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

INDICATIONS FOR COVERAGE
Key Points
According to the DSM, the onset of Oppositional Defiant Disorder (ODD) typically occurs by
age 8 and includes a pattern of negativistic, hostile, and defiant behavior lasting at least 6
months, during which there is a presence of four or more of the following (Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), 2000):
o
o
o
o
o
o
o
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Frequent loss of temper
Frequent arguments with adults
Often defies or refuses to comply with adults’ requests or rules
Often deliberately annoys people
Often blames others for his or her mistakes or misbehavior
Often touchy or easily annoyed by others
Often angry and resentful
Often spiteful or vindictive
Establishing a definitive diagnosis requires that the related disturbance (DSM-IV-TR):
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o
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Is more frequent than observed in individuals of comparable age and developmental
level;
Causes significant impairment in social, academic, or occupational functioning;
Does not occur during the course of a Psychotic or Mood Disorder; and
Does not meet the criteria for Conduct Disorder or Antisocial Personality Disorder.
Differential diagnosis to rule out disorders that mask or mimic ODD in addition to the
identification of common co-occurring conditions that may complicate treatment such as
ADHD, Substance Use Disorders, Mood Disorders, Anxiety Disorders, Adjustment Disorders
and learning and developmental disabilities should be completed. Specifically consider
whether the patient is exhibiting normal behavior according to age and stage of development
(American Academy of Child and Adolescent Psychiatry (AACAP), 2007).
Optum maintains that the treatment of ODD should be consistent with nationally recognized
scientific evidence as available, and prevailing medical standards and clinical guidelines.
Comprehensive treatment for ODD is typically treated in an outpatient setting. Members with
ODD should be treated in a level of care that is least restrictive and most likely to prove safe
and effective (Optum Level of Care Guidelines (LOCGs), 2012). Choice of intensive
outpatient treatment is indicated for members with at least one of the following:
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o
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Moderate symptoms of ODD that cannot be managed in a less intensive level of
care and/or a higher level of care may be required if IOP is not provided
(Association for Ambulatory Mental Healthcare (AABH), 2008);
Moderate impairment in the member’s psychological, social, occupational,
educational, or other area of functioning has impacted the member’s ability to
perform regular daily activities as compared to baseline (AABH, 2008);
The member has completed treatment at a higher level of care and continues to
require the monitoring provided in an IOP setting (AABH, 2008).
Intensive Outpatient Treatment of Oppositional Defiant Disorder (ODD) Page 2 of 14
Coverage Determination Guideline
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