UBH Outpatient Treatment of PTSD PDF

COVERAGE DETERMINATION GUIDELINE
Outpatient Treatment of Posttraumatic Stress Disorder

Guideline Number: BHCDG482010 Approval Date: January 2011 Revised Date: Table of Contents: Instructions for Use Plan Document Language Indications for Coverage Coverage Limitations and Exclusions Definitions References Coding 1 2 2 12 13 14 14 Product: 2001 Generic UnitedHealthcare COC/SPD 2007 Generic UnitedHealthcare COC/SPD 2009 Generic UnitedHealthcare COC/SPD May also be applicable to other health plans and products Related Medical Policies: Level of Care Guidelines American Psychiatric Association, Practice Guideline for the Treatment of Patients with Posttraumatic Stress Disorder, 2004 American Psychiatric Association, Guideline Watch for the Treatment of Patients with Posttraumatic Stress Disorder, 2009 American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder, 2010 VA/DoD Guideline, The Management of Posttraumatic Stress, 2004 INSTRUCTIONS FOR USE This Coverage Determination Guideline provides assistance in interpreting behavioral health benefit plans that are managed by United Behavioral Health (UBH). This Coverage Determination Guideline is also applicable to behavioral health benefit plans managed by Pacificare Behavioral Health, OptumHealth Behavioral Solutions, or U.S. Behavioral Health Plan, California. When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollees document (e.g., Certificates of Coverage (COCs), Schedules of Benefits (SOBs), or Summary Plan Descriptions (SPDs)) may differ greatly from the standard benefit plans upon which this guideline is based. In the event that the requested service or procedure is limited or excluded from the benefit, is defined differently, or there is otherwise a conflict between this document and the COC/SPD, the enrollee's specific benefit document supersedes these guidelines. All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements that supersede the COC/SPD and the plan benefit coverage prior to use of this guideline. Other coverage determination guidelines and clinical guideline may apply.
Outpatient Treatment of Posttraumatic Stress Disorder Coverage Determination Guideline Confidential and Proprietary, United Behavioral Health 2010
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United Behavioral Health reserves the right, in its sole discretion, to modify its coverage determination guidelines and clinical guidelines as necessary. While this Coverage Determination Guideline does reflect UBHs understanding of current best practices in care, it does not constitute medical advice.
PLAN DOCUMENT LANGUAGE Before using this guideline, please check enrollees specific plan document and any federal or state mandates, if applicable. INDICATIONS FOR COVERAGE
Key Points According to the DSM, the essential feature of Posttraumatic Stress Disorder (PTSD) is exposure to a traumatic experience involving actual or threatened death or serious injury of self or others with a response of intense fear that is persistently reexperienced via distressing recollections, dreams, or reenactments. Symptoms of PTSD include avoidance, diminished response and increased arousal associated with the trauma and symptoms have been present for more than one month. The following are traumatic events that may result in PTSD symptoms: Following are examples of: o o o o o o o o o o Combat trauma Rape Physical or sexual abuse School Violence Refugee Trauma Assault Transportation accidents Torture Acts of terrorism Natural disasters
The diagnosis of children my require a qualifying index (sexually transmitted disease, police report, witness reports, forensic evaluation) in the absence of a child disclosure of the trauma experienced or a diagnosis of PTSD cannot be assumed according to symptomotology alone. UBH maintains that outpatient treatment of PTSD should be consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines. Symptom severity, severity of trauma-related distress and the severity of functional impairment present should all be considered when choosing outpatient treatment. Factors which may rule out outpatient treatment include: o o o The patient is at imminent risk of harm to self or others and would be more safely treated in a more intensive level of care. A co-occurring behavioral health or medical condition complicates treatment to the extent that services in a more intensive level of care are indicated. The patients parents, spouse and/or support network cannot actively participate in
Page 2 of 16 Coverage Determination Guideline Confidential and Proprietary, United Behavioral Health 2010
the patients treatment. The goals of the outpatient treatment of PTSD are to reduce the severity of PTSD symptoms, improve the patients psychological sense of safety.. Best practice treatments include: Diagnostic Evaluation and Assessment o o Assessing the patient and the associated trauma. Use of self-rating scales such as the Trauma Symptom Inventory for adults, Childrens PTSD Inventory and Trauma Symptom Checklist for Young Children, TBI Screening and Military Scales. Structured Diagnostic Interviews such as the Detailed Assessment of PTSD for adults and the Endler Multidimensional Anxiety Scale for adolescents and adults. A full psychiatric evaluation to include a substance abuse evaluation if indicated for differential diagnosis and to identify substance use disorders as common comorbidities with PTSD.
Treatment Planning Pharmacotherapy o o o o SSRIs are first line treatments for adults and children. SNRIs may be used as an alternate first-line treatment for adults. MAOIs and Tricyclic antidepressants are second-line treatments for adults and not recommended for children. The use of Antiadrenergics such as prazosin and ciproheptadine to target symptoms of trauma related nightmares when SSRIs, SNRIs and MAOIs are not effective. Atypical antipsychotics as augmenting treatments with an SSRI for adult and child patients with aggressive and psychotic symptoms. Cognitive Behavior Therapy or CBT Combination Programs that include the following are first-line treatments for adults: o o o o Exposure Therapy Stress Inoculation Therapy Imagery Rehearsal Therapy Cognitive Therapy
Psychotherapy o
Eye Movement Desensitization and Reprocessing (EMDR) as a first-line treatment for adults and second-line treatment for children. Trauma-Focused Therapy first-line treatment for children Trauma-Focused CBT is a second-line treatment for children. Psychoeducation as an adjunct to first or second line treatments with both adults and children.
Discharge and Referral Management
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According to the DSM, the essential feature of Posttraumatic Stress Disorder is exposure to a traumatic experience involving actual or threatened death or serious injury of self or others with a response of intense fear that is persistently reexperienced via distressing recollections, dreams, or reenactments. Symptoms of avoidance and increased arousal associated with the trauma have been present for more than 1 month. Outpatient treatment in indicated when the presenting symptoms support a diagnosis of PTSD. Outpatient treatment care consists of visits provided in an ambulatory setting for the purpose of assessing and treating a mental health condition. United Behavioral Health maintains that outpatient treatment of PTSD should be consistent with its Level of Care Guidelines and the Best Practice Guidelines adopted by United Behavioral Health. As such United Behavioral Health also maintains that optimal clinical outcomes result when evidence-based treatment is provided in the least restrictive level of available care that is structured and intensive enough to safely and adequately treat a members presenting problem and support the members recovery. The goals of the outpatient treatment of PTSD are to reduce the severity of PTSD symptoms, improve the patients psychological sense of safety and improve the presenting signs and symptoms of PTSD. The requested treatment service or procedure for the treatment of a mental health condition must be reviewed against the language in the enrollee's benefit document. When the requested treatment service or procedure is limited or excluded from the enrollees benefit document, or is otherwise defined differently, it is the terms of the enrollee's benefit document that prevails. Benefits include the following services provided in an outpatient treatment setting: Diagnostic evaluations and assessment Treatment planning Referral services Medication management Individual, family, therapeutic group and provider-based case management services Crisis intervention
Indications for Coverage for Outpatient Treatment of Posttraumatic Stress Disorder Symptom severity, severity of trauma-related distress and the severity of functional impairment present should all be considered when choosing outpatient treatment. Factors which may rule out outpatient treatment include:
Outpatient Treatment of Posttraumatic Stress Disorder Coverage Determination Guideline Confidential and Proprietary, United Behavioral Health 2010 Page 4 of 16
o The patient is at imminent risk of harm to self or others and would be more safely treated in a more intensive level of care. o A co-occurring behavioral health or medical condition complicates treatment to the extent that services in a more intensive level of care are indicated. o The patients parents, spouse and/or support network cannot actively participate in the patients treatment. Best Practices for the Treatment of Posttraumatic Stress Disorder Diagnostic Evaluations and Assessment An assessment and evaluation should also address the following: History of exposure to traumatic event(s) Nature of the trauma Severity of the trauma Duration and frequency of the trauma Age at time of trauma Patients reaction at the time of the trauma Existence of multiple traumas Ability of patient to recount the trauma (look at information regarding a trigger)- The assessment should also include the following: Assessment of safety and severity of symptoms. Self-rating scales such as the Trauma Symptom Inventory for adults, Childrens PTSD Inventory and Trauma Symptom Checklist for Young Children. Structured Diagnostic Interviews such as the Detailed Assessment of PTSD for adults and the Endler Multidimensional Anxiety Scale for adolescents and adults. Differential diagnosis of ADHD, Bipolar Disorder, Substance Use Disorders, Anxiety Disorders and medical conditions in children and adults should occur as the symptoms of these disorders may be suggestive of PTSD or may be co-occurring conditions. The assessment should be performed cautiously, especially with patients who perceive themselves to be in danger. Family or social support should participate in the evaluation of children. Especially important for children.
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Interviewers should make every attempt to not lead children during interviews by asking the child to provide adequate detail about the onset, frequency and duration of the trauma. Once a PTSD diagnosis is confirmed, if symptoms of substance disorders are present, a full substance abuse evaluation is warranted to provide a differential diagnosis or confirm comorbidity. The provider and, whenever possible, the patient should document clear, reasonable and objective treatment goals and timeframes that stem from the patients diagnosis, and are supported by specific treatment strategies which address the patients symptoms and the precipitant for treatment. o The treatment plan should be continuously reassessed if new information becomes available or if the patients status changes. The treatment plan should always address co-occurring behavioral and medical conditions including substance disorders. All co-occurring conditions should be addressed equally in the treatment plan.
Treatment Planning
Pharmacotherapy Choice of medications and dosages are to be aligned with the current national standards of practice and care, the patients specific medical needs and manufacturer recommendations. Antidepressants Antidepressants have shown effective in treating the core symptomatology and functioning in adult and child/adolescent patients with PTSD. SSRIs should be chosen as the first-line treatment for PTSD in adults and children/adolescents. They not only reduce PTSD symptoms and produce global improvement but are also effective with comorbid disorders and associated symptoms. Treatment with the use of Paroxetine, Sertraline, Fluoxetine, Fluvoxamine or Citalopram is most common for PTSD. o SSRI efficacy is well established in women with PTSD resulting from civilian trauma, including childhood and adult sexual assault, other interpersonal traumas, and motor vehicle accidents. o SNRIs may also be considered a first line treatment as an alternative to an SSRI for the treatment of PTSD. o Fluoxetine and Fluvoxamine appear to be more effective for combat related PTSD due to the chronicity of the disorder in veterans.
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SNRIs may also be chosen as a first-line treatment for PTSD in adults, especially with Venlafaxine. It is as effective as an SSRI and useful in treating comorbid depression. o A common contraindication is the exacerbation of hypertension. Monoamine Oxidase Inhibitors (MAOIs) such as Phenelzine and Tranylcypromine are also considered second-line antidepressant agents for PTSD in adults. o Compliance with MAOI dietary restrictions is an important limitation of MAOI Treatment. o Contraindications exist for patients who use alcohol, illicit drugs or prescription drugs for the treatment of other conditions. o Cardiovascular and hepatotoxic side effects must be monitored with MAOIs.
Tricyclic antidepressants such as Imipramine, Amytriptyline, Desipramine, Nortriptyline, Protriptyline, and Clomipramine may be used as second-line antidepressant treatments for adults with PTSD. o TCAs are not recommended for the treatment of childhood PTSD due to cardiac effects to include sudden death in children. o TCAs appear to be less effective in global improvement than MAOIs but have fewer serious side effects. o Side effects include hypotension, cardiac arrhythmias, sedation and behavioral activation.
Antiadrenergic Agents Antiadrenergics or beta-blocking agents appear to reduce arousal, reexperiencing and dissociative symptoms. Special precautions must be taken when treating patients with low blood pressure. Prazosin and cyproheptadine may be used for the treatment of traumarelated nightmares and sleep disruption and has also shown efficacy in treating total PTSD symptoms in patients with chronic PTSD. Propranolol is effective specifically in treating high stress levels and frequency of reexperiencing of a traumatic event and in the prevention of further development of PTSD. Clonidine and Guanfacine are both effective in treating chronic forms of PTSD and Guanfacine has shown to be effective in treating dissociative symptoms. Antiadrenergic agents alone or in combination with an SSRI may be used with children and adolescents to target severe symptoms and/or comorbid conditions.
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Atyptical Antipsychotics
Atypical antipsychotics such as risperidone, quetiapine and olanzapine are recommended as adjunctive/augmenting treatments for patients who have partially responded to an SSRI or an SNRI. These agents are useful with patients who exhibit extreme hypervigilance, paranoia, physical aggression, social isolation and trauma-related psychotic symptoms. Patients receiving treatment with antipsychotics should be monitored for side effects including weight gain and metabolic changes due to the risk of type-2 diabetes. Atypical agents alone or in combination with an SSRI may be used with children and adolescents to target severe symptoms and/or comorbid conditions.
Psychotherapeutic Treatments Providers should explain to all patients with PTSD the range of therapeutic options that are available and should include general advantages and disadvantages associated with each therapeutic option. First-Line Treatments for Adults Cognitive Behavioral Therapy (CBT) combination treatments that include elements of exposure, stress inoculation, cognitive therapeutic techniques or a combination of one or more of the following therapies are recommended as firstline psychotherapeutic treatment for PTSD. Exposure Therapy Exposure Therapy (ET) helps patients with PTSD reduce the fear associated with their experience through repetitive, therapist-guided confrontation of feared places, situations, memories, thoughts, and feelings. o Patients are repeatedly exposed to their own individualized fear stimuli, until their arousal and fear responses are consistently diminished. o Exposure can be accomplished via imaginal exposure or in vivo exposure. Both methods involve encouraging the patient to revisit the experience, recalling the experience through verbally describing the emotional details of the trauma. o Exposure Therapy is typically delivered as part of a more comprehensive package of treatment, combined with PTSD education, coping skills training, and cognitive restructuring. o Because ET may temporarily increase patients level of distress, providers must take concrete steps to prepare patients for the treatment and ensure patients are suitable and stable enough to handle this type of treatment.
Stress Inoculation Training Stress inoculation training (SIT) is a type of CBT that can be thought of as a set of skills for managing anxiety and stress. This treatment was developed for the management of anxiety symptoms and adapted for treating women rape trauma survivors. o SIT typically consists of education and training of coping skills, including deep muscle relaxation training, breathing control, assertiveness, role playing, covert modeling, thought stopping, positive thinking and self-talk. Cognitive Therapy Cognitive Therapy (CT) is based on the understanding that an interpretation of an event rather than the event itself determines ones emotional reactions. The identification of erroneous or harmful cognitions, evaluating the evidence for and against such cognitions and the development of more realistic or useful cognitions are the goals of CT. o In the treatment of PTSD, CT is focused on cognitions related to safety/danger, trust and views of oneself. Imagery Rehearsal Therapy (IRT) IRT is aimed at changing the content of the patients nightmare to promote mastery over the threat, thereby altering the meaning, importance, and orientation to the nightmare. Imagery Rehearsal Therapy Approaches: o Deemphasizes exposure by avoiding discussion of trauma or traumatic content of nightmares o Focuses on habitual components of disturbing dreams and sleeplessness o Provides no group psychotherapy o Offers minimal instruction for dealing with unpleasant imagery o Emphasizes relaxation o Conveys no specific non-sleep-related instructions for managing post-traumatic stress, anxiety, or depressive symptoms Eye Movement Desensitization and Reprocessing (EMDR) EMDR is recommended as a first-line psychotherapeutic treatment for adults with PTSD. EMDR is a type of psychotherapy that was originally designed to alleviate the distress associated with traumatic memories and facilitates the accessing and processing of traumatic memories to bring these to an adaptive resolution.
o During EMDR patients are asked to identify: (1) a disturbing image that encapsulates the worst part of the traumatic event; (2) associated body sensations; (3) a negative thought that expresses what the patient learned from the trauma; (4) a positive thought that the patient wishes could replace the negative thought. o The patient is then asked to hold the disturbing image, sensations, and the negative cognition in mind while various procedures and protocols are used. One of the procedural elements is "dual stimulation" using either bilateral eye movements, tones, tactile stimulation or taps. The choice of procedure or combination of elements is customized to each client. o Between sessions, the patient is directed to keep a journal of any situations that provoke PTSD symptoms and of any insights or dreams about the trauma. o Standard CBT rating scales are used throughout the sessions to document changes in the intensity of the symptoms. First-Line Treatments for Children and Adolescents Trauma-Focused Therapy Trauma-focused therapy is the first-line recommended treatment for PTSD in children and adolescents. Trauma-focused therapy (1) directly addresses childrens traumatic experiences, (2) includes parents in treatment in some manner as important agents of change, and (3) focus not only on symptom improvement but also on enhancing functioning, resiliency, and/or development.
Second-Line Treatments for Children and Adolescents Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) In TF-CBT, the clinician typically provides stress-management skills in preparation for the exposure-based interventions that are aimed at providing mastery over trauma reminders. TF-CBT was designed for children with PTSD in addition to depression, anxiety, and other trauma-related difficulties such as shame and self-blame. TF-CBT is typically delivered individually to children and their nonperpetrator parents, although it has also been provided in group formats.
Eye Movement Desensitization and Reprocessing (EMDR) Although some deviations exist between the adult and child forms of EMDR, the child form being more similar to cognitive therapy than the adult version, it is an effective second-line treatment in pediatric PTSD.
Adjunctive Treatments Psychoeducation Psychoeducation is a useful adjunct to therapy and functions to educate patients and their families about the symptoms of PTSD and the various treatments that are available. Psychoeducation provides reassurance that trauma related symptoms are normal and expected shortly after a trauma and can often be overcome with time and treatment. Education about the symptoms and treatment of comorbid disorders may also be included as part of psychoeducation. Psychoeducational group treatment models for PTSD treatment may be an option for women with multiple traumas as well as combat veterans if available. The provider and, whenever possible, the patient should update the plan for discharge ultimately ensuring that an appropriate and final discharge plan is in place prior to discharge. With the patients documented consent, discharge planning will include the active involvement of the patients family and outpatient provider. Consultation and referral may be needed with other involved community, juvenile justice, and/or social welfare programs. For Military members, referrals to Veteran Affairs Medical Centers, affiliated Outpatient Vet Centers or Military Treatment Facilities may be necessary.
Discharge Planning and Referral Management
In Some Situations United Behavioral Health May Offer: Peer Review: United Behavioral Health will offer a peer review to the provider when services do not appear to conform to this guideline. The purpose of a peer review is to allow the provider the opportunity to share additional or new information about the case to assist the Peer Reviewer in making a determination including, when necessary, to clarify a diagnosis. Second Opinion Evaluation: United Behavioral Health facilitates obtaining a second opinion evaluation when requested by an enrollee, provider, or when United Behavioral Health otherwise determines that a second opinion is
necessary to make a determination, clarify a diagnosis or improve treatment planning and care for the enrollee. Referral Assistance: United Behavioral Health provides assistance with accessing care when the provider and/or enrollee determine that there is not an appropriate match with the enrollees clinical needs and goals, or if additional providers should be involved in delivering treatment. Covered Health Service(s) UnitedHealthcare 2001 Those health services provided for the purpose of preventing, diagnosing or treating a sickness, injury, mental illness, substance abuse, or their symptoms. A Covered Health Service is a health care service or supply described in Section 1: What's Covered--Benefits as a Covered Health Service, which is not excluded under Section 2: What's Not Covered--Exclusions. Covered Health Service(s) UnitedHealthcare 2007 and 2009 Those health services, including services, supplies, or Pharmaceutical Products, which we determine to be all of the following: Provided for the purpose of preventing, diagnosing or treating a Sickness, Injury, mental illness, substance abuse, or their symptoms. Consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines as described below. Not provided for the convenience of the Covered Person, Physician, facility or any other person. Described in this Certificate of Coverage under Section 1: Covered Health Services and in the Schedule of Benefits. Not otherwise excluded in this Certificate of Coverage under Section 2: Exclusions and Limitations.
In applying the above definition, "scientific evidence" and "prevailing medical standards" shall have the following meanings: "Scientific evidence" means the results of controlled clinical trials or other studies published in peer-reviewed, medical literature generally recognized by the relevant medical specialty community. "Prevailing medical standards and clinical guidelines" means nationally recognized professional standards of care including, but not limited to, national consensus statements, nationally recognized clinical guidelines, and national specialty society guidelines.
United Behavioral Health maintains clinical protocols for the treatment of PTSD that describe the scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding specific services. These clinical protocols (as revised from time to time), are available to Covered Persons
upon request, and to Physicians and other behavioral health care professionals on ubhonline. COVERAGE LIMITATIONS AND EXCLUSIONS Inconsistent or Inappropriate Services or Supplies UnitedHealthcare 2001, 2007, 2009 Services or supplies for the diagnosis or treatment of Mental Illness that, in the reasonable judgment of United Behavioral Health, are any of the following: Not consistent with generally accepted standards of medical practice for the treatment of such conditions. Not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and are therefore considered experimental. Not consistent with United Behavioral Healths level of care guidelines or best practice guidelines as modified from time to time. Not clinically appropriate for the patients Mental Illness or condition based on generally accepted standards of medical practice and benchmarks.
Additional Information: The lack of a specific exclusion of a service does not imply that the service is covered. The following are examples of inconsistent or inappropriate services for the treatment of PTSD (not an all inclusive list): Services that deviate from the indications for coverage summarized in the previous section. Not coordinating care when more than one practitioner is delivering treatment. Not addressing co-occurring behavioral health or medical conditions including substance disorders in the treatment plan. The use of Rebirthing Therapies or techniques in the treatment of children and adolescents with PTSD. Techniques that bind, restrict, withhold food or water or are otherwise coercive for the treatment of children with PTSD. The use of Recovered/Repressed Memory Therapy methods for the treatment of PTSD.
Please refer to the enrollees benefit document for ASO plans with benefit language other than the generic benefit document language. {INCLUDE FOR ASO ONLY: For ASO plans with SPD language other than 2001 and 2007 Generic COC language,
Please refer to the enrollees plan specific SPD for coverage.
DEFINITIONS Acute Mental Health Inpatient Acute mental health inpatient units are hospital based structured treatment services that provide 24-hour nursing care and monitoring. Services are for the treatment of covered mental health conditions. They are typically secured units. Cognitive Behavioral Therapy (CBT) A classification of therapies that are predicated on the idea that behavior and feelings are caused by thoughts. Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) A manual produced by the American Psychiatric Association which provides the diagnostic criteria for mental health and substance-related disorders, and other problems that may be the focus of clinical attention. Unless otherwise noted, the current edition of the DSM applies. Eye Movement Desensitization and Reprocessing (EMDR) is a type of psychotherapy treatment that was originally designed to alleviate the distress associated with traumatic memories and facilitates the accessing and processing of traumatic memories to bring these to an adaptive resolution. Exposure Therapy (ET) helps patients with PTSD reduce the fear associated with their experience through repetitive, therapist-guided confrontation of feared places, situations, memories, thoughts, and feelings. Imagery Rehearsal Therapy (IRT) is a type of cognitive behavior therapy aimed to help patients alter their nightmares while they are awake. IRT methods attempt to change the content of the patients nightmare to promote mastery over the threat, thereby altering the meaning, importance, and orientation to the nightmare. Mental Illness Those mental health or psychiatric diagnostic categories that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded under the Policy. Posttraumatic Stress Disorder is exposure to a traumatic experience involving actual or threatened injury of self or others with a response of intense fear that is persistently reexperienced via distressing recollections, dreams, or reenactments. Stress Inoculation Training (SIT) is a type of CBT that can be thought of as a set of skills for managing anxiety and stress. This treatment was developed for the management of anxiety symptoms and adapted for treating women rape trauma survivors.
Trauma-Focused Therapy is a cognitive behavioral treatment that involves individual sessions with the child and parent as well as joint parent-child sessions. TFT (1) directly addresses childrens traumatic experiences, (2) includes parents in treatment in some manner as important agents of change, and (3) focus not only on symptom improvement but also on enhancing functioning, resiliency, and/or development. REFERENCES 1. Generic UnitedHealthcare Certificate of Coverage, 2001 2. Generic UnitedHealthcare Certificate of Coverage, 2007, 2009 3. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Posttraumatic Stress Disorder, 2004. http://www.psychiatryonline.com/pracGuide/pracGuideChapToc_11.aspx 4. American Psychiatric Association, Guideline Watch for the Treatment of Posttraumatic Stress Disorder, 2009. http://www.psychiatryonline.com/pracGuide/PracticePDFs/AcuteStressDisord er-PTSD_GuidelineWatch.pdf 5. American Academy of Child and Adolescent Psychiatry, Practice Parameter for the Treatment of Posttraumatic Stress Disorder, 2010. http://www.aacap.org/galleries/PracticeParameters/JAACAP_PTSD_2010.pdf 6. Hayes Directory, Cognitive-Behavioral Therapy for the Treatment of Posttraumatic Stress Disorder in Adults, 2010. 7. Hayes Directory, Selective Serotonin Reuptake Inhibitors in the Treatment of Posttraumatic Stress Disorder, 2010. 8. International Society for Traumatic Stress Studies, PTSD Treatment Guidelines, 2010. 9. VA/DoD Clinical Practice Guideline, The Management of Posttraumatic Stress and Acute Stress Reaction, 2004. http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp CODING
The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this guideline are for reference purposes only. Listing of a service code in this guideline does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document. Limited to specific CPT and HCPCS codes? 90801-90815, 90845-90899 x YES NO Outpatient Treatment
Limited to specific diagnosis codes? 309.81 Limited to place of service (POS)?

x YES NO Posttraumatic Stress Disorder x YES NO

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Coverage Determination Guideline Confidential and Proprietary, United Behavioral Health 2010
Outpatient Treatment Limited to specific provider type? YES x NO
Limited to specific revenue codes?
x YES
NO
HISTORY Revision Date 1/14/11 Name L. Hernandez Revision Notes
The enrollee's specific benefit documents supersede these guidelines and are used to make coverage determinations. These Coverage Determination Guidelines are believed to be current as of the date noted.
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COVERAGE DETERMINATION GUIDELINE

Outpatient Treatment of Posttraumatic Stress Disorder

Outpatient Treatment of Posttraumatic Stress Disorder

Discharge and Referral Management

Outpatient Treatment of Posttraumatic Stress Disorder

Outpatient Treatment of Posttraumatic Stress Disorder

Discharge Planning and Referral Management

Please refer to the enrollees plan specific SPD for coverage.

Limited to specific diagnosis codes? 309.81 Limited to place of service (POS)?

x YES NO Posttraumatic Stress Disorder x YES NO

Outpatient Treatment Limited to specific provider type? YES x NO

Limited to specific revenue codes?

HISTORY Revision Date 1/14/11 Name L. Hernandez Revision Notes

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