Medically necessary mental health services and addiction and recovery services

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:

Medically necessary mental health services are 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 services, 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.

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

Mental health and wellness

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, intellectual disabilities, and academic or career counseling.
• Treatment specific to and solely for personal growth or relationship enhancement.
• 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.
• Wilderness therapy or boarding school that does not meet approved criteria for mental health 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. 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.

Addiction and recovery services
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 resulting from the proposed treatment 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. Aversion Therapy and Conversion Therapy).