OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedSelectHealthPolicy 638

Withdrawal Management

Customize your policy alerts

Sign up for SelectHealth Policy 638 alerts

Get alerted when Policy 638 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines SelectHealth coverage criteria, clinical requirements, and billing guidance for ABA therapy for individuals with Autism Spectrum Disorder across commercial, Medicare, and Medicaid products (state-specific rules may apply). Affects providers requesting authorization and delivering ABA services.

Policy Summary

PayerSelectHealth

PolicyWithdrawal Management

Policy CodePolicy 638

Change TypeClinical criteria revisedmaterial changes to TMS and detox thresholds

Effective DateN/A

Last ReviewMar 27, 2025

Next Review DateFeb 13, 2025

Key ActionObtain prior authorization and document required clinical trials, medication failures, and validated assessment scores when requesting services.

SourceLink

POLICY UPDATE CHANGES

Added clarifying language to criterion #4a: Documented failure, and prescribed by treating psychiatrist or psychiatric advanced practice registered nurse, of at least 2 antidepressant courses of maximally tolerated labeled dose and duration (> 4 weeks from two different agent classes for at least 6 months in the current, moderate-to-severe episode of depression).

Modified requirements in criteria #1 to #4 and added #5 in section A-I to align with updated clinical standards.

Added exclusion: Select Health does NOT cover TMS for ages 17 and under; this therapy is considered experimental/investigational for this age group.

Created criteria #AA and #4B to distinguish failure of medication therapy requirements for new onset/non-recurrent depression (4A) versus chronic/recurrent depressive disorder (4B).

Added exclusion: Select Health does not cover TMS for migraines (e.g., Spring TMS); considered experimental/investigational due to need for further high-quality studies.

For Commercial Plan modified scores in Ambulatory Detoxification criteria section for Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale [16 or above] or the Clinical Opiate Withdrawal Scale (COWS) scale [36 or greater] which would prompt seeking treatment at higher level of care.

15 minunit

>=20 hrs/wkintensive ABA

>=16CIWA escalation

>=36COWS escalation

<=17 excludedTMS pediatric

Coverage and Medical Necessity Criteria

Initial Medical Necessity Criteria

Covered when ALL of the following are met

Essential Elements: 1) DSM-V diagnosis of Autism Spectrum Disorder (ICD-10 F84.0; F84.3; F84.9) by an appropriate licensed provider. 2) Identifiable target behaviors that impair participation in developmentally appropriate activities or pose significant risk to self/others. 3) An individualized treatment plan with baseline objective measures, quantifiable progress/mastery criteria, caregiver training plan, start date, and staff identified. 4) Services provided or supervised by appropriately licensed/board-certified behavior analysts or other qualified professionals within their scope. 5) Parent/family/caregiver commitment to participate. 6) Documentation of coordination with other providers and schools as applicable.

Derived from Essential Elements section

Initiation and Continuation Criteria

Initiation and Continued Authorization conditions

Initiation: ABA must be recommended or prescribed by a qualified treating healthcare professional experienced in ASD and parent/family/caregiver will be provided necessary support and training to reinforce interventions and generalize gains.

Initiation requires essential elements to be met

Continuation: Continued authorization is determined by clinical review up to every 6 months and requires documented clinical improvement since last review OR documented plan modification with additional assessments and consultation if progress is lacking. Treatment plan should show tapering and transition to community supports as progress is made.every 6 months

Continuation and review frequency

Intensity/Hours Criteria

Intensity and hours approved when justified by assessment type and functional impairment

Assessment-based Units: Functional analysis assessment: 8–16 units (unit = 15 minutes). Focused assessment/treatment: 16–24 units. Comprehensive assessment/program: 32 units. Requested units/intensity must reflect severity, treatment goals, and response across settings.units as specified

Authorization and billing guidance

Intensity linked to impairment: Intensity (hours per week) should be justified by documented functional impairments; intensive programs (>20 hours/week) may be appropriate when supported by assessment and severity.>20 hours/week may be intensive

Based on evidence that intensive early intervention yields greater gains

Medical Necessity

Covered when ALL of the following are met

Medically necessary ABA: ABA is considered medically necessary for individuals with ASD when coverage is consistent with BACB/CASP guidance: focused/comprehensive assessment, individualized behavioral goals, direct observational data, frequent data-based analysis, and caregiver training to support generalization and maintenance of gains.

Policy basis: evidence and professional guidelines

Covered when ALL of the following are met — coordinated treatment plan requirement

Covered when delivered as part of a coordinated treatment plan that includes therapy and support

Chemical aversion therapy coverage conditions: Covered for treatment of alcoholism and similar substance use disorders only when provided as part of a coordinated treatment plan that includes therapy and supportive services. For Medicare, CMS determinations prevail; for Medicaid (Community Care) SelectHealth aligns with State Medicaid/InterQual as applicable. When chemical agents (e.g., emetine, apomorphine, lithium) are used, patients must be under medical observation as these agents are not FDA-approved for this indication.

Facility and monitoring requirements apply

Covered vs Experimental/Investigational Indications

SelectHealth coverage determination for EMDR:

Covered indication: EMDR is covered when used to treat post‑traumatic stress disorder (PTSD).

Prior authorization and benefit verification required per plan

Not covered/experimental indications: EMDR is considered experimental/investigational and is NOT covered for indications other than PTSD, including prevention of PTSD, chronic phantom limb pain, panic and anxiety disorders (other than PTSD), and other psychiatric/behavioral disorders (anger, depression, dissociative disorders, eating disorders, guilt, phobias).

Requests for these indications will be denied as experimental

Hippotherapy - Not Covered (Commercial)

SelectHealth Commercial coverage stance for hippotherapy

Hippotherapy Commercial Coverage: Select Health does NOT cover hippotherapy for Commercial and CHIP plans; the therapy is considered experimental/investigational due to limited and heterogeneous evidence and lack of standardized implementation guidance.

HCPCS S8940 referenced for informational coding only

Mickel Therapy - Not Covered (Commercial)

SelectHealth Commercial coverage stance for Mickel Therapy

Mickel Therapy Commercial Coverage: Select Health does NOT cover Mickel Therapy for the treatment of fibromyalgia under Commercial and CHIP plans; it is considered investigational/unproven with no demonstrated clinical utility beyond existing behavioral health services.

Services coded to the listed investigational codes would be denied

Initial TMS Coverage Criteria

Covered when ALL of the following are met (TMS for treatment-resistant depression):

Age and diagnosis: Patient is >= 18 years of age AND has a DSM-5 diagnosis of major depressive disorder (MDD) as confirmed by a licensed mental health professional.>=18 years

Provider recommendation and monitoring: TMS must be recommended by a psychiatrist or psychiatric APRN who examined the patient face‑to‑face, reviewed the record, and a physician/APP will monitor neurological status and determine motor threshold.

Documentation of face-to-face exam required

Medication failure - Option A (New/non-recurrent): New-onset/non-recurrent moderate-to-severe depression (initial diagnosis within past 24 months): documented failure of at least 4 antidepressant courses at maximally tolerated dose and duration (>4 weeks) from at least 2 different agent classes within the past 24 months OR demonstrated intolerance to at least 4 medication courses from >=2 classes within past 24 months.as described

TMS Retreatment Criteria

Retreatment covered when ALL of the following are met:

Meets initial criteria: Member meets the initiation criteria for TMS as described above.

Prior response: Member previously achieved >=50% reduction in depressive symptoms with prior TMS as documented by standardized rating scales and improvement was maintained for at least two months after the prior TMS course; repeat TMS within 60 days of prior course is considered not medically necessary.>=50% reduction; maintained >=2 months

Retreatment documentation required

Relapse after other treatments: Member has relapsed following prior TMS despite subsequent appropriate treatments (e.g., psychotherapy, pharmacotherapy).

Initial and Retreatment Criteria

Covered for treatment of major depressive disorder when ALL of the following are met:

Primary initiation criteria: Member has a current moderate-to-severe depressive episode (validated scale), has failed medications from at least 2 different agent classes within the past 12 months, and had an adequate trial of evidence-based psychotherapy (typically >=15 sessions over 4–6 months).as described

Includes typical TMS course of 36 treatments over 10 weeks

Retreatment criteria: For retreatment, member must meet initiation criteria and have had >=50% symptom reduction with prior TMS maintained >=2 months; repeat TMS within 60 days is not medically necessary. Documentation of prior response and maintenance required.50% reduction, >=2 months maintenance

Retreatment allowed after documented relapse despite other treatments

nTMS Coverage Criteria

nTMS (navigated TMS) is covered for presurgical mapping when criteria are met:

nTMS motor mapping: nTMS for motor mapping is covered when equipment/age limitations are satisfied (equipment-dependent minimum age) and the clinical indication requires high‑resolution motor mapping.age/equipment-dependent

See policy for specific pediatric age restrictions

nTMS language mapping: nTMS for language mapping is covered when patient meets age/participation requirements and the indication requires language mapping as part of presurgical evaluation.age/developmental ability to participate

Language mapping requires sustained attention

Pediatric specific indications: For children, nTMS is covered only for supratentorial tumors encroaching on motor/language cortex or for drug‑resistant epilepsy requiring detailed mapping as part of presurgical evaluation at an NAEC Level 4 center.

Revised Commercial Plan Criteria (partial)

Commercial Plan Policy — updated clinical criteria and exclusions (partial text available in this section of the document).

Medication failure requirement (criterion #4a): For applicable Commercial Plan criteria, documented failure, prescribed by the treating psychiatrist or psychiatric APRN, of at least 2 antidepressant courses at maximally tolerated labeled dose and duration (>4 weeks) from two different agent classes for at least 6 months in the current moderate‑to‑severe episode is required where criterion #4a is referenced.>=2 courses; >=6 months in current episode where specified

Partial text from revision history clarifying Commercial Plan standard

Withdrawal Management (Outpatient and Inpatient) Coverage

SelectHealth coverage for withdrawal management is conditional on meeting ASAM/InterQual criteria and facility capability.

Outpatient Withdrawal Management Coverage: Outpatient withdrawal management is covered when ASAM criteria are met, the level of care requested is consistent with the member's medical condition and needs, and the facility provides 24‑hour access to medical evaluation/consultation, credentialed personnel, physician‑approved protocols, and appropriate staffing.ASAM criteria; 24/7 evaluation access

Applies to ASAM levels 1, 2.1, 2.5

Inpatient Withdrawal Management Coverage: Inpatient withdrawal management (ASAM level 4) is covered when InterQual criteria for inpatient care are met.InterQual criteria

Discharge when withdrawal signs/symptoms resolved for lower level of care

Ultra‑Rapid Opioid Detoxification (UROD)

SelectHealth position regarding UROD

UROD Coverage Stance: Ultra‑rapid opioid detoxification (opioid antagonist detox under sedation or general anesthesia) is considered investigational/experimental/unproven and is NOT covered due to safety concerns (cardiovascular complications, deaths), inconsistent evidence of long‑term benefit, and randomized trials showing no superiority and increased serious adverse events.Not applicable

Listed as Not Covered: Investigational/Experimental/Unproven

Initial Ambulatory Detoxification Criteria

Ambulatory (SUD) Detoxification is covered when ALL of the following are met

Staffing and monitoring: Services are provided by medical personnel able to monitor withdrawal symptoms and implement physician‑approved protocols with access to evaluation/consultation 24 hours/day.24/7 access

Medical personnel defined (RN, NP, PA, MD, DO)

Assessment and documentation: DSM diagnosis of substance use disorder with withdrawal as primary focus; documentation of current substances (type, frequency, duration, last use, quantity); urine/breathalyzer monitoring; relevant labs/screens; use of validated withdrawal scales (CIWA or COWS); and at least three documented signs/symptoms of active moderate withdrawal or expectation of such within 48 hours.>=3 withdrawal signs or expectation within 48 hours

Validated scales required

Withdrawal severity and safety: Member's withdrawal severity and safety profile must be appropriate for ambulatory care (generally CIWA <16 and COWS <36); consider transition to higher level of care when CIWA >=16 or COWS >=36.

Continued Treatment Criteria

Continued ambulatory detoxification

Duration limit: Ambulatory detoxification is intended for up to 5–7 days; treatment beyond 7 days requires preauthorization with documentation of specific treatment goals to justify continued ambulatory services.>7 days requires prior auth

Preauthorization requirement

General alignment and referenced criteria

Referenced coverage aligns with State of Utah Medicaid policy and InterQual; providers should follow referenced criteria documents.

Referenced standards: SelectHealth aligns Community Care (Medicaid) coverage with State of Utah Medicaid policy and InterQual substance use criteria; providers should follow ASAM, InterQual, and state administrative rules cited in the policy for detailed clinical criteria and placement decisions.

See policy references for full criteria

SelectHealth coverage policies apply to Commercial, Medicare (CMS), and SelectHealth Community Care (Medicaid) products and are administrative documents that may be updated at any time. Policies are subject to change without notice; providers must verify current policy text and member benefits at the time of service.

Coverage under this policy is provided only when the specific clinical policy criteria are met and when the member’s benefit plan includes the service. The lists of procedure, diagnosis, and device codes in the policy are for informational purposes; inclusion or exclusion of codes does not guarantee member coverage or provider reimbursement. Providers should verify benefits and eligibility before delivering services.

When chemical aversion therapy involves chemical agents not specifically FDA‑approved for this use (for example, emetine, apomorphine, or lithium), the policy requires that patients be kept under medical observation while receiving treatment. Providers should document the agent used and monitoring provided.

SelectHealth covers Eye Movement Desensitization and Reprocessing (EMDR) only for the treatment of post‑traumatic stress disorder (PTSD). Requests for EMDR for other indications (for example, prevention of PTSD, phantom limb pain, panic or other anxiety disorders, or other psychiatric/behavioral disorders) will be treated as experimental/investigational and denied. Verify member benefits and prior authorization requirements prior to initiating EMDR.

SelectHealth considers hippotherapy (equine‑facilitated therapy) investigational for Commercial and CHIP lines of business and does not cover hippotherapy for these plans. The policy cites limited and small studies and lack of standardized implementation as reasons for this determination; the HCPCS code S8940 is listed in the document for reference but is excluded under the Commercial/CHIP stance.

SelectHealth classifies Mickel Therapy as investigational/unproven for the treatment of fibromyalgia and does not cover Mickel Therapy under the Commercial plan. The policy notes no demonstrated clinical utility beyond existing behavioral health services and lists associated investigational codes for reference.

More broadly, Mickel Therapy is treated by the plan as an investigational modality without sufficient evidence to support coverage; requests for Mickel Therapy for excluded indications will be denied as not medically necessary.

SelectHealth covers repetitive transcranial magnetic stimulation (TMS) only for the treatment of major depressive disorder (MDD) when the specific initiation criteria are met. The policy explicitly states that unilateral or bilateral rTMS for behavioral health indications other than MDD is considered experimental/investigational and is not covered, and that TMS is not covered as maintenance therapy to prevent relapse. Prior authorization is required and documentation must meet the stated clinical criteria.

For Commercial plans, SelectHealth considers TMS for patients aged 17 years and under to be investigational and does not cover TMS for pediatric patients (≤17). This pediatric exclusion is an explicit plan-level determination and should be checked against member benefits.

SelectHealth does not cover TMS when the indication is migraine (for example, Spring TMS); such uses are considered investigational pending higher‑quality evidence and are excluded from coverage under the Commercial plan.

Ultra‑rapid opioid detoxification (UROD / opioid antagonist detoxification under sedation or general anesthesia) is considered investigational and not covered by SelectHealth. The policy cites safety concerns, reports of serious adverse events and deaths, and a lack of demonstrated long‑term benefit in randomized trials to support this exclusion.

Ambulatory (outpatient) detoxification is covered only when the member meets the documented clinical criteria: a DSM diagnosis of a substance use disorder with withdrawal as the primary focus, specific documentation of substances used (type, frequency, duration, last use, quantity), urine or breathalyzer confirmation as appropriate, and at least three documented signs or a reasonable expectation of moderate withdrawal within 48 hours. The facility must provide appropriate medical monitoring and staffing and use validated withdrawal scales (CIWA or COWS).

Patients are not appropriate for ambulatory detoxification—and such requests should be denied or escalated—when exclusion criteria are present, including psychiatric comorbidity that prevents cooperation, severe or repeated substance abuse, severe/complicated medical comorbidities (for example, history of seizures or uncontrolled cardiopulmonary disease), accelerated symptoms creating instability, or presence of life‑threatening conditions.

SelectHealth lists certain long‑term residential, prevention, outreach, and specified supportive services as not covered in the contexts described (for example, long‑term nonmedical residential services greater than 30 days, HCPCS/CPT groupings in the "Not Covered" list). Inclusion of codes in this list indicates exclusion for the related conditions; providers should verify benefit applicability for individual members.

Applied Behavior Analysis (ABA) services may be considered not medically necessary if core program elements are no longer met. Triggers for denial or discontinuation include caregiver non‑participation for successive authorization periods, the essential elements no longer being met, or documented achievement of treatment goals or lack of progress over successive authorization periods. Providers must document ongoing need and caregiver engagement for continued authorization.

Policy materials and coding tables in this document are informational only and do not guarantee coverage; member benefits and eligibility determine actual coverage and reimbursement. Providers may contact SelectHealth Provider Relations or Customer Service to verify plan‑specific details.

The policy text does not include a general "not medically necessary" declaration for chemical aversion therapy or EMDR in the extracted chunks; rather, chemical aversion therapy has specific observation requirements when non‑FDA agents are used, and EMDR is explicitly limited to PTSD with other indications treated as investigational.

Use of EMDR for non‑PTSD indications (for example, prevention of PTSD, phantom limb pain, panic and other anxiety disorders, eating disorders, dissociative disorders, and other psychiatric conditions) is considered experimental/investigational by SelectHealth and will trigger denial as not medically necessary for those indications.

Both hippotherapy and Mickel Therapy are judged investigational/unproven in the Commercial plan context and therefore are listed as not medically necessary for the specified indications. Requests for these therapies for excluded indications will be denied.

Repeat TMS (retreatment) within 60 days following the termination of a prior TMS course is considered not medically necessary and may be denied. This timing restriction is an explicit denial trigger in the policy.

The policy reiterates that repeat TMS treatment within 60 days after completion of a prior course is not medically necessary; requests for retreatment should document the required prior response and maintenance interval to be considered.

TMS for pediatric patients (≤17 years) and TMS for migraine indications are considered investigational by SelectHealth and are not covered under the Commercial plan. These exclusions are highlighted in the revision history and coverage statements.

Ultra‑rapid opioid detoxification (UROD) is explicitly listed as not covered by SelectHealth as investigational/experimental/unproven. The policy references serious adverse events and randomized trials that did not demonstrate benefit, supporting the exclusion.

Members who meet the ambulatory detoxification exclusion criteria described (for example, severe psychiatric comorbidity, severe/complicated medical comorbidity, or inability to cooperate) are not appropriate candidates for outpatient detoxification and should instead be considered for higher levels of care.

The policy enumerates specific procedure and service codes that are listed as 'Not Covered' for the conditions referenced; providers should not rely on code lists alone to determine coverage and must verify plan benefits for each member.

Billing, Codes, and Documentation

CPT-like / HCPCS codesmixed

0362T	Behavior identification supporting assessment; each 15 minutes of technicians' time, face-to-face with a patient
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient
96202	Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s), initial 60 minutes
96203	Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s), subsequent

Covered CPT Codes for ABA servicesCPTCovered

97151	Behavior identification assessment; administered by a physician or other qualified health care professional, each 15 minutes
97152	Behavior identification-supporting assessment; administered by one technician under direction, face-to-face, each 15 minutes
97153	Adaptive behavior treatment by protocol, technician under direction, face-to-face with one patient, each 15 minutes
97154	Group adaptive behavior treatment by protocol, technician under direction, face-to-face with two or more patients, each 15 minutes
97155	Adaptive behavior treatment with protocol modification, administered by qualified professional, face-to-face with one patient, each 15 minutes
97156	Family adaptive behavior treatment guidance, administered by qualified professional, face-to-face with guardian(s)/caregiver(s), each 15 minutes
97157	Multiple-family group adaptive behavior treatment guidance, administered by qualified professionals, face-to-face with multiple sets of guardians/caregivers, each 15 minutes
97158	Group adaptive behavior treatment with protocol modification, administered by qualified professionals, face-to-face with multiple patients, each 15 minutes

CPT CODESCPT

90899

Unlisted psychiatric service or procedure

HCPCS CODESHCPCS

No codes listed

Example psychotherapy and related CPT codesCPT

90785	Interactive complexity (List separately in addition to the code for primary procedure)
90832	Psychotherapy, 30 minutes with patient and/or family member
90833	Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90834	Psychotherapy, 45 minutes with patient and/or family member
90836	Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90837	Psychotherapy, 60 minutes with patient and/or family member
90838	Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90880	Hypnotherapy
90899	Unlisted psychiatric service or procedure

HCPCS exampleHCPCS

H0004

Behavioral health counseling and therapy, per 15 minutes

Hippotherapy HCPCS CodesHCPCS

S8940

Equestrian/hippotherapy, per session (HCPCS)

General coding notemixed

No codes listed

Not covered / Investigational codes listed for Mickel TherapyCPTNot Covered

96150	Health and behavior assessment, each 15 minutes face-to-face; initial assessment
96151	Health and behavior assessment, each 15 minutes face-to-face; re-assessment
96152	Health and behavior intervention, each 15 minutes, face-to-face; individual
96154	Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)

HCPCS codesHCPCS

No codes listed

Covered CPT CodesCPTCovered

90867	Therapeutic repetitive transcranial magnetic stimulation treatment planning
90868	Therapeutic repetitive transcranial magnetic stimulation delivery and management, per session
90869	Therapeutic repetitive transcranial magnetic stimulation subsequent motor threshold re-determination with delivery and management

HCPCSHCPCS

No codes listed

Informational coding notemixed

CPT	CPT Only American Medical Association (codes listed for informational purposes in the policy)

CPL Codes (Unlisted anesthesia / acute detox)CPT

01999

Unlisted anesthesia procedure(s) Alcohol and/or drug services; acute detoxification (hospital inpatient)

HCPCS CodesHCPCS

J2310

Naloxone injection; per mg

Billing/Codingmixed

No codes listed

Covered HCPCS/CPT-like codesHCPCSCovered

H0001	Alcohol and/or drug assessment
H0001 (alt listing)	Alcohol and/or screening; laboratory analysis of specimens for presence of alcohol and/or drugs
H0004	Behavioral health screening to determine eligibility for admission to treatment program
H0005	Behavioral health counseling and therapy, per 15 minutes
H0006	Alcohol and/or drug services; case management
H0007	Alcohol and/or drug services; group counseling by a clinician
H0008	Alcohol and/or drug services; crisis intervention (outpatient)
H0009	Alcohol and/or drug services; acute detoxification (hospital inpatient)
H0010	Alcohol and/or drug services; subacute detoxification (residential addiction program inpatient)
H0011	Alcohol and/or drug services; acute detoxification (residential addiction program inpatient)

1–10 of 35

1/4

Not covered HCPCS-like services (for conditions listed above)HCPCSNot Covered

H0019	Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program longer than 30 days), without room and board, per diem stay
H0022	Alcohol and/or intervention service (planned facilitation)
H0023	Behavioral health outreach service (planned approach to reach a targeted population)
H0025	Behavioral health prevention education service
H0024	Behavioral health prevention information dissemination service
H0034	Medication training and support, per 15 minutes
H0037	Community psychiatric supportive treatment program , per diem
H0036	Community psychiatric supportive treatment, face-to-face, per 15 minutes
H0048	Alcohol and/or other testing: collection and handling only, specimens other than blood
H2001	Rehabilitation program, per 1/2 day

1–10 of 17

1/2

inv-62: Assessment unit — 15 minutes

Assessment unitUnit = 15 minutes (billing/service unit)

Assessment units (Functional)Functional analysis assessment guide: 8–16 units (15‑minute units)

Assessment units (Focused)Focused assessment guide: 16–24 units (15‑minute units)

Assessment units (Comprehensive)

Prior Authorization, Documentation, and Denial Triggers

Prior Authorization

Authorize units/intensity based on assessment and severity

Requested units and intensity must be justified by the severity of functional impairment and the type of assessment. Use the policy's assessment-unit guidance when requesting authorization: Functional analysis 8–16 units; Focused assessment 16–24 units; Comprehensive assessment 32 units (unit = 15 minutes).

Document how severity and assessment type support the number of units requested.
Use 15-minute billing units and the assessment-specific unit ranges (8–16; 16–24; 32).

Prior Authorization

Obtain prior authorization for listed ABA services

Prior authorization is required for the ABA and related CPT/CPT‑like services listed in the policy; coverage is limited to services and situations that meet the policy's medical necessity criteria.

Submit prior authorization for codes such as 97151–97158, 0362T, 0373T, 96202, 96203 when requesting ABA services.
Ensure requests include the essential elements and individualized treatment plan required by the policy.

Clinical Background and Scope

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition typically identified in early childhood with variable presentation and severity. Applied Behavior Analysis (ABA) aims to increase socially important skills, reduce interfering behaviors, generalize skills across settings, and maintain gains through individualized, data‑driven interventions.

inv-122: Comprehensive ABA — definition and characteristics

DefinitionComprehensive ABA: treatment provided across many skill areas and multiple domains (cognitive, communicative, social, behavioral, adaptive) to establish new skills and reduce challenging behaviors; access not restricted by age, cognitive level, diagnosis, or co-occurring conditions.

CharacteristicsOften emphasizes establishing new skills but may also focus on reducing challenging behaviors (e.g., elopement, stereotypy); intensity determined by assessment and functional impairment

Authorization considerationsComprehensive programs correspond to higher assessment unit guidance (e.g., comprehensive assessment = 32 units of 15 minutes)

inv-123: Focused ABA — definition and characteristics

Level of Care and Service Setting Criteria

Applied Behavior Analysis (ABA) Program and Clinical Criteria

inv-166: ABA therapy hours — variable hours per week tied to severity domain scores

ABA therapy hours guidanceHours per week are variable and tied to severity domain scores and assessment type; authorization may increase based on functional impairment

Assessment unitService unit = 15 minutes; units requested must be justified by assessment type and severity

Additional authorizationAdditional authorization may be provided for protocol modification/direction (QHP) up to 2 hours per 10 hours of treatment by protocol

inv-167: ABA therapy intensity — intensive defined as >20 hours/week may be associated with better outcomes

Intensive ABA threshold>20 hours/week defined as intensive ABA and may be associated with better outcomes when started early

Justification requirement

Therapies, Modalities, and Service Descriptions

Service Frequency, Duration, and Limits

inv-168: TMS sessions (initial + taper) — 36

TMS sessions (initial + taper)36 sessions (typical planned course including initial and tapering)

Course durationCorresponds to approximately a 10‑week treatment course

Coverage expectationPlanned course of 36 treatments/10 weeks is specified in coverage criteria for initiation

inv-169: TMS treatment course (initial + taper) — 36

TMS treatment course36 treatments (initial + taper) over ~10 weeks — standard course referenced in policy

DocumentationPlanned course must be included in authorization and treatment plan

Definitions and Terms

inv-122: Comprehensive ABA — definition

Comprehensive ABA definitionTreatment across multiple domains to establish new skills and reduce challenging behaviors; not restricted by age or co‑occurring conditions

Focus and intensityComprehensive programs address many skill areas (cognitive, communicative, social, adaptive) and may require higher intensity/units

Access statementAccess to comprehensive ABA should not be restricted by age, cognitive level, diagnosis, or co‑occurring conditions

inv-123: Focused ABA — definition

Focused ABA definitionTargeted treatment to improve or maintain behaviors in a limited number of domains or skill areas; access not restricted by age or co‑occurring conditions

Assessment mappingFocused interventions map to assessment guidance (16–24 units for focused assessments) and are selected based on specific needs

Policy Changes and Revision History

2026-06-12revision_note

Commercial Plan Policy: added exclusion that TMS is not covered for migraine indications (e.g., Spring TMS) as investigational.

2025-03-10revision_note

Commercial Plan Policy: created criteria #AA and #4B to distinguish medication-failure requirements for new onset/non-recurrent versus chronic/recurrent depressive disorders.

2024-07-08revision_note

Policy Summary

PayerSelectHealth

PolicyWithdrawal Management

Policy CodePolicy 638

Change TypeClinical criteria revisedmaterial changes to TMS and detox thresholds

Effective DateN/A

Last ReviewMar 27, 2025

Next Review DateFeb 13, 2025

Key ActionObtain prior authorization and document required clinical trials, medication failures, and validated assessment scores when requesting services.

SourceLink

On This Page

Applies when criterion A is invoked

Medication failure - Option B (Chronic/recurrent): Chronic/recurrent depressive disorder (treated >=24 months): documented failure of at least 2 antidepressant courses at maximally tolerated dose and duration (>4 weeks) from at least 2 different agent classes within the past 12 months OR demonstrated intolerance to at least 2 medication courses from >=2 classes within past 12 months.as described

Applies when criterion B is invoked

Psychotherapy trial: An adequate trial of evidence‑based psychotherapy was attempted (typically >=15 sessions over 4–6 months) without documented significant improvement.>=15 sessions over 4–6 months

Documentation required

Course parameters: Planned TMS course consistent with policy (typical course: 36 treatments over a 10‑week period, including initial and tapering sessions).36 treatments/10 weeks

Authorization tied to planned course

specific clinical indications

Coverage limited to defined surgical presurgical uses

CIWA <16; COWS <36 for outpatient appropriateness

Revision clarified escalation thresholds

Treatment planning and aftercare: An individualized treatment plan developed within 24 hours of admission that includes psychosocial supports, aftercare availability, consideration of MAT when indicated, contact with recent providers, and coordination with family/supports.treatment plan within 24 hours

Regularly scheduled face‑to‑face sessions and documented aftercare

Patient suitability: Member demonstrates commitment to ongoing care and has a supportive environment or sufficient coping skills for outpatient detoxification; exclusions include psychiatric comorbidity preventing cooperation, severe/complicated medical conditions, or life‑threatening conditions.member commitment and coping skills

Exclusion triggers described elsewhere in policy

Comprehensive assessment guide: 32 units (15‑minute units)

inv-63: Intensive ABA hours — more than 20 hours per week

Intensive ABA hours definition>20 hours per week (intensive ABA may be associated with larger developmental gains when started early and delivered intensively)

Intensity tied to severityRequested hours and intensity should be justified based on severity of impairment and assessment type (functional/focused/comprehensive)

Authorization basisUnits and intensity must reflect treatment goals, response to treatment, and caregiver participation

inv-64: Study size — small randomized trial n=19 reported no significant effects

Study size (hippotherapy randomized trial)Small randomized trial n=19 reported no significant effects in most outcome measures

Evidence limitationMost literature consists of small case series; implementation guidelines lacking

Conclusion on evidenceAvailable small trials are inadequate to permit scientific conclusions

inv-65: Age — >= 18 years (TMS typical age limit)

Age requirement for TMS initiation>= 18 years (patient must be 18 years of age or older for outpatient TMS coverage)

DSM-5 diagnosisDiagnosis of major depressive disorder (MDD) by a licensed mental health professional required

Provider requirementTMS must be recommended by a psychiatrist or psychiatric APRN who examined the patient face-to-face

inv-66: Typical treatment course — 36 treatments over a 10-week period

Typical TMS coursePlanned IMS/TMS course: 36 treatments over a 10‑week period (includes initial and tapering sessions)

Session duration range (evidence summary)Primary studies evaluated 10–30 sessions, typically ~15 minutes each

Authorization alignmentPlanned course parameter (36/10 weeks) is required as part of coverage criteria

inv-67: Motor threshold re-determination limit — No more than 3 re-determinations in a rolling 6-month period

Motor threshold re-determination limitNo more than 3 motor threshold re-determinations in a rolling 6‑month period (routine re-determinations without documented rationale are not reasonable/necessary)

Documentation requirementMedical record must clearly document rationale for any motor threshold re-determination (change in clinical status or regimen expected to alter cortical excitability)

Appeal noteDenied claims may be appealed with supporting documentation addressing medical necessity for additional re-determinations

inv-68: CIWA escalation threshold — >= 16

CIWA escalation thresholdCIWA score >= 16 prompts consideration of transition to inpatient setting/higher level of care

Use of validated scalesFacilities required to use validated withdrawal scales such as CIWA to guide level-of-care decisions

ContextThreshold referenced in ambulatory detoxification criteria and revision history for Commercial plan

inv-69: COWS escalation threshold — >= 36

COWS escalation thresholdCOWS score >= 36 prompts consideration of transition to inpatient setting/higher level of care

Scoring interpretationCOWS scoring: >36 indicates severe withdrawal; validated scale required for monitoring

Outpatient suitabilityCOWS <36 implied for outpatient appropriateness per ambulatory detox criteria

inv-70: CIWA / COWS escalation thresholds — CIWA >= 16; COWS >= 36

Escalation thresholds (CIWA/COWS)CIWA >= 16; COWS >= 36 — thresholds prompting consideration for higher level of care in ambulatory detoxification (Commercial plan revision)

Validated tools requiredUse CIWA for alcohol withdrawal and COWS for opioid withdrawal to inform transitions between levels of care

Policy noteThresholds were modified in Commercial plan revision history (4/26/24) and incorporated into ambulatory detoxification criteria

Prior Authorization

Follow plan-specific prior authorization path for chemical aversion therapy

Chemical aversion therapy is covered for Commercial and CHIP only when provided as part of a coordinated treatment plan; for Medicare beneficiaries, CMS determinations govern coverage and if none exist the commercial policy applies.

Include the coordinated treatment plan and supporting documentation with any prior authorization request.
For Medicare patients, verify CMS coverage decisions before submitting authorization requests; if no CMS decision, follow SelectHealth commercial policy.

Prior Authorization

Verify benefits and prior authorization for EMDR (PTSD only)

EMDR is covered only for PTSD; verify member benefits and follow plan-specific prior authorization requirements (Commercial, Medicare per CMS determinations, Community Care per state/InterQual alignment).

Confirm the diagnosis of PTSD and include documentation supporting PTSD indication when requesting authorization.
Verify the member's line of business (Commercial, Medicare, Community Care) to determine which prior‑auth rules apply.

Note

Follow CMS (or SelectHealth commercial) determinations for Medicare

For Medicare beneficiaries, coverage decisions follow CMS determinations; when no CMS determination exists and InterQual is unavailable, SelectHealth's commercial policy applies.

Check CMS coverage guidance before submitting authorization for Medicare members.
If CMS/InterQual guidance is absent, use the SelectHealth commercial policy as the default for coverage decisions.

Prior Authorization

Prior authorization required for TMS; Mickel Therapy excluded

TMS requires prior authorization and must meet the policy's clinical criteria (age ≥18, DSM‑5 MDD diagnosis, psychiatrist/APRN recommendation after face‑to‑face exam, documented medication failures/intolerances, psychotherapy trial, and planned course parameters). Mickel Therapy for fibromyalgia is not covered.

Obtain a psychiatrist or psychiatric APRN face‑to‑face examination and recommendation documented in the record.
Provide documentation of medication failure/intolerance and psychotherapy trial as required by the criteria.

Billing Rule

Authorize TMS CPT codes 90867/90868/90869

Authorization is expected for TMS-related CPT codes 90867 (treatment planning), 90868 (delivery/management per session), and 90869 (motor threshold re‑determination with delivery/management).

Include these CPT codes on authorization requests and claims only when documentation supports medical necessity per the TMS criteria.
Ensure motor threshold re‑determination requests include documented rationale per policy.

Prior Authorization

Use updated TMS prior‑auth criteria (modified #1–#5; added distinctions)

Prior authorization criteria for TMS were revised: criteria #1–#4 were modified, criterion #5 was added, and new distinctions (criteria #AA and #4B) were created to differentiate medication‑failure standards by depression type; prior authorization requests must align with the updated criteria.

When requesting authorization, document which criterion (A, B, or AA/4B distinctions) applies and provide supporting medication‑failure evidence.
Apply the updated medication‑failure definitions appropriate to new/non‑recurrent versus chronic/recurrent depression.

Prior Authorization

Require ASAM/InterQual criteria and facility capability for withdrawal management

Outpatient and inpatient withdrawal management require that ASAM (outpatient) or InterQual (inpatient) criteria are met and that the facility is equipped to provide the requested level of care (24‑hour medical evaluation, credentialed staff, physician‑approved protocols).

Provide documentation that ASAM or InterQual criteria are satisfied for the requested level of withdrawal management.
Confirm facility capabilities (24/7 medical evaluation access, credentialed personnel, safe staffing) in the authorization submission.

Prior Authorization

Preauthorize ambulatory detox beyond 5–7 days

Ambulatory detoxification beyond 5–7 days requires preauthorization with documentation and specific treatment goals to justify continued outpatient detoxification.

For requests exceeding 7 days, submit preauthorization including the individualized treatment plan, progress to date, and explicit treatment goals.
Document why outpatient care remains appropriate and alternatives considered.

Prior Authorization

Follow plan‑specific preauthorization paths and InterQual when applicable

Select Health Community Care (Medicaid) aligns with State of Utah Medicaid and InterQual; providers must follow plan‑specific preauthorization processes and applicable InterQual/State Medicaid criteria when seeking authorization.

Verify the member's plan (Community Care vs Commercial vs Medicare) and follow the corresponding prior authorization pathway.
If InterQual or state Medicaid criteria apply, include InterQual findings or state-required documentation with the authorization request.

Documentation Required

Submit clinical documentation for continued authorization (up to every 6 months)

Continued authorization reviews (for services such as ABA) are adjusted based on clinical review and may occur up to every six consecutive months; requests for continued services must document clinical improvement or plan modifications.

Include objective measures of clinical improvement, updated treatment plan, and validated scale results at each continued‑authorization submission.
If progress is lacking, document assessment updates and modifications to the plan.

Note

No fixed step‑therapy sequence — use individualized assessment and CASP guidance

The policy does not prescribe an explicit step‑therapy sequence for behavioral interventions; instead it emphasizes individualized assessment, caregiver training, and frequent data‑based treatment planning per CASP guidance.

Document individualized assessment findings and the rationale for chosen interventions rather than relying on a mandated step sequence.
Demonstrate caregiver training and data‑driven decision making in authorization materials.

Prior Authorization

Tie authorization to coordinated treatment plan with therapy and supports

Coverage for services described in the policy is contingent on delivery as part of a coordinated treatment plan that includes therapy and support; authorization requests must document coordination with other providers and caregiver participation.

Include evidence of coordination (communications, referrals, school involvement) and the caregiver training plan in authorization submissions.
Services provided outside a coordinated plan risk denial as experimental or not medically necessary.

Note

Align authorization pathway to plan (CMS for Medicare; InterQual/State for Community Care)

Medicare coverage follows CMS determinations; SelectHealth Community Care aligns with state Medicaid/InterQual — verify the member's line of business and follow the appropriate authorization pathway for Medicare, Commercial, or Community Care.

For Medicare members, check CMS decisions first; for Community Care, follow state Medicaid/InterQual criteria.
Document which program's criteria were applied in the authorization request.

Note

No step‑therapy requirements specified in these chunks

These policy excerpts do not specify any prescriptive step‑therapy requirements for medications or therapies in the sections cited.

When seeking authorization, do not assume a separate step‑therapy ladder unless specified elsewhere in the member's benefit plan.
Verify medication step requirements in the member's contract if concerned.

Step Therapy

Document failed medication and psychotherapy trials before TMS

For TMS, patients must have failed adequate trials of antidepressant medications and an evidence‑based psychotherapy trial per the policy's medication‑failure definitions (see criteria A/B and updated Commercial distinctions).

Document the number, agent classes, doses, durations, and prescribing clinician for each failed antidepressant trial.
Document the psychotherapy trial (typically ≥15 sessions over 4–6 months) and its outcome.

Prior Authorization

Show documented failure of ≥2 antidepressant classes and psychotherapy trial

Prior authorization requests for TMS must document that the member failed medications from at least two different agent classes and had an adequate trial of evidence‑based psychotherapy prior to initiation (timing/duration requirements vary by criterion A vs B).

Provide dates and durations of medication trials and psychotherapy sessions, and state which TMS criterion (A or B) applies.
Include prescriber information showing the medications were prescribed by an appropriate clinician.

Documentation Required

Meet revised Commercial medication‑failure documentation standards

Where the Commercial policy applies, documented failure (prescribed by treating psychiatrist or psychiatric APRN) of at least two antidepressant courses at maximally tolerated labeled dose and duration is required in specified criteria; ensure medication‑failure documentation meets the revised wording.

Include prescribing clinician credentials and that the antidepressant courses were maximally tolerated and of adequate duration.
Reference the specific criterion number (e.g., #4a) that the documentation is intended to satisfy.

Denial Risk

Do not request authorization for UROD (investigational; no demonstrated benefit)

Randomized trials report no superiority and safety concerns for ultra‑rapid opioid detoxification under general anesthesia; such procedures are considered investigational and not covered — do not request authorization for UROD.

Avoid submitting prior authorization requests for UROD; cite investigational status if inquiries are made.
If considering rapid antagonist protocols, document non‑anesthesia approaches and supporting evidence rather than general‑anesthesia UROD.

Documentation Required

Consider and document MAT for withdrawal management

When treating opioid withdrawal, consider Medication‑Assisted Treatment (MAT) unless medically contraindicated and document MAT consideration or reason for contraindication in the authorization record.

Document whether MAT was offered, initiated, or contraindicated and include rationale.
Include MAT plans in the individualized treatment plan for withdrawal management authorization submissions.

Note

No explicit step‑therapy sequences in these policy excerpts

No additional explicit step‑therapy sequences are listed in these sections of the policy; verify plan‑specific documents for any medication step requirements.

If a payer or plan requires step‑therapy, obtain and follow that plan's documented requirements.
Document any prior steps taken in the patient's history when requesting authorization.

Documentation Required

Include DSM‑5 diagnosis and individualized treatment plan in authorization

Authorization requests must include DSM‑5 diagnosis (e.g., ICD‑10 F84.0, F84.3, F84.9 for ASD), an individualized treatment plan with baseline objective measures, quantifiable goals, caregiver training plan, and periodic validated scale results.

Attach DSM‑5 diagnosis and relevant ICD‑10 code from the policy when requesting ABA authorizations.
Provide baseline measures, target behaviors, progress/mastery criteria, staff identifiers, start date, and evidence of caregiver training.

Billing Rule

Document services per listed CPT codes (97151–97158 etc.)

Document assessments and treatment activities using the policy‑listed CPT codes (e.g., 97151 behavior identification assessment, 97153 technician‑delivered treatment, 97156 family guidance) and include face‑to‑face time and assessment findings.

Map documented assessment and treatment tasks to the corresponding CPT codes listed in the policy.
Ensure records show face‑to‑face time, objective assessment results, and treatment plan linkage to billed services.

Documentation Required

Verify benefits and contact Select Health for questions

Verify member benefits and eligibility before submitting authorization requests; providers may contact Select Health Provider Relations or Customer Service for benefit questions.

Confirm the member's line of business and covered services at time of service.
Contact Provider Relations at (801) 442‑3692 for coverage questions as noted in the policy.

Billing Rule

Use appropriate psychotherapy CPT codes and support with documentation

When billing psychotherapy or related services, include the appropriate CPT psychotherapy codes (e.g., 90832, 90834, 90837) and interactive complexity code 90785 when applicable; documentation must support diagnosis and medical necessity.

Include psychotherapy CPT codes consistent with the documented therapy session length and content.
Use 90785 when interactive complexity is present and document the factors justifying it.

Note

Verify coverage for listed codes — policy codes are informational

Codes listed in the policy are informational; verify member coverage for listed codes and confirm with Select Health if uncertain before assuming coverage.

Do not assume inclusion of a code in the policy guarantees coverage—always verify the individual member's benefits.
If questions remain, contact Provider Relations or Customer Service per the policy.

Documentation Required

Require psychiatrist/APRN face‑to‑face recommendation and monitoring for TMS

TMS must be recommended by a psychiatrist or psychiatric APRN who examined the patient face‑to‑face; the recommending clinician must review the record and the monitoring clinician must be responsible for motor threshold determination and neurological monitoring.

Include face‑to‑face exam documentation, prescribing/monitoring clinician credentials, and record review notes with prior‑auth submissions.
Document plans for neurological monitoring and motor threshold determination by the responsible clinician.

Documentation Required

Provide prior response evidence (≥50% reduction maintained ≥2 months) for TMS retreatment

For TMS retreatment, documentation must show prior ≥50% reduction in depressive symptoms (standardized rating scales) that was maintained for at least two months after the prior course; repeat TMS within 60 days of termination of a prior course is not medically necessary.

Attach standardized rating scale scores demonstrating ≥50% symptom reduction and dates showing maintenance ≥2 months.
Do not request retreatment within 60 days of prior TMS course termination unless appealable exceptional circumstances are documented.

Documentation Required

Document rationale for motor threshold re‑determination; limit applies

Motor threshold re‑determination requests must include the clinical rationale; routine re‑determinations are not appropriate and more than three re‑determinations in a rolling six‑month period will be denied.

Document the clinical change or regimen alteration expected to affect cortical excitability to justify re‑determination.
Track prior motor threshold re‑determinations to avoid exceeding the three per six‑month limit.

Documentation Required

Include psychotherapy (≥15 sessions) and medication trial documentation for TMS

Authorization for TMS requires documentation of an adequate trial of evidence‑based psychotherapy (typically ≥15 sessions over 4–6 months) and medication trials as specified in the criteria.

Provide psychotherapy session counts, dates, clinician credentials, and outcomes when submitting TMS authorization requests.
Include medication trial details (names, doses, durations, prescribers) per the policy's medication‑failure definitions.

Documentation Required

Ensure medication‑failure documentation is prescribed by treating psychiatrist/APRN

Medication‑failure documentation must demonstrate failure or intolerance and be prescribed by the treating psychiatrist or psychiatric APRN as required by the Commercial policy clarifications.

Include prescriber name and credentials showing psychiatric prescriber prescribed the antidepressant trials.
Detail the trial duration, dose, and reason for discontinuation (failure vs intolerance) for each medication.

Prior Authorization

Demonstrate level‑of‑care appropriateness and facility capability for withdrawal management

When requesting a level‑of‑care (withdrawal management) authorization, demonstrate that the requested level is consistent with the member's medical condition and that the facility is equipped (24/7 medical evaluation, credentialed staff, physician‑approved protocols).

Include facility capability documentation (staffing, 24‑hour evaluation access, physician‑approved protocols) with the authorization.
Map the member's ASAM dimensions to the requested level of care in the submission.

Documentation Required

Provide required clinical documentation at admission for ambulatory detox

At admission for ambulatory detoxification, document DSM diagnosis of substance use disorder with withdrawal focus, substances used (frequency, duration, last use), urine/breathalyzer results, at least three signs/symptoms of active moderate withdrawal or expectation within 48 hours, and use of a validated withdrawal scale (CIWA or COWS).

Attach validated withdrawal scale scores and objective findings supporting active moderate withdrawal.
Provide urine/breathalyzer and relevant labs as part of the admission documentation.

Documentation Required

Verify benefits and document plan‑specific coverage for authorization

Verify member benefits and document plan‑specific coverage; inclusion of codes in the policy does not guarantee coverage for an individual—contact Customer Service or Provider Relations as needed.

Reference the member's contract benefits in effect at time of service in the authorization.
Contact Customer Service or Provider Relations when eligibility or coverage is unclear.

Denial Risk

Risk of denial when essential elements or caregiver participation lapse

Services may be denied or discontinued if essential elements are no longer met, caregivers fail to participate for successive authorizations, or the member has achieved treatment goals or not demonstrated progress over successive authorization periods.

Ensure continued caregiver participation is documented for each authorization period.
Provide objective progress data to demonstrate ongoing medical necessity.

Denial Risk

Coverage contingent on meeting policy criteria — include evidence

Coverage is contingent on meeting the policy's medical necessity criteria; failure to meet those criteria may result in denial of the requested services.

Include evidence that all policy criteria are satisfied in the authorization request.
If criteria are unmet, document rationale and any alternative plans or appeals.

Denial Risk

Denial risk if services are not part of a coordinated treatment plan

Coverage is provided only as part of a coordinated treatment plan that includes therapy and support; services requested outside such coordination may be denied.

Provide documentation of coordination with other providers, schools, and caregiver training when relevant.
Demonstrate how the requested service fits into the member's overall coordinated plan.

Denial Risk

EMDR for non‑PTSD indications will be denied

Requests for EMDR for indications other than PTSD (e.g., prevention of PTSD, phantom limb pain, panic/anxiety disorders other than PTSD, other psychiatric disorders) will be denied as experimental/investigational.

Do not submit EMDR authorization for non‑PTSD indications; if submitted, expect denial as investigational.
For PTSD requests, include documentation supporting the PTSD diagnosis and medical necessity.

Denial Risk

Hippotherapy (S8940) not covered for Commercial/CHIP — expect denial

Select Health does not cover hippotherapy for Commercial plans; do not request prior authorization for hippotherapy under Commercial or CHIP lines of business.

Avoid submitting authorization for HCPCS S8940 for Commercial/CHIP members as coverage is excluded.
If a provider believes exceptional coverage is warranted, contact Provider Relations to discuss but expect investigational denial.

Denial Risk

Mickel Therapy for fibromyalgia is not covered — denials expected

Select Health does not cover Mickel Therapy for fibromyalgia (Commercial); requests for this investigational therapy will be denied.

Do not submit authorization for Mickel Therapy for fibromyalgia under Commercial plans.
If questioned, reference the policy's investigational status for Mickel Therapy.

Denial Risk

Retreatment within 60 days is not medically necessary — avoid or justify carefully

Repeat TMS within 60 days of termination of a prior TMS course is considered not medically necessary and may be denied; document timing carefully when requesting retreatment.

Do not request retreatment within 60 days of prior course termination unless appealing with exceptional supporting documentation.
Include dates of prior TMS course termination and rationale if requesting earlier retreatment.

Denial Risk

Motor threshold re‑determination limit: >3 per rolling 6 months denied

More than three motor threshold re‑determinations in a rolling six‑month period will be denied; include clinical justification in the medical record when re‑determination is requested.

Track prior re‑determinations and provide clear clinical rationale for any additional motor threshold testing.
Anticipate denial if the three‑in‑six‑months limit is exceeded without documented justification.

Denial Risk

TMS for non‑MDD indications, maintenance, or age ≤17 is investigational — not covered

Unilateral or bilateral rTMS for behavioral health indications other than MDD, TMS as maintenance therapy, and TMS for ages 17 and under are considered experimental/investigational and are not covered.

Do not submit authorization for TMS for non‑MDD behavioral health indications, for maintenance therapy, or for patients ≤17 years.
If exceptional cases are considered, expect investigational denial and prepare supporting evidence for appeal.

Denial Risk

Pediatric TMS (≤17 years) excluded — do not request authorization

Select Health excludes coverage for TMS for pediatric patients (age 17 and under); do not submit authorization for patients ≤17 years.

Verify the patient's age before submitting TMS requests; pediatric TMS requests will be denied as investigational.
For adolescents, consider alternative evidence‑based treatments covered by the plan.

Denial Risk

TMS for migraine indications is excluded — expect denial

TMS for migraine indications (e.g., Spring TMS) is not covered and considered investigational; do not request authorization for migraine indications under this behavioral health policy.

Avoid submitting TMS authorization for migraine treatment; reference the policy exclusion if coverage is queried.
If a member has migraine-related TMS request, direct providers to seek guidance on neurology/headache‑specific coverage policies.

Denial Risk

Exclude ambulatory detox when psychiatric, substance‑use, or severe medical comorbidities present

Ambulatory detoxification exclusions include psychiatric comorbidity that prevents cooperation, severe/repeated substance abuse, severe complicated medical comorbidities (e.g., seizure history, uncontrolled BP, cardiopulmonary disease), accelerating symptoms creating instability, or life‑threatening conditions; such cases should be escalated to higher level of care.

Screen patients for exclusion criteria before authorizing ambulatory detox and document findings.
If exclusions are present, request a higher level of care authorization (e.g., inpatient) with supporting ASAM/InterQual documentation.

Billing Rule

Verify member benefit plan — policy code lists are informational only

Inclusion or exclusion of codes in the policy does not guarantee member coverage or reimbursement; always verify the member's individual benefit plan prior to submitting authorization or billing.

Confirm coverage for requested services with the member's contract benefits at time of service.
If coverage is uncertain, contact Customer Service or Provider Relations as instructed in the policy.

DefinitionFocused ABA: treatment targeting a limited number of domains or specific skill areas; access not restricted by age, cognitive level, diagnosis, or co-occurring conditions.

CharacteristicsAppropriate when symptoms are limited to one or two areas requiring targeted intervention; corresponding assessment unit guidance: 16–24 units (15‑minute units)

Care planningCaregiver involvement and objective baseline measures remain required for focused interventions

inv-124: Autism Spectrum Disorder (ASD) diagnostic criteria per DSM-5

Core DSM-5 featuresASD: persistent deficits in social communication and social interaction across contexts, and restricted, repetitive patterns of behavior, interests, or activities present in early development and causing clinically significant impairment.

Severity specificationSeverity is specified based on social communication impairments and restricted/repetitive behaviors; assessment guides hours and service intensity

Screening and timingScreening recommended at 18‑ and 24‑/30‑month well-child visits; regression can occur around 18–24 months warranting re-screening

inv-125: M-CHAT-R/F screening tool description

Tool descriptionM-CHAT‑R/F: 20‑item parent questionnaire screening tool for autism for ages 16–30 months, with a follow‑up interview when indicated

Use caseDesigned for primary care screening at 18‑month and 24/30‑month visits to stratify autism risk

Follow-upFollow-up interview recommended when initial screen indicates elevated risk

inv-126: Chemical aversion therapy definition

DefinitionChemical aversion therapy: behavior modification technique pairing substances (alcohol, cannabis, cocaine) with unpleasant symptoms induced by chemical agents to develop conditioned aversions

Agents commonly usedAgents reported include emetine, apomorphine, and lithium — none FDA‑approved for this use

Safety considerationWhen used, patients require medical observation due to unapproved agent use and induced adverse symptoms

inv-127: EMDR — therapy description

DescriptionEMDR: psychotherapy combining identification of target traumatic memories with alternating bilateral stimulation (eye movements, sound, touch) plus exposure and cognitive restructuring to reduce PTSD‑related distress

Therapeutic componentsUses exposure, cognitive restructuring, and bilateral rhythmic stimulation to modulate emotional responses and reduce distress

Scope of indicationDeveloped for PTSD; proposed for other disorders but coverage limited to PTSD per policy

inv-129: Hippotherapy definition

DefinitionHippotherapy: rehabilitative therapy using horse movement (or mechanical equivalent) to induce pelvic movement and equilibrium responses in the rider to improve posture and ambulation; sometimes proposed as equine‑facilitated psychotherapy

DeliveryMay be provided by physical, occupational, speech therapists, psychologists, or psychotherapists; implementation guidelines lacking in literature

Evidence noteLiterature limited to small case series and small trials; evidence insufficient to support efficacy

inv-130: Mickel Therapy definition

DefinitionMickel Therapy: a spoken, one‑to‑one wellness approach developed by Mickel Health Initiatives involving education and guided sessions intended to resolve symptoms without medication, supplements, or hands‑on techniques

Typical deliveryOne‑hour private sessions typically every 1–3 weeks; focuses on education, redefining symptoms, and behavioral guidance

Coverage stanceSelectHealth considers Mickel Therapy investigational/unproven for fibromyalgia and does not cover it for that indication

inv-131: Mickel Therapy additional context

Additional contextNo demonstrated clinical utility for fibromyalgia in available studies; considered investigational and not covered for that indication

Modality characteristicsDelivered as spoken sessions without hands‑on techniques, medications, or supplements

Provider claimsProponents claim cessation of symptoms via education and behavioral guidance, but objective evidence is lacking

inv-132: Transcranial Magnetic Stimulation (TMS) definition

DefinitionTranscranial Magnetic Stimulation (TMS): noninvasive procedure using electromagnetic fields to stimulate cortical neurons, used for treatment‑resistant depression; can be unilateral or bilateral and delivered in repeated sessions

Typical parametersStudies evaluated 10–30 sessions typically ~15 minutes each; FDA approval for MDD after failure of prior antidepressant in current episode

SettingUsually outpatient; coil positioning and pulse administration may be performed by trained technicians under clinician oversight

inv-133: Navigated TMS (nTMS) definition

DefinitionNavigated TMS (nTMS): noninvasive functional mapping technique using magnetic stimulation with navigation (often MRI‑based) for high‑resolution cortical motor and language mapping to aid presurgical planning and intraoperative guidance

ApplicationsUsed for motor and language mapping; motor mapping easier due to early motor pathway maturation; language mapping requires sustained attention and may be limited by age/developmental ability

Role in surgerynTMS mapping results are used pre‑operatively to plan resections and intraoperatively alongside direct cortical stimulation

inv-134: nTMS outpatient mapping description

Outpatient mapping descriptionnTMS performs motor and language cortical mapping outside the OR/MRI/MEG environments using magnetic induction; provides high‑resolution data comparable to direct cortical stimulation

Age/development limitsnTMS motor mapping can be performed in children/adolescents in reclining chair with distraction; language mapping requires sustained participation and is generally feasible in adolescents and older

Clinical utilitynTMS aids presurgical planning for tumor resection and epilepsy surgery when detailed cortical mapping is required

inv-135: dTMS definition and evidence note

dTMS definitionDeep TMS (dTMS): a TMS modality evaluated in a limited number of primary studies for MDD; supports efficacy and safety in small noncomparative trials but comparative effectiveness vs rTMS is unclear

Evidence noteOnly a few primary studies assess dTMS; comparative data to rTMS are limited, and maintenance therapy evidence is sparse

Coverage implicationdTMS evidence exists but comparative effectiveness vs standard rTMS remains uncertain

inv-136: TMS / rTMS general definition

General definitionrTMS/TMS: repetitive transcranial magnetic stimulation techniques targeting prefrontal cortex and other regions for treatment of depression and other neuropsychiatric conditions

Evidence baseMultiple systematic reviews, randomized trials, and technology assessments cited support rTMS efficacy for treatment‑resistant depression though heterogeneity exists across studies

Clinical considerationsrTMS is generally less effective than ECT for severe MDD but is FDA‑approved for adult MDD after prior antidepressant failure

inv-137: UROD / OADUSA definition

DefinitionUROD / OADUSA: opioid antagonist‑assisted detoxification performed under sedation or general anesthesia to accelerate withdrawal

Safety/evidence concernsRandomized trials found no improved retention or relapse outcomes with general anesthesia rapid detox and serious adverse events (cardiac arrest, pulmonary edema) have been reported

Coverage stanceConsidered investigational/experimental/unproven and not covered due to safety concerns and lack of controlled benefit evidence

inv-138: ASAM levels definition

ASAM levels overviewASAM levels define levels of care from Level 1 outpatient to Level 4 medically managed inpatient across six dimensions (withdrawal potential, biomedical conditions, emotional/behavioral/cognitive, readiness, relapse potential, recovery environment)

Level matchingAdmission and continued stay decisions are determined by severity across dimensions and mapped to appropriate ASAM level (1, 2.1, 2.5, 3.x, 4)

Facility requirementsFacility must demonstrate capability (24/7 evaluation access, credentialed personnel, physician‑approved protocols) for the requested level of care

inv-139: Validated withdrawal scales — CIWA and COWS

Validated withdrawal scalesValidated tools required: CIWA for alcohol withdrawal and COWS for opioid withdrawal to assess severity and guide transitions

CIWA componentsCIWA assesses symptoms such as agitation, anxiety, auditory/visual disturbances, nausea/vomiting, sweats, tremor; used to guide level‑of‑care decisions

COWS componentsCOWS includes pulse, GI upset, tremor, sweating, restlessness, pupil size, anxiety/irritability; scoring categories define mild to severe withdrawal

inv-140: CIWA / COWS thresholds — CIWA 16+, COWS 36+

CIWA / COWS thresholdsCIWA score of 16 or above and COWS score of 36 or greater prompt consideration for higher level of care (transition to inpatient) — Commercial plan revision reflected these thresholds

Outpatient suitability guidanceCIWA <16 and COWS <36 implied for outpatient ambulatory detoxification appropriateness

Policy revision noteThreshold changes for ambulatory detoxification were noted in revision history (4/26/24)

Intensive hours must be justified by assessment type, functional impairment, and treatment goals

Caregiver roleCaregiver training and engagement required to generalize gains from intensive programs

Primary studies evaluated various session counts (10–30), but policy sets 36 as typical IMS/taper regimen

inv-170: motor threshold re-determinations — 3

Motor threshold re‑determinations limitLimit = 3 re‑determinations in a rolling 6‑month period; >3 will be denied absent documented medical necessity

Reason for re‑determinationAllowed when change in clinical status or regimen expected to alter cortical excitability; must document rationale

Appeal pathwayDenied claims may be appealed with supporting documentation showing medical necessity for additional re‑determinations

inv-171: Ambulatory detoxification duration before prior auth required — 5-7

Ambulatory detox duration before prior authAmbulatory detoxification intended for up to 5–7 days; treatment beyond 7 days requires preauthorization with documentation and specific treatment goals

Documentation requiredPreauthorization for extension must include treatment goals and clinical justification

Operational noteProviders must seek prior auth when anticipated ambulatory detox exceeds typical 5–7 day window

Caregiver requirementCaregiver engagement remains an essential component for focused ABA to generalize gains

inv-124: ASD diagnostic criteria — DSM-5 summary

DSM-5 ASD summaryASD requires persistent deficits in social communication/interaction and restricted, repetitive patterns of behavior present in early development causing significant impairment

Severity determinationSeverity specified using social communication impairments and restricted/repetitive behaviors to guide treatment intensity

Diagnostic contextAssessment typically involves interview and play‑based testing by qualified professionals

inv-125: M-CHAT-R/F — screening tool definition

M-CHAT‑R/F descriptionA 20‑item parent questionnaire screening tool for autism for ages 16–30 months, with a follow‑up interview when indicated

Screening scheduleRecommended screening at 18‑month and 24/30‑month well‑child visits; re‑screen when regression suspected

Follow‑up interviewFollow‑up interview performed in office or by telephone when indicated by initial screen

inv-126: Chemical aversion therapy definition

Chemical aversion therapyBehavior modification pairing substances with unpleasant symptoms induced by chemical agents (e.g., emetine, apomorphine, lithium); agents not FDA‑approved for this use; patients require medical observation

IndicationsUsed in treatment of alcoholism and other substance use disorders as described in policy when part of coordinated plan

Safety noteUse of unapproved agents necessitates medical monitoring and observation during treatment

inv-127: EMDR definition

EMDR definitionA psychotherapy combining exposure, cognitive restructuring, and bilateral rhythmic stimulation (eye movements, sound, touch) to reduce traumatic memory‑related distress, originally developed for PTSD

Mechanisms proposedProposed mechanisms include accelerated conditioning processes and modulation of neurobiological substrates to reduce emotional responses

Coverage scopeSelectHealth covers EMDR for PTSD only; other indications are considered experimental/investigational

inv-132: TMS definition

TMS definitionNoninvasive electromagnetic stimulation of cortical neurons used for treatment‑resistant depression; sessions typically last ~15 minutes and are delivered in multiple sessions

FDA indicationFDA‑cleared for adult MDD after inadequate response to prior antidepressant therapy in current episode

DeliveryMay be administered unilaterally or bilaterally with clinician oversight; typical course per policy is 36 treatments over 10 weeks

inv-133: nTMS definition

nTMS definitionNavigated TMS: magnetic stimulation with navigation (often MRI‑based) for high‑resolution cortical motor and language mapping to aid presurgical planning

Mapping modalitiesUsed for motor and language mapping; motor mapping more feasible in younger patients due to passive testing, language mapping requires sustained participation

Clinical rolenTMS results inform surgical planning and may be used with direct cortical stimulation intraoperatively

inv-137: UROD / OADUSA definition

UROD / OADUSA definitionOpioid antagonist detoxification performed under sedation or general anesthesia to rapidly precipitate withdrawal (ultra‑rapid opioid detoxification)

Safety concernsAssociated with cardiovascular complications and serious adverse events; randomized trials show no improved retention or relapse outcomes vs other methods

Coverage stanceConsidered investigational/experimental/unproven and not covered

inv-138: ASAM levels definition

ASAM levels summaryLevels of care defined across six dimensions (withdrawal potential; biomedical; emotional/behavioral/cognitive; readiness; relapse potential; recovery environment) guiding placement from outpatient to medically managed inpatient

Level descriptorsLevels include Level 1 outpatient, 2.1 IOP, 2.5 PHP, 3.x residential services, and Level 4 medically managed inpatient; dimension severities determine appropriate level

Evaluation requirementAdmission and continued stay decisions should align with ASAM dimensional criteria and facility capability

inv-139: Validated withdrawal scales

Validated withdrawal scalesCIWA (Clinical Institute Withdrawal Assessment for Alcohol) and COWS (Clinical Opiate Withdrawal Scale) are required validated tools for assessing withdrawal severity and guiding level‑of‑care transitions

Escalation thresholdsCommercial plan notes CIWA >=16 or COWS >=36 should prompt consideration for higher level of care (revision 4/26/24)

Operational useFacilities must use validated scales at admission and as clinically indicated to document withdrawal signs and trigger appropriate transitions

Commercial Plan Policy: modified requirements in criteria #1–#4 and added criterion #5 in section A–I to align with updated clinical standards.

2024-04-26revision_note

Commercial Plan Policy: modified ambulatory detoxification escalation thresholds—CIWA score of 16 or above or COWS score of 36 or greater now prompt consideration of higher level of care.

2024-02-12revision_noteLatest

Commercial Plan Policy: added clarifying language to criterion #4a requiring documented failure, prescribed by a treating psychiatrist or psychiatric APRN, of at least 2 antidepressant courses at maximally tolerated labeled dose and duration (greater than 4 weeks from two different agent classes for at least 6 months in the current moderate-to-severe episode).

Revision history notes that prior authorization criteria for TMS were updated for the Commercial Plan: criteria #1–#4 were modified, a new criterion #5 was added, distinctions were created to separate medication‑failure standards (criteria #AA and #4B), and clarifying language was added to the medication‑failure requirement (for example, documentation that at least 2 antidepressant courses were prescribed by a treating psychiatrist or psychiatric APRN at maximally tolerated dose and duration in applicable criteria). Providers should follow the revised prior authorization requirements when requesting TMS services.