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Moda Health
Subject: Outpatient Treatment for
Medical Necessity Criteria
Posttraumatic Stress Disorder
Page 1 of 4
Origination Date: 02/10/09 Revision Date(s): 8/25/09, 4/20/10, 5/12, Developed By: Medical Criteria Committee 5/13, 5/14, 5/15 Approved:
Mary Engrav, MD
Date: 05/27/2015

Description: Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder triggered by a traumatic event in
which the person experienced, witnessed, or was exposed to the threat of serious injury or death to self or
others. Symptoms of PTSD include intense fear, helplessness or horror resulting in persistent sustained
arousal symptoms including sleep problems, hypervigilance, loss of concentration, irritability/anger, an
exaggerated startle response, and psychological and emotional reactivity or avoidance. Individuals may
also experience emotional numbing, dissociation and detachment from others, with a sense of a
foreshortened future. In children experiences of intense fear may also be expressed in dysregulated or
agitated behavior. It should be noted that exposure to trauma is insufficient to establish a diagnosis of
PTSD; appropriate diagnosis is made only when the patient also meets the symptom criteria established in
the current edition of the Diagnostic and Statistical Manual of Mental Disorders.
Assessment Notes:

 Assessment should include symptoms (specifically those that meet the DSM criteria for the diagnosis), trauma history, and prior treatment.  Individuals with PTSD often present with comorbid disorders, and should be assessed for the - Substance abuse or dependency - Major depressive disorder - Panic disorder/agoraphobia - Generalized anxiety disorder - Obsessive-Compulsive disorder - Social phobia - Bipolar disorder - Suicidality - Domestic Violence - Head trauma - Eating disorder Treatment Notes:
 Psychotherapy is considered the first line of treatment for PTSD, with pharmacological treatment added if symptoms are severe with SSRIs and SNRIs preferred for non-combat related PTSD and Adrenergic Agents (e.g.Prazosin) favored for other types of PTSD. Moda Health
Subject: Outpatient Treatment for
Medical Necessity Criteria
Posttraumatic Stress Disorder
Page 2 of 4
Origination Date: 02/10/09 Revision Date(s): 8/25/09, 4/20/10, 5/12, Developed By: Medical Criteria Committee 5/13, 5/14, 5/15  Cognitive-behavioral therapies, exposure therapy (imaginal and in vivo), anxiety and sleep management cognitive restructuring, and psychoeducation have been shown to be most effective in treating PTSD. Play therapy is effective with children.  Recent literature emphasizes the importance of focusing therapy on the facilitation of grief  Research has shown that EMDR (Eye Movement Desensitization and Reprocessing) may help with symptoms, but eye movements are not a necessary part of treatment. It is notable, however, that the research supports benefit of EMDR to other types of trauma, but does not generalize to combat veterans.

Information to be submitted with request:

1. Diagnosis and presenting symptoms 2. Relevant psycho-social and treatment history 3. Assessment of both substance abuse and mental health concerns 4. Measurable treatment goals 5. Scope and duration of planned treatment interventions 6. Response to treatment, including measurable change in symptom presentation, outcomes measures used, and results of outcomes measures 7. Medical conditions affecting treatment and coordination with medical providers
Criteria for Continued Treatment:
Continued authorization is indicated by ALL of the following:
1. The treatment plan establishes achievable recovery goals appropriate to the patient's symptoms, resources, and functioning. 2. Treatment is provided at the lowest level of intensity (including frequency and duration of outpatient sessions and duration of the treatment episode) necessary to maintain the patient's stability and achieve progress toward appropriate treatment goals. 3. The treatment plan includes a realistic plan for termination and promotes the patient's ability to independently manage symptoms and resolve problems.
Plus 1 or more of the following:
4. Continued measurable progress toward restoration of premorbid functioning as evidenced by
improvement in behavioral outcome measures. 5. Continued progress toward development of skills to prevent relapse. Moda Health
Subject: Outpatient Treatment for
Medical Necessity Criteria
Posttraumatic Stress Disorder
Page 3 of 4
Origination Date: 02/10/09 Revision Date(s): 8/25/09, 4/20/10, 5/12, Developed By: Medical Criteria Committee 5/13, 5/14, 5/15 6. Treatment plan revision to address lack of progress. If no improvement is noted, the treatment plan should be modified to include the consideration of a. Need for medication evaluation b. Need for psychosocial interventions (e.g., support groups) c. Possibility of co-occurring conditions that need attention (e.g., medical conditions, substance abuse, personality disorder) 7. If there is a clear risk of deterioration with no further treatment, appropriate maintenance treatment is covered. If continued treatment is intended primarily to prevent deterioration, and significant improvement in symptoms is not expected, treatment should be provided at the least intensive level required to prevent deterioration. If above criteria are met, the treatment plan should include a plan for terminating treatment.

Termination Criteria:

Termination of continued authorization is indicated by 1 or more of the following:
1. Patient has returned to premorbid functioning and has developed appropriate relapse prevention 2. Patient is not improving, despite amendments to the treatment plan (consider referral to another therapist or another form of treatment) 3. Patient has achieved a stable level of functioning and further treatment is not expected to produce significant improvement.
Review Date
Revisions
Effective Date
Annual Review: Added table with review date, revisions, and effective date. Minor wording changes. Annual Review. Clarification in Subject line. Moda Health
Subject: Outpatient Treatment for
Medical Necessity Criteria
Posttraumatic Stress Disorder
Page 4 of 4
Origination Date: 02/10/09 Revision Date(s): 8/25/09, 4/20/10, 5/12, Developed By: Medical Criteria Committee 5/13, 5/14, 5/15
References:

 American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revised (DSM-IV-TR). Washington, DC.  Chard, KM. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology. (73)5: 965-971.  Courtois, CA. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, and Policy. S(1): 86-100.  Feeny, NC, Foa, EB, Treadwell, KRH, March, J. (2004). Posttraumatic stress disorder in youth: A critical review of the cognitive and behavioral treatment outcome literature. Professional Psychology: Research and Practice. 35(5): 466-476.  National Center for Post-Traumatic Stress Disorder. Treatment of PTSD. U.S. Department of Veteran Affairs. Available at http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_treatmentfor ptsd.html. Accessed 1/02/09.  Resick, PA et al. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology. 70(4): 867-879.  The Expert Consensus Guideline Series: Treatment of Posttraumatic Stress Disorder. (1999). Foa, EB, Davidson, JRT, Frances, A. (Eds.). Journal of Clinical Psychiatry. 60(suppl 16).  David M.Benedek, Matthew J. Friedman, Douglas Zatzick, Robert J. Ursano: Guideline Watch (March 2009) : Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder, in American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders 2004.

Source: http://odscompany.biz/pdfs/med_criteria/PTSD.pdf