UBH Outpatient Treatment of Dysthymic Disorder.pdf

COVERAGE DETERMINATION GUIDELINE

Outpatient Treatment of Dysthymic Disorder Page 1 of 14

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

Outpatient Treatment of Dysthymic DisorderGuideline Number: BHCDG632011

Approval Date: April, 2011

Revised Date:

Table of Contents:

Instructions for Use 1

Plan Document Language 2

Indications for Coverage 2

Coverage Limitations and Exclusions 12

Definitions 13

References 14

Coding 14

Product:

2001 Generic UnitedHealthcare COC/SPD



May also be applicable to other health plans and products

Related Coverage Determination Guidelines:

Covered Health Services

Related Medical Policies:

Level of Care Guidelines

American Academy of Child and Adolescent Psychiatry, Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders, 2007

American Psychiatric Association, Practice Guideline for the Treatment of Patients with Major Depressive Disorder, 2010

INSTRUCTIONS FOR USE

This Coverage Determination Guideline provides assistance in interpreting behavioral health benefit plans that are managed by United Behavioral Health. This Coverage Determination Guideline is also applicable to behavioral health benefit plans managed by Pacificare Behavioral Health, OptumHealth Behavioral Solutions, or U.S. Behavioral Health Plan, California.

When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee’s document (e.g., Certificates of Coverage (COCs), Schedules of Benefits (SOBs), or Summary Plan Descriptions (SPDs)) may differ greatly from the standard benefit plans upon which this guideline is based. In the event that the requested service or procedure is limited or excluded from the benefit, is defined differently, or there is otherwise a conflict between this document and the COC/SPD, the enrollee's specific benefit document supersedes these guidelines.

All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements that supersede the COC/SPD and the plan benefit coverage prior to use of this guideline. Other coverage determination guidelines and clinical guideline may apply.

United Behavioral Health reserves the right, in its sole discretion, to modify its coverage determination guidelines and clinical guidelines as necessary.

While this Coverage Determination Guideline does reflect United Behavioral Health’s understanding of current best practices in care, it does not constitute medical advice.



PLAN DOCUMENT LANGUAGE

Before using this guideline, please check enrollee’s specific plan document and any federal or state mandates, if applicable.

INDICATIONS FOR COVERAGE

Key Points

According to the DSM, the essential feature of Dysthymic Disorder is the presence of a depressed mood for more days than not, for at least two years in adults and one year in children and adolescents. Accompanying symptoms may include poor appetite, overeating, insomnia, hypersomnia, low energy, fatigue, low self-esteem, poor concentration, difficulty making decisions and feelings of hopelessness. Children and adolescents may also present with irritable mood. Symptoms of Dysthymic Disorder are generally less severe than major depression, but may be more persistent.

Establishing a definitive diagnosis of Dysthymic Disorder requires a thorough evaluation of symptoms, psychiatric, medical, medication and substance use histories. Careful differential diagnosis from other depressive disorders, mood disorders, psychotic disorders, substance use and medical conditions that share similar symptoms is needed to avoid misdiagnosis.

United Behavioral Health maintains that the treatment of Dysthymic Disorder should be consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines.

Symptom severity, current level of functioning and the intensity of services required to address the active symptoms of Dysthymic Disorder should all be considered when choosing outpatient treatment. Factors which may rule out outpatient treatment include:

o The patient is at imminent risk of harm to self or others and would be more safely treated in a more intensive level of care.

o The severity of symptoms or severity in functional impairment cannot be safely managed in an outpatient setting.

o A co-occurring behavioral health or medical condition complicates treatment to the extent that services in a more intensive level of care are indicated.

The goal of outpatient treatment is to improve the presenting signs and symptoms, monitor and manage response to treatment, and assist the patient and the family/support network with developing and maintaining treatment gains.

Best practices include the following:

o Assessment and Evaluation

Identify the precipitants for treatment.

Complete psychiatric evaluation to include mental status, family history, functional impairments and the administration of indicated rating scales.

Physical examination and medical history (provided by a psychiatrist or other healthcare professional) to include laboratory testing as needed.

Treatment and medication history.

Consider utilizing ancillary sources of information such as the member’s family/social supports when gathering history and details about current functioning.

Evaluate the safety of the patient including current suicide risk.



Differential diagnosis from other depressive disorders, substance use disorders, medical conditions, psychotic disorders and other mood disorders.

Establish the diagnosis of Dysthymic Disorder and determine if there are co-occurring medical and behavioral health conditions including substance use disorders.

Identify strengths and risk factors.

Evaluate the ability of the member’s family/social supports to participate in the member’s treatment.

o Treatment Planning

The treatment plan must include objectives, actions and timeframes to address all of the following:

Identification of impairments and interventions that will maximize the patient’s quality of life.

How symptom reduction and rapid stabilization will be achieved.

How co-occurring behavioral health and medical conditions, if any, will be managed.

How the patient’s ability to manage their condition will be improved.

How risk issues related to the patient’s presenting condition, co-occurring behavioral health or medical conditions will be managed.

Whether the patient has an advance directive, a recovery plan, and a plan for managing relapse.

Methods of Measurement

Tools such as the HAM-D and the PHQ-9 for screening and measuring progress.

Algorithms such as the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) can be used as an adjunct to treatment planning.

o Psychotherapy – Cognitive Behavioral Therapy or Interpersonal Therapy are both indicated for the treatment of Dysthymic Disorder alone or in combination with pharmacotherapy.

o Pharmacotherapy

SSRIs are considered first line medications for adults and children.

TCAs are considered second line medications for adults and not indicated for children.

MAOIs are considered third line medications for adults and not indicated for children.

o Treatment Maintenance or Discontinuation

The decision to continue, taper or discontinue treatment should be a joint decision with the member and should be derived from the member’s response to treatment, availability of family/social supports, a clear recovery and/or aftercare plan and consideration of the following:

Due to the high incidence of relapse with Dysthymic Disorder, when medications are prescribed, medication management follow up for at least 6 months before consideration of a medication taper is encouraged.



Due to the persistence of symptoms in Dysthymic Disorder, if medications are prescribed, long-term treatment with medications is often advisable and in cases where a medication loses its effectiveness, a new regimen should be considered.

It may be appropriate to incorporate maintenance treatment that includes periodic psychosocial sessions focused on relapse prevention in order to maintain a positive response to treatment.

If prescribed, medication management and monitoring for possible relapse may no longer be required, or medications are stabilized well enough and the primary care physician has agreed to take over prescribing requirements.

Discontinuation of treatment may be indicated with successful completion of treatment goals and when the member and provider agree that treatment goals have been met, and remaining recovery goals can be self-managed or managed with peer support.

Discontinuation may be warranted when there is refusal of treatment or repeated failures to adhere with the recommended treatment despite the deployment of motivational enhancement interventions and other community support services.

There is resolution or adequate reduction in clinical symptoms and behaviors that necessitated treatment as assessed by the provider.

Demonstration of sufficient improvement, and the ability to function adequately without evidence of significant risk to self or others and without significant impairment in psychosocial functioning.

The member should confirm that he/she understands and agrees with the plan including the risks of continuation or discontinuation of treatment.

According to the DSM, the essential feature of Dysthymic Disorder is the presence of a depressed mood for more days than not, for at least two years in adults and one year in children and adolescents. Accompanying symptoms may include poor appetite, overeating, insomnia, hypersomnia, low energy, fatigue, low self-esteem, poor concentration, difficulty making decisions and feelings of hopelessness. Children and adolescents may also present with irritable mood. Symptoms of Dysthymic Disorder are generally less severe than major depression, but may be more persistent.

Establishing a definitive diagnosis of Dysthymic Disorder requires a thorough evaluation of symptom, psychiatric, medical, medication and substance use histories. Careful differential diagnosis from other depressive disorders, mood disorders, psychotic disorders, substance use and medical conditions that share similar symptoms is needed to avoid misdiagnosis.

Outpatient care consists of visits provided in an ambulatory setting for the purpose of assessing and treating a mental health condition. The goal of outpatient treatment is to improve the presenting signs and symptoms, monitor and manage response to treatment, and assist the patient and the family/support network with developing and maintaining treatment gains.



United Behavioral Health maintains that Outpatient Treatment should be consistent with its Level of Care Guidelines and the Best Practice Guidelines adopted by United Behavioral Health. As such United Behavioral Health also maintains that optimal clinical outcomes result when evidence-based treatment is provided in the least restrictive level of available care that is structured and intensive enough to safely and adequately treat a member’s presenting problem and support the member’s recovery.

The requested Outpatient Treatment service or procedure must be reviewed against the language in the enrollee's benefit document. When the requested Outpatient Treatment service or procedure is limited or excluded from the enrollee’s benefit document, or is otherwise defined differently, it is the terms of the enrollee's benefit document that prevails.

Benefits include the following services provided in Outpatient Treatment:

Diagnostic evaluations and assessment

Treatment planning

Referral services

Medication management

Individual, family, therapeutic group and provider-based case management services

Crisis intervention

Indications for Outpatient Treatment of Dysthymic Disorder

Symptom severity, current level of functioning and the intensity of services required to address the active symptoms of Dysthymic Disorder should all be considered when choosing outpatient treatment. Factors which may rule out outpatient treatment include:

o The patient is at imminent risk of harm to self or others and would be more safely treated in a more intensive level of care.

o The severity of symptoms or severity in functional impairment cannot be safely managed in an outpatient setting.

o A co-occurring behavioral health or medical condition complicates treatment to the extent that services in a more intensive level of care are indicated.

o The patient’s parents, spouse and/or support network cannot actively participate in the patient’s treatment.

Best Practices for the Treatment of Dysthymic Disorder

Assessment and Evaluation

Identify the precipitants for the initiation of outpatient treatment, current symptoms and history of depression.



Complete psychiatric evaluation to include mental status, family history, functional impairments and the administration of indicated rating scales.

Physical examination and medical history (provided by a psychiatrist or other healthcare professional) to include laboratory testing as needed.

o Laboratory tests to rule out common medical conditions often mistaken for Dysthymic Disorder may include thyroid function tests (hypothyroidism) and complete blood count (anemia).

Treatment and medication histories to include names and dosages of medications, type of psychosocial interventions, duration of treatment and response.

Consider utilizing ancillary sources of information such as the member’s family/social supports when gathering history and details about current functioning.

Evaluate the safety of the patient including current suicide risk.

o Assess for the presence of suicidal ideation, plan, means, history of attempts and protective factors.

Differential diagnosis from other depressive disorders, substance use disorders, medical conditions, psychotic disorders and other mood disorders.

o Clinicians may commonly need to rule out the following: major depressive disorder, cyclothymic disorder, bipolar disorder, adjustment disorder, hypothyroidism, anemia and alcoholism.

o In children and adolescents, common rule outs include anxiety, ADHD, oppositional defiant disorder, pervasive developmental disorder and substance abuse in addition to the above.

Establish the diagnosis of Dysthymic Disorder and determine if there are co-occurring medical and behavioral health conditions including substance use disorders.

Identify strengths and risk factors.

Evaluate the ability of the member’s family/social supports to participate in the member’s treatment.

Treatment Planning

The provider and the patient document clear, reasonable and objective treatment and recovery goals that stem from the patient’s diagnosis, focus which address the patient’s symptoms, and take into account the patient’s preferences.

The treatment plan must include objectives, actions and timeframes to address all of the following:

o Identify impairments and interventions that will maximize the patient’s quality of life.



o Determine how symptom reduction and rapid stabilization will be achieved.

o Determine how co-occurring behavioral health and medical conditions, if any, will be managed.

o Determine how the patient’s ability to manage their condition will be improved such as by providing health education, and linking the patient with peer services and other community resources.

o Determine how risk issues related to the patient’s presenting condition, co-occurring behavioral health or medical conditions will be managed including how the patient’s motivation will be maintained/enhanced, and collaborating with the patient to develop/revise the advance directive or relapse prevention plan.

o Determine whether the patient has an advance directive, a recovery plan, and a plan for managing relapse.

Integrating Measurement Tools and Algorithms Into the Treatment Plan

o Tailoring the treatment plan requires ongoing and systematic assessment of the patient’s needs. This can be facilitated by integrating clinician and/or patient administered rating scale measurements into initial and ongoing evaluation.

o Clinician rated and/or self rated scales help determine the course and effects of treatment and require review, interpretation, and discussion with the patient.

o Commonly used tools include the following:

Inventory of Depressive Symptoms (IDS), which is available in clinician-rated and self-rated versions, Clinician-rated Hamilton Rating Scale for Depression (HAM-D), Clinician-rated Montgomery Asberg Depression Rating Scale (MADRS), Self-rated Patient Health Questionnaire (PHQ-9), and The Beck Depression Inventory (BDI, BDI-II), copyrighted, 21-question multiple-choice self-rated instrument.

o Sequenced Treatment Alternatives to Relieve Depression – (STAR*D) can be used as an adjunct to the treatment plan particularly to augment or change the course of treatment for patients who have not responded to initial treatment of Depression with an antidepressant.

The purpose of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) is to determine the most effective treatment for people who have not responded to initial treatment with an antidepressant.

STAR*D aims at defining which subsequent treatment strategies, in what order or sequence, and in what



combination(s) are both acceptable to patients and provide the best clinical results with the least side effects.

The STAR*D algorithm provides a four-level sequence of treatments designed to increase adherence and remission rates in a measurable way.

The primary goal of each level is to determine if the treatment used during that level could adequately treat participants’ depressive disorder. Those who did not become symptom-free could proceed to the next level of treatment.

The chart of treatment options throughout STAR*D can be accessed here: http://www.nimh.nih.gov/trials/practical/stard/stard-treatment-flowchart.pdf

Contact the patient’s family and/or social support network, with the patient’s documented consent to regularly participate in the patient’s treatment and discharge planning when such participation is essential and clinically appropriate.

Parents/guardians of child and adolescent patients should be contacted and should participate in the patient’s treatment unless clinically contraindicated. Optimally, the patient’s family and/or social support group should participate in treatment when the patient is a child or adolescent.

Contact the patient’s outside providers and primary care practitioner, with the patient’s documented consent, if the patient was in treatment prior to admission to obtain information about the patient’s presenting condition and its treatment.

The provider and the patient collaborate to update the treatment plan in response to changes in the patient’s condition.

Psychosocial Interventions

Depression-focused psychotherapies include cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT).

CBT helps dysthymic patients make connections between depressive thoughts, moods and behavior. Strategies such as reformulating distorted thinking and daily behavioral change may improve symptoms.

IPT focuses on problems and the interpersonal context in which they occur. Success in solving interpersonal conflicts in IPT is associated with improved symptoms of Dysthymic Disorder.

CBT and IPT are also helpful forms of group therapy for Dysthymic patients.

Pharmacotherapy combined with psychotherapy may offer advantages over either modality alone.



Pharmacotherapy

If medication is indicated, antidepressant medication choices for Dysthymic Disorder must be made jointly with patients, with consideration of patient preference, prior response to medication, safety, tolerability, anticipated side effects, co-occurring conditions and cost.

Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclic Antidepressants (TCA’s) and Monoamine Oxidase Inhibitors (MAOIs) are all indicated for the treatment Dysthymic Disorder for adults and SSRIs only are indicated for children.

SSRIs are considered first line treatments, TCAs second line treatments and MAOIs should be restricted to patients who have not responded to a first line or second line medication.

If side effects occur, lowering the dose or changing to another first line treatment should be considered prior to choosing a second line or third line medication.

Consider TCAs for patients who have a history of poor response to standard first line agents, and who have been successfully treated with tricyclic antidepressants agents in the past, however, TCAs should be avoided with children and patients with a history of cardiac concerns.

Some antidepressants can be lethal in overdose (e.g., ingestion of a 10-day supply of a tricyclic agent administered at a dose of 200 mg/day). Early on in treatment, it is prudent to dispense only small quantities of such medications.

MAOIs are not indicated for use with children. When the medication is being changed to or from an MAOI, a washout period is essential to prevent a potentially lethal interaction.

Given that Dysthymic Disorder is a condition with persistent symptoms, tolerability is an important factor facilitating the likelihood for patients to continue taking medications on a long-term basis.

With all antidepressants, the initial dose should be raised incrementally as tolerated until a therapeutic dose is reached or the patient achieves remission. Titration generally can be accomplished over initial weeks, but more time may be needed depending on development of side effects, the patient’s age, and the presence of co-occurring medical and psychiatric conditions.

Improvement may be observed as early as the first 1–2 weeks and continue for up to 12 weeks. Patients should be reminded that although there has been some improvement during the initial weeks, that full benefit at a given dose may not be achieved until 4–8 weeks.

Treatment resistance should be addressed with either a medication change or augmented with buspirone, bupropion, stimulants and mirtazapine.

Treatment Maintenance or Discontinuation



The decision to continue, taper or discontinue treatment should be a joint decision with the member and should be derived from the member’s response to treatment, availability of family/social supports, a clear recovery and/or aftercare plan and consideration of the following:

o Due to the high incidence of relapse with Dysthymic Disorder, when medications are prescribed, follow up for at least 6 months before consideration of a medication taper is encouraged.

o Due to the persistence of symptoms in Dysthymic Disorder, if medications are prescribed, long-term treatment with medication is often advisable and in cases where a medication loses its effectiveness, a new regimen should be considered.

o It may be appropriate to incorporate maintenance treatment that includes periodic psychosocial sessions focused on relapse prevention in order to maintain a positive response to treatment.

o If prescribed, medication management and monitoring for possible relapse may no longer be required, or medications are stabilized well enough and the primary care physician has agreed to take over prescribing requirements.

o Discontinuation of treatment may be indicated with successful completion of treatment goals and when the member and provider agree that treatment goals have been met, and remaining recovery goals can be self-managed or managed with peer support.

o Discontinuation may be warranted when there is refusal of treatment or repeated failures to adhere with the recommended treatment despite the deployment of motivational enhancement interventions and other community support services.

o There is resolution or adequate reduction in clinical symptoms and behaviors that necessitated treatment as assessed by the provider.

o Demonstration of sufficient improvement, and the ability to function adequately without evidence of significant risk to self or others and without significant impairment in psychosocial functioning.

o The member should confirm that he/she understands and agrees with the plan including the risks of continuation or discontinuation of treatment.

In Some Situations United Behavioral Health May Offer:

Peer Review: United Behavioral Health will offer a peer review to the provider when services do not appear to conform with this guideline. The purpose of a peer review is to allow the provider the opportunity to share additional or new information about the case to assist the Peer Reviewer in making a determination including, when necessary, to clarify a diagnosis.



Second Opinion Evaluation: United Behavioral Health facilitates obtaining a second opinion evaluation when requested by an enrollee, provider, or when United Behavioral Health otherwise determines that a second opinion is necessary to make a determination, clarify a diagnosis or improve treatment planning and care for the enrollee.

Referral Assistance: United Behavioral Health provides assistance with accessing care when the provider and/or enrollee determine that there is not an appropriate match with the enrollee’s clinical needs and goals, or if additional providers should be involved in delivering treatment.

Covered Health Service(s) – UnitedHealthcare 2001

Those health services provided for the purpose of preventing, diagnosing or treating a sickness, injury, mental illness, substance abuse, or their symptoms. A Covered Health Service is a health care service or supply described in Section 1: What's Covered--Benefits as a Covered Health Service, which is not excluded under Section 2: What's Not Covered--Exclusions.

Covered Health Service(s) – UnitedHealthcare 2007 and 2009

Those health services, including services, supplies, or Pharmaceutical Products, which we determine to be all of the following:

Provided for the purpose of preventing, diagnosing or treating a Sickness, Injury, mental illness, substance abuse, or their symptoms.

Consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines as described below.

Not provided for the convenience of the Covered Person, Physician, facility or any other person.

Described in this Certificate of Coverage under Section 1: Covered Health Services and in the Schedule of Benefits.

Not otherwise excluded in this Certificate of Coverage under Section 2: Exclusions and Limitations.

In applying the above definition, "scientific evidence" and "prevailing medical standards" shall have the following meanings:

"Scientific evidence" means the results of controlled clinical trials or other studies published in peer-reviewed, medical literature generally recognized by the relevant medical specialty community.

"Prevailing medical standards and clinical guidelines" means nationally recognized professional standards of care including, but not limited to, national consensus statements, nationally recognized clinical guidelines, and national specialty society guidelines.

United Behavioral Health maintains clinical protocols for the treatment of Dysthymic Disorder that describe the scientific evidence, prevailing medical



standards and clinical guidelines supporting our determinations regarding specific services. These clinical protocols (as revised from time to time), are available to Covered Persons upon request, and to Physicians and other behavioral health care professionals on ubhonline.

COVERAGE LIMITATIONS AND EXCLUSIONS

Inconsistent or Inappropriate Services or Supplies – UnitedHealthcare 2001, 2007, 2009

Services or supplies for the diagnosis or treatment of Mental Illness that, in the reasonable judgment of United Behavioral Health, are any of the following:

Not consistent with generally accepted standards of medical practice for the treatment of such conditions.

Not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and are therefore considered experimental.

Not consistent with United Behavioral Health’s level of care guidelines or best practice guidelines as modified from time to time.

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 Dysthymic 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 the dysthymia, 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.

o The use of Psychoanalysis to treat Depression.

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 and other community resources.



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.

DEFINITIONS

Cognitive Behavioral Therapy (CBT) A classification of therapies that are predicated on the idea that behavior and feelings are caused by thoughts.

Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) A manual produced by the American Psychiatric Association which provides the diagnostic criteria for mental health and substance use disorders, and other problems that may be the focus of clinical attention. Unless otherwise noted, the current edition of the DSM applies.

Dysthymic Disorder According to the DSM, the essential feature of Dysthymic Disorder is the presence of a depressed mood for more days than not, for at least two years in adults and one year in children and adolescents. Accompanying symptoms may include poor appetite, overeating, insomnia, hypersomnia, low energy, fatigue, low self-esteem, poor concentration, difficulty making decisions and feelings of hopelessness. Children and adolescents may also present with irritable mood.

Interpersonal Therapy A brief and highly structured manual-based form of psychotherapy which focuses on understanding and improving the handling of interpersonal events such as disputes, role transitions and impoverished relationships that, if not addressed, may impact the development of mental illness.

Mental Illness Those mental health or psychiatric diagnostic categories that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded under the Policy.

Outpatient Treatment Outpatient treatment in indicated when the presenting symptoms support a diagnosis of Dysthymic Disorder. Outpatient treatment care consists of visits provided in an ambulatory setting for the purpose of assessing and treating a mental health condition.

REFERENCES

1. Generic UnitedHealthcare Certificate of Coverage, 2001





4. American Academy of Child and Adolescent Psychiatry, Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders, 2007, http://www.aacap.org/galleries/PracticeParameters/JAACAP%2005.pdf

5. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition, 2010, http://www.psych.org/guidelines/mdd2010

6. The Cochrane Library, Intervention Review: Pharmacotherapy for Dysthymic Disorder, 2009, http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004047.frame.html.

7. National Institute of Mental Health, Sequenced Treatment Alternatives to Relieve Depression, 2010, http://www.nimh.nih.gov/trials/practical/stard/stard-treatment-flowchart.pdf

CODING

The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this guideline are for reference purposes only. Listing of a service code in this guideline does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

Limited to specific CPT and HCPCS codes? x YES □ NO 90801-90815, 90845-90899 Outpatient

Limited to specific diagnosis codes? x YES □ NO 300.4 Dysthymic Disorder

Limited to place of service (POS)? x YES □ NO

Outpatient

Limited to specific provider type? □ YES x NO

Limited to specific revenue codes? □ YES x NO

HISTORY

Revision Date Name Revision Notes 03/23/11 L. Hernandez The enrollee's specific benefit documents supersede these guidelines and are used to make coverage determinations. These Coverage Determination Guidelines are believed to be current as of the date noted.

Documents

UBH Outpatient Treatment of Dysthymic Disorder.pdf