Changes to Behavioral Medical Necessity, Feedback Wanted

Each year, Cigna adopts industry guidelines to assist contracted health care professionals (HCPs) and Cigna staff in care planning and decision-making. Updates to Medical Necessity Criteria are considered at least every two years based on changes in literature, research, and evidence-based community practices. Although service authorization requests are always considered on a case-by-case basis and include an assessment of the availability of services in the local delivery system, HCPs in Cigna's treatment network are encouraged to consider these guidelines as a community standard in care planning.

During the fourth quarter of 2014, Cigna's Quality Committee is adopting the following changes to Medical Necessity Criteria for use in 2015:

• Revised title to: "Cigna Standards and Guidelines / Medical Necessity Criteria for Treatment of Behavioral Health and Substance Use Disorders."
• Added the heading, "Standards and Guidelines" to each of the introductory sections, in an effort to emphasize that these sections are not simply descriptive, but rather a significant part of the entire document.
• Clearly labeled the "Basic Elements of Medical Necessity."
• Added a section on "Exclusions" to the four Residential Treatment sections, based on language developed by American Academy of Child and Adolescent Psychiatry, to separate non-medical programs from behavioral health residential treatment programs.
• Included statements from Association for Ambulatory Behavioral Healthcare in the four Partial Hospital Program sections that specifically describe and define a Partial Hospital Programs and its major functions:
  • Included language in the Admission Criteria for Partial Hospital Programs and Intensive Outpatient Programs that better differentiate and define the indications and purposes of each of these levels of care.
  • Added language in the Partial Hospital Program and Intensive Outpatient Program Standards and Admission Criteria to clarify that these are ambulatory programs without 24-hour supervision, except as age-appropriate for children and adolescents.
  • The Eating Disorder Criteria specifies that these levels of care may be indicated when there is a diagnosis of Anorexia Nervosa, Bulimia Nervosa, or Other Specified Eating Disorder.
  • Revised language for consistency with Parity legislation.
• Enlarged and updated our list of References.

The proposed 2015 revision to Cigna's Medical Necessity Criteria has been added to our website for your review and feedback. We encourage you to download the current version, and to review the 2015 revision. A feedback mechanism is located near the guidelines, so that input can be captured from psychiatrists, therapists and facilities. You can also email locgfeedback@cignabehavioral.com. Both versions are posted at CignaforHCP.com > Resources > Behavioral Resources > Medical Necessity Criteria.