UC2004 Просмотр технического описания (PDF) - Unspecified

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UC2004

Behavioral Health Benefits for Blue Cross PLUS

Unspecified 

§ Services performed in connection with conditions not classified in the current edition of the Diagnostic and

Statistical Manual of Mental Health Disorders (DSM).

§ Prescription drugs or over the counter drugs and treatments. (Refer to your medical plan to determine whether

prescription drugs are a covered benefit.)

§ Services or supplies for MHSA Treatment that, in the reasonable judgment of UBH are any of the following:

§ not consistent with the symptoms and signs of diagnosis and treatment of the behavioral disorder,

psychological injury or substance abuse;

§ not consistent with prevailing national standards of clinical practice for the treatment of such conditions;

§ not consistent with prevailing professional research demonstrating that the service or supplies will have a

measurable and beneficial health outcome;

§ typically do not result in outcomes demonstrably better than other available treatment alternative that are less

intensive or more cost effective; or

§ not consistent with UBH's Level of Care Guidelines or best practices as modified from time to time.

UBH may consult with professional clinical consultants, peer review committees or other appropriate sources for

recommendations and information.

§ Treatment or services, except for the initial diagnoses, for a primary diagnoses of Mental Retardation

(317,318,319), Learning, Motor Skills, and Communication Disorders (315), Pervasive Developmental Disorder

(299), Conduct Disorder (312), Dementia (290, 294), Sexual, Paraphilia, and Gender Identity Disorders (302), and

Personality Disorders (301), as well as other mental illnesses that will not substantially improve beyond the

current level of functioning, or that are not subject to modification or management according to prevailing national

standards of clinical practice, as reasonably determined by UBH.

§ Unproven, Investigational or Experimental Services. Services, supplies, or treatments that are considered

unproven, investigational, or experimental because they do not meet generally accepted stands of medical practice

in the United States. The fact that a service, treatment, or device is the only available treatment for a particular

condition will not result in it being a Covered Service if the service, treatment, or device is considered to be

unproven, investigational, or experimental.

§ Custodial Care except for the acute stabilization of the Covered Person and returning the Covered Person back to

his or her baseline levels of individual functioning. Care is determined to be custodial when:

§ it provides a protected, controlled environment for the primary purpose of protective detention and/or

providing services necessary to assure the Covered Person's competent functioning in activities of daily

living; or

§ it is not expected that the care provided or psychiatric treatment alone will reduce the disorder, injury or

impairment to the extent necessary for the Covered Person to function outside a structured environment. This

applies to Covered Persons for whom there is little expectation of improvement in spite of any and all

treatment attempts.

Covered Persons whose repeated and volitional non-compliance with treatment recommendations result in a situation

in which there can be no reasonable expectation of a successful outcome.

§ Neuropsychological testing when used for the diagnosis of attention deficit disorder.

§ Examinations or treatment, unless it otherwise qualifies as Behavioral Health Services, when:

§ required solely for purposes of career, education, sports or camp, travel, employment, insurance or adoption;

§ ordered by a court except as required by law;

§ conducted for purposes of medical research; or

§ required to obtain or maintain a license of any type.

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