effect and good‑enough models to indicate lack of benefit from very frequent sessions.

Implication for providersNo fixed visit cap in this policy — clinical necessity and LOCUS/CALOCUS placement determinations should guide frequency.

Key Definitions and Tools

LOCUS / CALOCUS (level-of-care tools)

DefinitionLevel of Care Utilization System (LOCUS) and Child and Adolescent LOCUS (CALOCUS) are used for placement and medical necessity determinations for mental health services.

Effective date noteMPC approved adoption of LOCUS FT/CALOCUS and discontinuation of prior MCG criteria (effective 01/01/2026 as noted in changes).

Covered levelsApply LOCUS/CALOCUS across Inpatient, Residential, Partial Hospitalization/Day Treatment, Intensive Outpatient, and Outpatient services.

Clinical useAdmission, placement, and continued‑stay decisions are to be made using LOCUS for adults and CALOCUS for children/adolescents.

Psychoanalysis (CPT 90845)

Coverage stancePsychoanalysis (CPT 90845) is designated not medically necessary due to insufficient evidence compared with evidence‑based therapies.

Background and Policy Rationale

Kaiser Permanente uses standardized level-of-care frameworks to determine placement and medical necessity for mental health services: the Level of Care Utilization System (LOCUS) FT for adults and the Child and Adolescent Level of Care Utilization System (CALOCUS) for children and adolescents. These tools are applied across all levels of care (inpatient, residential, partial hospitalization/day treatment, intensive outpatient, and outpatient) to align with age-appropriate placement criteria and generally accepted standards of care.