§2035.30. Medical Necessity Criteria for Utilization Review of Treatment Models for Serious Mental Illnesses for Individuals Under Age 26

 

Any medical necessity criteria that an issuer, nonfederal governmental payor, or utilization review organization prescribes or uses for utilization review on any of the following interdisciplinary, team-based treatment models for serious mental illnesses in individuals under the age of 26 shall conform to the criteria in this Section. The services are delivered through the appropriate interdisciplinary team of mental health professionals to enable early treatment and recovery, improved functioning, improved and/or managed mental health symptoms, medication adherence, and the prevention of any further functional impairment. For individuals with Medicaid coverage, the medical necessity criteria will continue to be governed by the criteria established by the Illinois Department of Healthcare and Family Services.

 

a)         Coordinated Specialty Care (CSC) for First Episode Psychosis Treatment

 

1)         Service Initiation Criteria.  An individual meets the medical necessity criteria for initiating CSC services if they meet all of the following:

 

A)        The individual is 14 through 25 years of age;

 

B)        The individual experienced significant symptoms of psychosis or a psychotic episode, as defined in DSM, for the first time in the last 18 months; and

 

C)        The individual (and parent or legal guardian when appropriate and with consent) is willing to accept CSC services.

 

2)         Continuing Service Criteria.  An individual shall meet the medical necessity criteria for continuing to receive CSC services if he or she meets all of the following:

 

A)        The individual's severity of illness and resulting impairment continues to require this level of service;

 

B)        Without these services, the individual would not be able to sustain treatment gains, and there would be an increase in symptoms and a decrease in functioning;

 

C)        Treatment planning is individualized and appropriate to the individual's changing condition, with realistic and specific goals and objectives stated;

 

D)        The mode, intensity and frequency of treatment are appropriate;

 

E)        Active treatment is occurring and continued progress toward goals is evident, or adjustments to the treatment plan have been made to address lack of progress; and

 

F)         The individual (and parent or legal guardian when appropriate and with consent) is actively participating in the treatment plan and is willing to continue.

 

3)         Service Termination Criteria.  Individuals meeting any of the following criteria no longer meet the medical necessity criteria for CSC:

 

A)        The individual's treatment plan and discharge goals have been substantially met;

 

B)        Consent for treatment has been withdrawn;

 

C)        The individual no longer meets the service initiation criteria in subsection (a)(1) or meets the service initiation criteria for a less or more intensive level of care; or

 

D)        The individual (and parent or legal guardian when appropriate and with consent) is not engaged in or utilizing the service to such a degree that treatment at this level of care becomes ineffective or unsafe despite use of motivational techniques and multiple documented attempts to address engagement issues.

 

4)         Exclusion Criteria.  CSC is not appropriate for any of the following:

 

A)        The individual experienced a first psychotic episode more than 18 months ago;

 

B)        The symptoms to be addressed have their primary origin in an intellectual disability, neurodevelopmental or neurocognitive disorder, substance-related or -induced disorder, personality disorder, or brain injury; or

 

C)        A rapid onset of psychosis occurred due to sleep deprivation not associated with another psychotic disorder or condition. 

 

b)         Community Support Team (CST) Treatment

 

1)         Service Initiation Criteria.  An individual meets the medical necessity criteria for initiating CST treatment services if he or she meets all of the following:

 

A)        The individual has a psychiatric diagnosis defined in the DSM, and has a LOCUS or CALOCUS composite score of 14-20 causing moderate to severe psychiatric symptoms;

 

B)        The individual (and parent or legal guardian when appropriate and with consent) is willing to accept CST treatment services; and

 

C)        Outpatient mental health treatment has not resulted in improved symptoms or functioning, or is not appropriate at the current time, and the individual exhibits three or more of the following:

 

i)          Psychiatric inpatient admission in the last year;

 

ii)         Four or more hospital emergency room services in the last year;

 

iii)        History of the lack of treatment follow-through, including medication non-adherence;

 

iv)        Medication resistance due to intolerable side effects or the illness interferes with consistent self-management of medications;

 

v)         A lack of improvement in traditional outpatient mental health treatment and requires coordinated clinical and supportive interventions;

 

vi)        Clinical evidence of suicidal ideation or gesture in the last year;

 

vii)       Self harm or threats of harm to others in the last year;

 

viii)      Evidence of significant complications such as cognitive impairment, behavioral problems or medical problems that compromise the ability to adhere to the behavioral health treatment plan; or

 

ix)        The severity or complexity of symptoms and level of functional impairment that require coordinated services provided by a team of mental health professionals and support specialists, as evidenced by at least one of the following:

 

•           Continuous functional deficits in achieving treatment continuity or self-management of prescription medication;

 

•           Persistent or severe psychiatric symptoms, serious behavioral difficulties, a co-occurring disorder, and/or a high relapse rate; or

 

•           Danger of requiring acute level of care if more intensive services are not available.

 

2)         Continuing Service Criteria.  A person shall meet the medical necessity criteria for continuing to receive CST treatment services if they meet all of the following:

 

A)        The individual's severity of illness and resulting impairment continues to meet service initiation criteria;

 

B)        Without these services, the individual would not be able to sustain treatment gains, and there would be an increase in symptoms and a decrease in functioning;

 

C)        Treatment planning is individualized and appropriate to the individual's changing condition, with realistic and specific goals and objectives stated;

 

D)        The mode, intensity and frequency of treatment are appropriate;

 

E)        Active treatment is occurring and continued progress toward goals is evident, or adjustments to the treatment plan have been made to address lack of progress; and

 

F)         The individual (and parent or legal guardian when appropriate and with consent) is actively participating in the treatment plan and is willing to continue.

 

3)         Service Termination Criteria.  Individuals meeting any of the following criteria no longer meet the medical necessity criteria for CST treatment:

 

A)        The individual's treatment plan and discharge goals have been substantially met;

 

B)        Consent for treatment has been withdrawn;

 

C)        The individual no longer meets the service initiation criteria in subsection (b)(1) or meets the service initiation criteria for a less or more intensive level of care;

 

D)        The individual (and parent or legal guardian when appropriate and with consent) is not engaged in or utilizing the service to such a degree that treatment at this level of care becomes ineffective or unsafe despite use of motivational techniques and multiple attempts to address engagement issues; or

 

E)        The individual experiences a significant increase in symptoms paired with a significant decrease in functioning, resulting in a transition to the more intensive ACT service level.

 

4)         Exclusion Criteria.  CST treatment is not appropriate for the following individuals:

 

A)        The symptoms to be addressed have their primary origin in an intellectual disability, neurodevelopmental or neurocognitive disorder, substance-related or -induced disorder, or personality disorder;

 

B)        A rapid onset of psychosis occurred due to sleep deprivation not associated with another psychotic disorder or condition;

 

C)        The individual's daily living skills are sufficient to enable him or her to progress in his or her recovery with the support of outpatient mental health services;

 

D)        The individual's level of cognitive impairment, current mental status or development level make it unlikely for him or her to benefit from CST treatment services; or

 

E)        The individual requires a more intensive level of service and cannot be safely or effectively treated with CST treatment services.

 

c)         Assertive Community Treatment (ACT)

 

1)         Service Initiation Criteria.  An individual meets the medical necessity criteria for initiating ACT services if they meet all of the following:

 

A)        The individual has a psychiatric diagnosis, as defined in the DSM, causing severe and persistent symptoms;

 

B)        The individual has a minimum LOCUS or CALOCUS composite score of 17;

 

C)        The individual (and parent or legal guardian when appropriate and with consent) is willing to accept ACT services; and

 

D)        Less intensive mental health treatment has not resulted in improved symptoms or functioning, or is not appropriate at the current time, and the individual exhibits three or more of the following:

 

i)          Evidence the psychiatric diagnosis is co-existing with a substance disorder and/or serious physical health condition;

 

ii)         Two or more psychiatric inpatient admissions in the last year;

 

iii)        Four or more emergency room visits in the last year;

 

iv)        History of the lack of treatment follow-through, including medication non-adherence;

 

v)         Medication resistance due to intolerable side effects or his or her illness interferes with consistent self-management of medications;

 

vi)        Clinical evidence of suicidal ideation or gesture in the last year;

 

vii)       Self-harm or threats of harm to others in the last year;

 

viii)      Evidence of significant complications, such as cognitive impairment, behavioral problems or medical problems, that compromise the ability to adhere to the behavioral health treatment plan;

 

ix)        History of violence due to untreated mental illness;

 

x)         History of significant psychotic symptomatology, such as command hallucinations to harm others;

 

xi)        Danger of requiring acute level of care if more intensive services are not available; or

 

xii)       Currently residing in an inpatient bed, but clinically assessed to be able to receive ACT following discharge.

 

2)         Continuing Service Criteria.  An individual shall meet the medical necessity criteria for continuing to receive ACT services if he or she meets all of the following:

 

A)        The individual's severity of illness and resulting impairment continues to meet service initiation criteria;

 

B)        Without these services, the individual would not be able to sustain treatment gains, and there would be an increase in symptoms and a decrease in functioning;

 

C)        Treatment planning is individualized and appropriate to the individual's changing condition, with realistic and specific goals and objectives stated;

 

D)        The mode, intensity and frequency of treatment are appropriate;

 

E)        Active treatment is occurring and continued progress toward goals is evident, or adjustments to the treatment plan have been made to address lack of progress; and

 

F)         The individual (and parent or legal guardian when appropriate and with consent) is actively participating in the treatment plan and is willing to continue.

 

3)         Service Termination Criteria.  Individuals meeting any of the following criteria no longer meet the medical necessity criteria for ACT:

 

A)        The individual's treatment plan and discharge goals have been substantially met;

 

B)        Consent for treatment has been withdrawn;

 

C)        The individual no longer meets the service initiation criteria in subsection (c)(1) or meets the service initiation criteria for a less or more intensive level of care; or

 

D)        The individual (and parent or legal guardian when appropriate and with consent) is not engaged in or utilizing the service to such a degree that treatment at this level of care becomes ineffective or unsafe despite use of motivational techniques and multiple documented attempts to address engagement issues.

 

4)         Exclusion Criteria.  ACT is not appropriate for any the following:

 

A)        The symptoms to be addressed have their primary origin in an intellectual disability, neurodevelopmental or neurocognitive disorder, substance-related or -induced disorder, or personality disorder;

 

B)        A rapid onset of psychosis occurred due to sleep deprivation not associated with another psychotic disorder or condition;

 

C)        The individual's symptoms and functioning are sufficient to enable him or her to progress in his or her recovery with less intensive mental health services;

 

D)        The individual's level of cognitive impairment, current mental status or development level make it unlikely for him or her to benefit from ACT services; or

 

E)        The individual has an impairment that requires a more intensive level of service.