Mental Health Services Policy (Mental Health Services Coverage, Prior Authorization, and Medical Necessity Criteria)
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This policy governs Longevity Health Plan of Colorado's coverage, prior authorization, and medical necessity criteria for mental health services (including psychotherapy, psychological testing, and related psychiatric procedures) for plan enrollees.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
General coverage and psychotherapy authorization
Covered when ALL of the following are met
Supports application of CMS Psychiatry and Psychology LCD.
See appendix template or screening form as optional submission.
If criteria not met, psychotherapy does not qualify.
Prior authorization required for psychotherapy beyond initial 5 visits and for listed psychiatric procedures regardless of network status.
Crisis services
Emergency/urgent care exception
Emergency medical condition defined per §422.113(b)(1)(i); services necessary to evaluate or stabilize the condition are covered.
When a member's condition has reached a level of stability such that care can be maintained without further treatment or can be managed with a less intensive level of care, continued psychological services are no longer medically necessary. Services will be authorized in increments of 90 days or up to 12 visits; members who have exceeded these timelines, are not showing improvement, or are no longer appropriate for the current level of care will be referred to alternative options. Any services beyond the authorized period require additional prior authorization documenting ongoing medical necessity.
Outpatient psychiatric services are considered not medically necessary when further clinical improvement is not indicated and there is no reasonable expectation of additional benefit. In such cases, authorization for continued outpatient services will not be approved, and alternative care approaches should be considered.
Assessment Thresholds and Coding Notes
Prior Authorization, Documentation, and Authorization Timeframes
Prior authorization required for psychotherapy beyond 5 visits and for listed procedures
Prior authorization is required for psychotherapy services beyond the initial 5 visits and for listed psychiatric procedures and testing, regardless of provider network status.
- Services listed: Psychiatric Diagnostic Procedures; Interactive Complexity; Psychotherapy (for services exceeding 5 initial visits); Psychiatric Somatotherapy; Other Psychiatric Services or Procedures; Central Nervous System Assessments/Tests.
Authorization time frames — 90 days / 12 visits per authorization
Services are authorized in increments of up to 90 days or up to 12 visits per authorization. Any member requiring services beyond that authorization period must submit an additional prior authorization demonstrating ongoing medical necessity.
- Authorization period: 90 days or 12 visits.
- Additional prior authorization required for services beyond the 90-day/12-visit authorization.
Required documentation for prior authorization
Prior authorization requests must include an individualized treatment plan and supporting evidence to allow application of the CMS guidance and medical necessity determination.
- Include an individualized treatment plan stating type, amount, frequency, and duration of services, diagnoses, and anticipated goals.
- Provide evidence that services are for diagnostic study or are reasonably expected to improve the patient's condition (designed to reduce/control symptoms to prevent relapse/hospitalization and improve/maintain functioning).
- For psychotherapy, include cognitive capacity evidence: most recent BIMS ≥13 within 90 days OR most recent MMSE ≥15 within 90 days.
- The screening form in the appendix may be included with the prior authorization request.
Insufficient documentation may lead to denial
Failure to include the individualized treatment plan with the required elements in the prior authorization request may result in inability to approve services.
- Required elements: type, amount, frequency, duration, diagnoses, and anticipated goals — omission may lead to denial or inability to approve services.
Clinical Background
Psychotherapy and other psychiatric services are provided with the goal of reducing or controlling psychiatric symptoms to prevent relapse or hospitalization and to improve or maintain functioning. Treatment should be continued only while it is reasonably expected to produce clinical benefit; when stability is achieved and less intensive management is sufficient, ongoing services are no longer deemed medically necessary.
Key Definitions and References
Outpatient / Psychotherapy Level-of-Care
Psychotherapy and Related Procedures
Psychotherapy and related psychiatric procedures
Prior authorization is required as listed in the policy.
Authorized Visit Limits
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