Excluded mental health care, including addiction and recovery

The following services may not meet the definition of clinical necessity. Check a member's eligibility before proceeding with care.

Addiction and recovery

Members must have a current diagnosis and symptoms of a substance use disorder as defined by the current Diagnostic and Statistical Manual of Mental Disorders (e.g. DSM V) to be eligible for treatment services, with symptoms significantly interfering with the individual’s ability to function in at least one life area.

There must be a reasonable expectation that the patient can make changes as a result of the treatment plan and that stabilization is possible.

The proposed medical treatment must involve a level of care with appropriate resources to assess and treat the client’s condition according to its severity and the consumer’s health and level of functioning.

The proposed medical treatment must involve the least intensive level of care necessary to accomplish the treatment objectives in a clinically appropriate manner.

Exclusions exist in medical coverage agreements. In addition to contractual exclusions, additional exclusions may include:

  • Court, school, or work-ordered treatment that is not medically necessary.
  • Educational and early intervention substance abuse programs, such as Alcohol Drug Information School (ADIS) (American Society of Addiction Medicine, ASAM, level 0.5).
  • Urinalysis for drug screens, unless medically necessary, authorized by Kaiser Permanente, or both.
  • Halfway houses.
  • Wilderness therapy or boarding school programs that do not meet approved criteria for substance use disorder residential level of care.
  • Genetic testing or genetic sequencing solely for psychotropic treatment and/or management that does not currently meet mental health medical necessity criteria due to unclear guidance of how test results should be used to direct treatment decisions and insufficient evidence of improved patient health outcomes.
  • Kaiser Permanente will only approve treatment with providers/facilities that are in alignment with treatment standards that employ evidence-based programs and practices. Kaiser Permanente will not authorize treatment that utilizes experimental or investigational therapies (e.g. Counter-Conditioning Method, Aversion Therapy, and Conversion Therapy).

Mental health

Any services deemed not medically necessary by Kaiser Permanente.

We may exclude the following services from coverage depending on the member's health plan. Below are the most common exclusions in many of the plans covered by Kaiser Permanente. For specific patients, contact Member Services or the Mental Health Access Center.

  • Assessment and treatment services primarily vocational and academic in nature (such as educational testing, sensitivity training, etc.) if not medically necessary.
  • Treatment for conditions where improvement or stabilization cannot be reasonably expected per the medically necessary care definition.
  • Evaluation or treatment mandated by a third-party unless considered medically necessary (for example, court, employer, or school).
  • Documentation in the form of reports or summaries of clinical information.
  • Long-Term and Custodial care.
  • Experimental or investigational therapies.
  • Educational programs (for example, experiential programs such as Wilderness Therapy or Boarding School programs).
  • Nicotine-related disorders.
  • Treatment specific to and solely for learning, communication and motor skills disorders, mental retardation, and academic or career counseling. Communication skills and motor disorders treated by a rehabilitation therapist would be covered under the rehab therapy benefit and not subject to review. Benefit (rehab vs. mental health) will be determined by the treating provider's specialty. Autism spectrum disorder, other pervasive developmental disorders, and tic disorders would be reviewed in the Mental Health Access Center.
  • Treatment specific to and solely for personal growth or relationship enhancement.
  • Treatment of overeating (without a formal eating disorder diagnosis as defined by the current DSM Criteria).
  • Treatment of obesity or weight reduction (without a formal eating disorder diagnosis as defined by the current DSM Criteria).
  • Work or school ordered assessment and treatment not determined to be medically necessary.
  • Services solely for marital counseling, parent/child relationship counseling, or other relational counseling services that do not meet mental health clinical medical necessity criteria.
  • Services solely for bereavement or other phase of life problems that do not meet mental health clinical medical necessity criteria.
  • Genetic testing or genetic sequencing solely for psychotropic treatment and/or management that does not currently meet mental health medical necessity criteria due to unclear guidance of how test results should be used to direct treatment decisions and insufficient evidence of improved patient health outcomes.
  • Kaiser Permanente will only approve treatment with providers/facilities that are in alignment with treatment standards that employ evidence-based programs and practices. Kaiser Permanente will not authorize treatment that utilizes experimental or investigational therapies (e.g. Counter-Conditioning Method, Aversion Therapy, and Conversion Therapy).
  • Any other service not specifically listed as covered or excluded in the member's benefit contract and does not meet medical necessity criteria and/or is not approved by Kaiser Permanente as an evidence-based treatment in alignment with the Kaiser Permanente treatment philosophy.

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