Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 486. Medical necessity determinations for mental health rehabilitation services

7 AAC 43.486. Medical necessity determinations for mental health rehabilitation services

(a) The division will, in its discretion, periodically review the recipient's clinical record to determine whether the services requested are medically necessary. A medically necessary mental health rehabilitation service is a service designed to

(1) screen recipients for the presence of a mental or emotional disorder;

(2) assess the nature and extent of the mental or emotional disorder and its impact upon the recipient's ability to meet the demands of daily living, social, occupational, or educational functioning;

(3) diagnose the mental or emotional disorder;

(4) treat the mental or emotional disorder;

(5) provide rehabilitation for the mental or emotional disorder;

(6) prevent the relapse or deterioration of the recipient's condition due to the mental or emotional disorder.

(b) In making its determination as to whether the proposed services are medically necessary, the division will consider the following:

(1) the recommendations of the referring physician, mental health professional clinician, or interdisciplinary team organized under 7 AAC 43.470 that prescribed, ordered, recommended, or approved the service;

(2) the recipient's diagnosis and level of functioning;

(3) the risk of danger from the recipient to self or other individuals;

(4) the appropriateness of the level of care and the need for inpatient or residential care;

(5) whether the intervention targets specific symptoms and behavioral and social dysfunction, and logically derives from the assessments and diagnosis;

(6) whether the proposed services in the individualized treatment plan are consistent with generally accepted community-based treatments and practices for the treatment of the specific symptoms and behavioral and social dysfunction;

(7) whether the recipient agrees with the referring physician, mental health professional clinician, or interdisciplinary team under (1) of this subsection that the focus of the treatment will be the symptoms and behavioral and social dysfunction targeted for intervention;

(8) the extent to which past and current treatment has been successful in treating the symptoms and behavioral and social dysfunction;

(9) if the recipient is under 21 years of age, whether the recipient has, as indicated by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition, dated 1994, an Axis V Global Assessment of Functioning (GAF) rating at admission of 50 or less, or the recipient has an Axis V Global Assessment of Functioning (GAF) rating at admission of more than 50, but exhibits specific mental, behavioral, or emotional disorders that place the recipient at imminent risk for out-of-home supervision or protective custody of state or local authorities; the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition, dated 1994, is adopted by reference;

(10) the extent to which a less restrictive or intrusive alternative treatment is not available;

(11) the extent to which a less expensive alternative is not available;

(12) the extent to which the units of service requested are no more than are necessary to meet the treatment or rehabilitation needs of the recipient;

(13) the extent to which the duration of services requested are no more than are necessary to reach the recipient-approved goals outlined in the individualized treatment plan;

(14) if the requested services are intended to prevent the relapse or deterioration of a mental disorder, the extent to which social functioning is improved through interventions provided as active treatment, targeted in specific therapeutic goals, and included in the individualized treatment plan;

(15) the likelihood that the recipient will benefit from any therapy provided on the same day as the recipient has received crisis intervention services.

(c) Payment for services determined not to be medically necessary under this section is subject to recovery under 7 AAC 43.081.

History: Eff. 11/1/2000, Register 156

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.040

Editor's note: The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, dated 1994 and adopted by reference in 7 AAC 43.486, may be obtained by writing to the American Psychiatric Association, 1400 K Street, N.W., Washington, D.C. 20005. This manual is also available for inspection at the Department of Health and Social Services, Division of Medical Assistance, 350 Main Street, Suite 412, Juneau, Alaska or 4501 Business Park Boulevard, Anchorage, Alaska.