Clinically necessary mental health care, including addiction and recovery

All mental health clinical services must be medically necessary to be covered by Kaiser Permanente. The overall definition of medical necessity for mental health care is consistent with the definition of medical necessity as provided by the organization, which is as follows:

Appropriate and clinically necessary mental health care is defined in manner consistent with other medical services if recommended by the enrollee's treating provider and determined to meet medical necessity by Kaiser Permanente's medical director of the Mental Health Access Center, or his or her designee, according to generally accepted principles and standards of quality, evidence-based medical/psychiatric practice and Kaiser Permanente’s approved medical necessity criteria, which are rendered to an enrollee for the diagnosis, care, or treatment of a formal diagnosis based on current Diagnostic Statistical Manual (e.g. DSM V) diagnostic criteria. To be medically necessary, services and supplies must meet the following requirements:

  • Are not solely for the convenience of the enrollee, his or her family, or the provider of the services or supplies.
  • Are the most appropriate level of service or supply which can be safely provided to the enrollee.
  • Are for the diagnosis or treatment of an actual or existing mental health condition or substance use disorder as defined by the current Diagnostic Statistical Manual for psychiatric conditions (e.g. DSM V) – see below –unless being provided under Kaiser Permanente's schedule for preventive services.
  • Are not for recreational, life enhancing, relaxation, or palliative therapy, except for treatment of terminal conditions.
  • Are appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the state of Washington, could not have been omitted without adversely affecting the enrollee's condition or the quality of health services rendered.
  • As to inpatient care (whether inpatient hospital or residential level of care), could not have been provided in a provider's office, the outpatient department of a hospital, or a non-residential facility without affecting the enrollee's condition or quality of health services rendered.
  • Are not primarily for research and data accumulation.
  • Are not experimental or investigational services.

The length and type of the treatment program and the frequency and modality of visits covered shall be determined by Kaiser Permanente's medical director of mental health utilization review/utilization management, or his or her designee.

In addition, as it pertains specifically to mental health care, medical necessity is defined as follows:

  • The MCG Criteria, ASAM Criteria, and/or Kaiser Permanente specific medical necessity criteria for the mental health or substance use disorder treatment program are met. Note: The MCG, ASAM, and Kaiser Permanente manuals are proprietary and cannot be published or distributed. However, on an individual member basis, Kaiser Permanente can share a copy of the specific criteria document used to make a utilization-management decision. If the care of one of your patients is being reviewed by our Mental Health Access Center, you may request a copy of the criteria that is being used to make the coverage determination. Call the Mental Health Access Center for more information regarding the case under review.
  • Current diagnosis and symptoms from the Diagnostic and Statistical Manual of Mental Disorders except excluded conditions (as noted in separate section of this manual), are present and the focus of treatment.
  • The patient is experiencing significant functional impairment (i.e. employment, school, social) resulting from current symptoms.
  • Treatment planning is individualized and appropriate to the clinical condition being treated with realistic, specific, and measurable goals established to alleviate symptoms or functional impairment.
  • There is a reasonable expectation that treatment will improve the patient's symptoms and level of functioning with focus of treatment on improving the patient's functioning to baseline level prior to onset of acute symptoms.

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