Oppositional Defiant Disorder, Intensive Outpatient ... - Ubhonline.com

Not clinically appropriate for the patient’s 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 Oppositional Defiant Disorder (not an all inclusive list):
Services that deviate from the indications for coverage summarized in the
previous section such as:
o A mis-match between the symptoms of Oppositional Defiant
Disorder, and the type and/or duration of treatment.
o A treatment plan that has not been modified when there has been
partial or no response to an adequate trial of treatment.
Admission to IOP treatment without appropriate management of acute
symptoms.
Admission to IOP treatment solely as a substitute for an available lower
level of care, an intensified schedule of ambulatory care, or a broadened
treatment plan.
Admission to IOP treatment that does not provide an adequate program of
treatment.
Not coordinating care when more than one practitioner is delivering
treatment.
Not addressing co-occurring behavioral health medical conditions
including substance use disorders in the treatment plan.
Services continue even though treatment goals have been completed.
Services continue despite repeated failures to adhere with recommended
treatment despite the deployment of motivational enhancement
interventions, peer support, school-based and other community resources.
Coverage for school-based services such as screening and testing for
learning disabilities and/or school delivered programs not supported by the
benefit plan.
Please refer to the enrollee’s 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 enrollee’s plan specific SPD for coverage.
Intensive Outpatient Treatment of Oppositional Defiant Disorder (ODD) Page 12 of 14
Coverage Determination Guideline
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