AACP Newsletter, Volume 12,
Number 4, Autumn 1998
Medical Necessity Criteria:
Appropriate Concepts for Behavioral Health
What follows are some guidelines originally sent to the Iowa Department of Human Services (DHS). It presents more of a framework for thinking about the approach toward "medical necessity" than it does a working definition and should be considered as a draft or starting point. One of the problems that DHS had with the Iowa RFP is that they wanted a definition that could be applied to mental illness, substance abuse, and child welfare. This made it difficult to come up with a definition that was generalizable to all groups but still meaningful to each. The following concepts attempt to approach a solution.
Biopsychosocial Criteria for the Assessment of Necessity for Treatment/Intervention by a Behavioral Health Entity
- Assessment of the Presenting Problem.
Crisis or non-crisis? If crisis, apply the strategy for crisis intervention (similar to procedure used for involuntary admission).- Emergent Care for remediation of dangerousness to self
or others.
- Is a mental illness present (or suspected)?
- As a consequence of the mental illness, is the person
a danger to themselves or others?
- Assessment of immediate risk to harm self
- Assessment of immediate risk to harm others
- Assessment of immediate risk of being harmed by others
(by other persons or by being unable to protect oneself
from potentially dangerous environmental conditions,
e.g., an abused child, an intoxicated adult, or a
psychotic adult)
- Assessment of immediate risk to harm self
- Is this condition amenable to treatment or intervention?
- If so, what type of treatment or intervention is most
likely to be effective (i.e., type of treatment, level
of care intensity)?
- If so, what type of treatment or intervention is most
likely to be effective (i.e., type of treatment, level
of care intensity)?
- Is a mental illness present (or suspected)?
- Emergent Care for remediation of dangerousness to self
or others.
- Assessment of Necessity of Intervention
Focus should be away from the assessment of the symptoms present and directed toward functional status. The classic "medical model" should not be thrown out; it needs to be expanded in order to appreciate that not all problems are the result of a disease and not all treatment requires a medical intervention.The biopsychosocial model should be applied, that is, evaluate the situation from its biologic, psychological, and social perspectives. Assess whether or not an intervention is necessary and likely to be helpful. Focus on functional status (i.e., quality of life, life situation) of the individual rather than the symptoms that are present.
Biologic perspective (disease): Is a DSM IV condition present? What are the observable signs and reportable symptoms that support the belief that a psychiatric illness is present? What treatment is most likely to resolve or alleviate the disease and restore the individual to the functional status that they had prior to the onset of their illness (or to the acute exacerbation of their existing illness)? What is likely to help in the short run (crisis intervention)? In the long run (resolution of underlying problem or prevention of acute crisis)? Examples of conditions likely to have a strong biologic component: schizophrenia, bipolar disorder, depression, panic disorder, obsessive-compulsive disorder.
Psychological perspective (person): What developmental traumas, neglect, or disturbed relationships exist now, or were present in the past and have contributed to the individual's present state? What learned maladaptive thoughts and behaviors does the individual demonstrate? What type of treatment can assist this individual to adapt to or function in their present chosen social environment? What is likely to help in the short run (crisis intervention)? In the long run (resolution of underlying problem or prevention of acute crisis)? Examples of conditions likely to have a strong psychological component: borderline personality disorder, PTSD, many behavioral problems of children.
Social perspective (social situation): What environmental disturbances and dislocations (e.g., family crises, economic misfortunes) are present that make it difficult for this person to thrive in their present environment? What intervention (directed at the environment, not the person) will alleviate this situation? What is likely to help in the short run (crisis intervention)? In the long run (resolution of underlying problem or prevention of acute crisis)? Examples of conditions likely to have a strong social component: many child welfare issues and persons on chemical dependency.
In short,
- What is the disease?
- What is the intrinsic ability of the person (and
their caretakers) to cope with the problem?
- Is this problem likely to be resolved while the
person remains in their present environment?
- What is the disease?
- Assessment of appropriate intervention (type of treatment and intensity of service).
Specific guidelines for type of treatment and level of care or assignment should be developed for mental illness/health, substance abuse, and child welfare. A task force of persons with professional expertise in each of those areas could be assigned this task and each should consist of persons with medical (e.g., a psychiatrist), psychological (e.g., psychologist or nurse) and social (e.g., social worker, school teacher, or rehab counselor) perspectives. Instruments such as LOCUS and CALOCUS, developed by our organization, will address issues related to intensity of services needed, but additional guidelines will be required to answer questions related to what types of treatment are required.
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