Alliance Approved Clinical Practice Guidelines

Clinical Practice Guidelines have been developed nationally by a variety of expert sources including the American Psychiatric Association (APA), American Academy of Child and Adolescent Psychiatry (AACAP), American Society of Addiction Medicine (ASAM), Substance Abuse and Mental Health Services Administration (SAMHSA) and other national and international societies, government/VA/DoD, and other care delivery systems such as Magellan and Managed Care organizations (MCOs).

When national guidelines are unavailable, work groups comprised of Alliance staff, providers and consultants who are experts in their fields have developed clinical guidelines. All of these guidelines have been reviewed and adopted by the Alliance Clinical Advisory Committee to assist providers and individuals alike in the clinical decision making process for a variety of mental health and substance use disorders with the goal of improved patient management and enhanced quality of care. As a result of this explosion of knowledge, concerns about the quality of care, access and cost and to determine “appropriate” or “reimbursable” care, it is necessary to describe the range of treatments available for patients with Mental Illness, Behavioral Disorders and/or Substance Use Disorders.

Clinical Practice Guidelines clearly and concisely document what is known and what is not known about a condition or disorder for the treatment of patients with the ultimate goal of improving care. These guidelines reflect evidence based treatment, but are not intended to be service definitions, or medical necessity criteria, though they may overlap. Additionally, guidelines should enhance individualized care, sound clinical practice and good judgment. Guidelines also do not supersede federal and/or state regulations. Alliance will continue to review, revise and update its approved clinical practice guidelines. Your comments and suggestions are welcome.

DisorderDiagnosisGuideline
Attention Deficit Hyperactivity Disorder in Children and Adolescents314.00-314.9AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention Deficit/Hyperactivity Disorder
Autism Spectrum Disorder299Practice Parameter for the Assessment and Treatment of Children and Adolescents With Autism Spectrum Disorder
Benzodiazepines Prescribing GuidelinesBenzodiazepines Prescribing Guidelines
Bipolar Disorder in Children and Adolescents296.00-296.06
2966.40-296.89
AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder
Bipolar Disorder in Adults 296.00-296.06
296.40-296.89
APA Practice Guideline for the Treatment of Patients with Bipolar Disorder

2005 Guideline Watch-Practice Guideline For The Treatment of Patients With Bipolar Disorder, 2nd Edition

VA/DoD Clinical Practice Guidelines for the Management of Bipolar Disorder
Dementia290.0-290.43294.1APA Practice Guideline for the Treatment of Patients with Alzheimers and other Dementia Disorders

2014 Guideline Watch-Alzheimers Disease and other Dementias

APA Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia
Generalized Anxiety Disorder
in Children and Adolescents
300.02AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders
Generalized Anxiety Disorder in Adults300.02Clinical Practice Guidelines for the Treatment of Generalized Anxiety Disorder
Major Depressive Disorder in Adults296.20-296.36APA Practice Guideline For the Treatment of Patients with Major Depressive Disorder
Major Depressive Disorder in Children296.20-296.36AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders
Obsessive-Compulsive Disorders
in Children and Adolescents
300.3AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders

AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorders in Adults300.3APA Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder

Guideline Watch (March 2013): Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
Opioid Treatment for Adults304.00, 305.50ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use

CDC Guideline for Prescribing Opioids for Chronic Pain

Prescribing Resources
Oppositional Defiant Disorder313.81AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents with Oppositional Defiant Disorder
Panic Disorder
in Children and Adolescents
300.01, 300.21AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders
Panic Disorder in Adults300.01, 300.21Practice Guideline for the Treatment of Patients with Panic Disorder
Post-Traumatic Stress Disorder
in Children and Adolescents
309.81, 308.3AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents with Post-Traumatic Stress Disorder
Post-Traumatic Stress Disorder in Adults309.81, 308.3APA Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post-Traumatic Stress Disorder

APA Guideline Watch (March 2009): APA Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post-Traumatic Stress Disorder

VA/DoD Clinical Practice Guidelines for Management of Post-Traumatic Stress
Schizophrenia in Adults295.10-295.9
298.9, 297.1
APA Practice Guideline for the Treatment of Patients with Schizophrenia

APA Guideline Watch (September 2009): Practice Guideline for the Treatment of Patients With Schitzophrenia
Schizophrenia in Children and Adolescents295.10-295.9
298.9, 297.1
AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents with Schizophrenia
Sexualized Behavior in AdolescentsClinical Practice Guideline for Intervention with Adolescents with Sexualized Behavior Problems
Substance Use Disorders
in Children and Adolescents
291.0-292.9
303.00-305.90
AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders
Substance Use Disorders in Adults291.0-292.9
303.00-305.90
APA Practice Guideline for the Treatment of Patients with Substance Use Disorders

Guideline Watch (April 2007): Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd Edition

Guidelines and Information

Psychological Testing

Psychological testing involves the use of formal procedures using reliable and valid instruments to measure the areas of intellectual, cognitive, adaptive, emotional and behavioral functioning along with personality styles, interpersonal skills and psychopathology. Prior to administering a battery of tests, it is important for the evaluator to gather (or review) updated clinical information. Relevant clinical information should be considered from the Comprehensive Clinical Assessment and/or most recent medical, psychiatric, and/or educational evaluations. The evaluator should consider historical clinical information, identify specific questions to be addressed by the evaluation, and determine that the clinical questions cannot be addressed through a diagnostic interview with a skilled clinician.

The evaluator should inquire about and review any prior psycho-educational, psychological, developmental and neuropsychological testing that may have been administered and request copies for review prior to conducting a new battery. If prior testing cannot be reviewed, the provider should document their attempts to access the information and offer an explanation pertaining to the clear medical necessity for a new assessment. Attempts should be made to determine when tests were previously administered to ensure that test exposure is not a factor in the outcome of the evaluation.

The evaluator should take note on the dates of administration and whether questions presented for testing have been addressed in a prior evaluation. The evaluator should be conscious of factors that may interfere with the validity of outcomes including recent exposure to a standardized test, active substance use/abuse, vision or hearing impairments, health and/or medication related concerns. Testing related to the treatment of pain or as a component of a pre-surgical evaluation may be considered medically necessary if consistent with the expectations per policy.

It is expected that the request for testing will include information regarding prior screening and assessment, prior intervention for the given diagnosis, an explanation pertaining to why the clinical evaluation was inconclusive, and a statement regarding the need for psychological testing to clarify the diagnosis. Tests must be standardized and validated measures recognized by the scientific and professional community as a national standard for professional practice. Practitioners administering psychological batteries should practice within their scope and be credentialed in a manner consistent with the expectations of the North Carolina Psychology Board.

Developmental Testing

Developmental testing involves the use of standardized and validated measures to explore developmental concerns for individuals who may have been identified through the use of screening tools. Tests included in a developmental battery focus on cognitive, language, motor, and socio-emotional development. The findings of these evaluations can assist in identifying children who may have developmental delays and developing targeted intervention plans to support them in making gains. The evaluator should be conscious of factors that may interfere with the validity of outcomes including: recent exposure to a standardized test, vision or hearing impairments, health and/or other related concerns.

Prior to administering a battery of tests, it is important for the evaluator to gather (or review) relevant information. Relevant clinical information should be considered from the Comprehensive Clinical Assessment and/or most recent medical, psychiatric, and/or educational evaluations. The evaluator should consider historical clinical information, identify specific questions to be addressed by the evaluation, and determine that the clinical questions cannot be addressed through a diagnostic interview with a skilled clinician.

The evaluator should inquire about and review any prior psycho-educational, psychological, developmental, and neuropsychological testing that may have been administered and request copies for review prior to conducting a new battery. If prior testing cannot be reviewed, the provider should document their attempts to access the information and offer an explanation pertaining to the clear medical necessity for a new assessment.  Attempts should be made to determine when tests were previously administered to ensure that test exposure is not a factor in the outcome of the evaluation. The evaluator should take note on the dates of administration and whether questions presented for testing have been addressed in a prior evaluation.

It is expected that the request for testing will include information regarding prior screening and assessment, any prior intervention, an explanation pertaining to why the clinical evaluation was inconclusive, and a statement regarding the need for developmental testing to clarify the diagnosis. Tests must be standardized and validated measures recognized by the scientific and professional community as a national standard for professional practice. Practitioners administering psychological tests (within developmental batteries) should practice within their scope and be credentialed in a manner consistent with the expectations of the North Carolina Psychology Board.

Neuropsychological Testing

Neuropsychological testing involves the use of formal procedures using reliable and valid instruments to detect the existence of brain damage, dysfunction, injury, and/or functional deficits associated with the deterioration of brain function related to a condition or medical disease process. Prior to administering a battery of tests, it is important for the evaluator to gather (or review) updated clinical information. Relevant clinical information should be considered from the Comprehensive Clinical Assessment and/or most recent medical, psychiatric and/or educational evaluations. The evaluator should consider historical clinical information, identify specific questions to be addressed by the evaluation, and determine that the clinical questions cannot be addressed through a diagnostic interview with a skilled clinician.

The evaluator should inquire about and review any prior psycho-educational, psychological, developmental and neuropsychological testing that may have been administered and request copies for review prior to conducting a new battery. If prior testing cannot be reviewed, the provider should document their attempts to access the information and offer an explanation pertaining to the clear medical necessity for a new assessment. Attempts should be made to determine when tests were previously administered to ensure that test exposure is not a factor in the outcome of the evaluation. The evaluator should take note on the dates of administration and whether questions presented for testing have been addressed in a prior evaluation.

Testing related to the treatment of pain or as a component of a pre-surgical evaluation may be considered medically necessary if consistent with the expectations per policy. Prior to a neuropsychological evaluation, a clinical evaluation should have been completed and found to be inconclusive. Physicians may refer patients with suspected or known cognitive deficits for neuropsychological testing to quantify their cognitive and behavioral capabilities. Common measures used in neuropsychological batteries include tests of cognitive, attention, language, motor, achievement, and personality.

Neuropsychological tests are used to clarify the patient’s diagnosis in instances where the patient presents with atypical symptoms, a behavioral health condition or a medical condition. The tests are also used to establish a baseline of neurocognitive functioning, monitor changes from baseline in functioning, and to assist with treatment, placement, and/or discharge planning. Neuropsychological testing may be considered medically necessary for patients diagnosed with ADHD when medical screenings (including the use of screening tools used by an MD) support further assessment of specific neurocognitive behavioral deficits.

The evaluator should be conscious of factors that may interfere with the validity of outcomes including: recent exposure to a standardized test, active substance use/abuse, vision or hearing impairments, and health and/or medication related concerns. It is expected that the request for testing will include information regarding prior medical screening and assessment, prior intervention for the given diagnosis, an explanation pertaining to why the clinical evaluation was inconclusive, and a statement regarding the need for neuropsychological testing to clarify the diagnosis. Tests must be standardized and validated measures recognized by the scientific and professional community as a national standard for professional practice. Practitioners administering neuropsychological batteries should practice within their scope and be credentialed in a matter consistent with the expectations of the North Carolina Psychology Board.

Psychological, Developmental and Neuropsychological Testing Requests

Please note that the number of units approved for testing is based on the average amount of time needed to administer, score, and interpret test results per developer guidelines. Providers should be prepared to provide Alliance with the following information when requesting psychological, developmental and/or neuropsychological testing:

  • The reason testing is medically necessary (e.g. differential diagnosis, atypical symptomatology, prior/current mental health treatment is ineffective). Information should be provided to explain why a clinical evaluation was inconclusive and why testing is needed to clarify the diagnosis.
  • Clinical information relevant to the referral for testing and source of referral.
  • The specific names of the standardized, validated tests planned for the evaluation (Clinical Coverage Policy 8 C).
  • Information regarding prior mental health treatment and other interventions.
  • Information pertaining to prior testing/evaluation (tests, dates, results).
  • Justification for the medical necessity of further testing if prior testing has been completed.

Medical Necessity

Medical necessity for testing may be met in the following cases:

  • Best practice clinical intervention has not been effective.
  • Differential diagnosis is indicated to develop a more effective treatment plan.
  • The individual has a medical or neurological condition and has been referred by a physician for further assessment after being evaluated by the MD.
  • An individual presents with concerns regarding possible Intellectual/Developmental Disability and testing is needed for specialized services (Innovations).
  • Testing related to the treatment of pain or as a component of a pre-surgical evaluation may be considered medically necessary if consistent with the expectations per policy.
Psychological, developmental and neuropsychological testing requests will not meet medical necessity if:
  • Service is not considered consistent with generally accepted standards of practice or supported by credible research demonstrating the service will have a measurable and beneficial health outcome for the enrollee.
  • Tests are not standardized, valid measures nationally recognized by licensed practitioners in the field.
  • Requests are for educational placement/services (e.g., IEP), career/vocational, sports, camp, marriage, adoption, or insurance purposes.
  • Requests are for judicial or legal proceedings such as Guardianship (Clerk of the Court and/or the NC Division of Aging and Adult Services) or parental competency (Department of Social Services (DSS) and/or the court system).
  • The evaluation is for Disability as these evaluations are adjudicated through North Carolina Disability Determination Services (DDS)
  • The enrollee has not had a diagnostic evaluation by a licensed mental health practitioner.
  • The enrollee presents with symptoms of ADHD and has not had a thorough evaluation by a psychiatrist or prior screening using questionnaires or rating scales.  Requests for testing for ADHD should include an explanation of the reason the initial evaluation (e.g., by a licensed mental health practitioner and/or physician) was insufficient.
  • Testing for the primary purpose of titrating medications.
  • Routine/periodic testing without clinical justification will not meet medical necessity.  Exemption: It is noted that children/adolescents with I/DD diagnoses will need updated testing every 3 years to determine I/DD eligibility, and adults entering waiver services must have evaluations within the past 5 years.
  • The enrollee is actively abusing substances, in acute withdrawal, or recently entered recovery as the testing results may not be valid.
  • If mental health symptoms are causing significant impairment (e.g., enrollee is actively psychotic, manic, aggressive, etc.) such that the testing results may not be valid.
  • Testing has been previously completed and there is no clinical justification for further testing (e.g., TBI, medical condition, developmental changes, or other factors that render the previous evaluation inaccurate).
  • There is no indication based on Clinical Coverage Policy/Service Definition that testing is required to access the covered service.

Psychological Testing vs. Neuropsychological Testing

Providers requesting neuropsychological testing/evaluations should provide statements explaining why neuropsychological testing is necessary for the purpose of exploring questions related to the enrollee’s diagnosis and for treatment recommendations.  Neuropsychological testing is considered medically necessary for the assessment of cognitive impairment due to medical or psychiatric conditions. Psychological testing should be summarized in a report reflecting psychological testing has been completed (“Psychological Evaluation”).  Neuropsychological testing should be summarized in a report reflecting neuropsychological testing has been completed (“Neuropsychological Evaluation”). Neuropsychological testing should not be requested when the clinical questions can be addressed through a psychological evaluation.

References

North Carolina Psychology Practice Act: http://www.ncpsychologyboard.org/Office/PDFiles/PRACACT.pdf
Clinical Coverage Policy 8C: https://ncdma.s3.amazonaws.com/s3fs-public/documents/files/8C.pdf



Page last modified: July 6, 2017