Download Other Specified and Unspecified Disorders

COVERAGE
DETERMINATION
GUIDELINE
OPTUM™
By United Behavioral Health
Other Specified and Unspecified Disorders
(Previously NOS Disorders)
Guideline Number: BHCDG662016
Product:
Approval Date: April, 2011
2001 Generic UnitedHealthcare COC/SPD
Revised Date: October, 2016
2007 Generic UnitedHealthcare COC/SPD
Table of Contents:
2009 Generic UnitedHealthcare COC/SPD
Instructions for Use
1
2011 Generic UnitedHealthcare COC/SPD
Key Points
2
Clinical Best Practice
5
May also be applicable to other health plans
and products
Benefits
3
Coverage Limitations and Exclusions
4
Definitions
7
References
8
Coding
9
Related Coverage Determination
Guidelines:
Related Medical Policies:
INSTRUCTIONS FOR USE
This Coverage Determination Guideline provides assistance in interpreting behavioral health
benefit plans that are managed by Optum. This Coverage Determination Guideline is also
applicable to behavioral health benefit plans managed by Optum or U.S. Behavioral Health Plan,
California.
When deciding coverage, the enrollee specific document must be referenced. The terms of an
enrollee’s document (e.g., Certificates of Coverage (COCs), Schedules of Benefits (SOBs), or
Summary Plan Descriptions (SPDs) may differ greatly from the standard benefit plans upon which
this guideline is based. In the event of a conflict, the enrollee's specific benefit document
supersedes these guidelines.
All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements
and the plan benefit coverage prior to use of this guideline. Other coverage determination
guidelines and clinical guideline may apply.
Optum reserves the right, in its sole discretion, to modify its coverage determination guidelines
and clinical guidelines as necessary. While this Coverage Determination Guideline does reflect
Optum’s understanding of current best practices in care, it does not constitute medical advice.
Other Specified and Unspecified Disorders
Coverage Determination Guideline
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Key Points

Effective and efficient treatment is facilitated by the clarity and accuracy of t he diagnosis. An
“Other Specified” or “Unspecified” diagnosis is used when a comprehensive evaluation and
further diagnostic specificity is not possible. Clinicians assign these diagnoses when there
are diagnostic features of a disorder within a diagnostic class but the presenting signs,
symptoms and features do not meet the full criteria for a specific disorder.

The “Other Specified Disorder” category allows the clinician to communicate the specific
reason that the presentation does not meet the criteria for any specific category within a
diagnostic class. This is done by recording the name of the category, followed by the specific
reason (Diagnostic and Statistical Manual of Mental Disorders, 5 th ed.; DSM-5; American
Psychiatric Association, p.15, 2013).
o

For example, a member has clinically significant depressive symptoms lasting 4
weeks but symptomotology falls short of the diagnostic threshold for a major
depressive episode, then the clinician would record “Other Specified Depressive
Disorder, depressive episode with insufficient symptoms (DSM-5, p. 15, 2013).”
The use of the “Unspecified Disorder” in the current edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association is excluded. It is given when
the clinician does not specify the reason that the criteria are not met within a diagnostic class.
(DSM-5, p. 16, 2013).
o
For example, in an emergency department setting, only the most prominent symptom
expressions associated with a particular category are identified (e.g., delusions,
hallucinations, mania, depression, anxiety, or substance intoxication) rather than
assigning the “Other Specified Disorder” (DSM-5, p. 20).

Benefits are available for covered services that are not otherwise limited or excluded.

Services should be consistent with evidence-based interventions and clinical best practices
as described in Part III, and should be of sufficient intensity to address the member's needs
(Certificate of Coverage, 2007, 2009 & 2011).
PART I: BENEFITS
Before using this guideline, please check enrollee’s specific plan document and
any federal or state mandates, if applicable.
Benefits
Benefits include the following services:

Diagnostic evaluation and assessment

Treatment planning

Referral services

Medication management

Individual, family, therapeutic group and provider-based case
management services
Other Specified and Unspecified Disorders
Coverage Determination Guideline
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
Crisis intervention
Covered Services
Covered Health Service(s) – 2001
Those health services provided for the purpose of preventing, diagnosing or
treating a sickness, injury, mental illness, substance abuse, or their
symptoms.
A Covered Health Service is a health care service or supply described in
Section 1: What's Covered--Benefits as a Covered Health Service, which is
not excluded under Section 2: What's Not Covered--Exclusions.
Covered Health Service(s) – 2007 and 2009
Those health services, including services, supplies, or Pharmaceutical
Products, which we determine to be all of the following:

Provided for the purpose of preventing, diagnosing or treating a
sickness, injury, mental illness, substance abuse, or their symptoms.

Consistent with nationally recognized scientific evidence as available,
and prevailing medical standards and clinical guidelines as described
below.

Not provided for the convenience of the Covered Person, Physician,
facility or any other person.

Described in the Certificate of Coverage under Section 1: Covered
Health Services and in the Schedule of Benefits.

Not otherwise excluded in this Certificate of Coverage under Section 2:
Exclusions and Limitations.
In applying the above definition, "scientific evidence" and "prevailing medical
standards" shall have the following meanings:

"Scientific evidence" means the results of controlled clinical trials or
other studies published in peer-reviewed, medical literature generally
recognized by the relevant medical specialty community.

"Prevailing medical standards and clinical guidelines" means nationally
recognized professional standards of care including, but not limited to,
national consensus statements, nationally recognized clinical
guidelines, and national specialty society guidelines.
Pre-Service Notification
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Notification of scheduled treatment must occur at least five (5) business days
before admission. Notification of unscheduled treatment (including Emergency
admissions) should occur as soon as is reasonably possible. In the event that the
Mental Health/Substance Use Disorder Designee is not notified of home-based
outpatient treatment, benefits may be reduced. Check the member’s specific
benefit plan document for the applicable penalty and allowance of a grace period
before applying a penalty for failure to provide notification as required.
Limitations and Exclusions
Unspecified Disorders in the current edition of the American Psychiatric
Association Diagnostic and Statistical Manual of Mental Disorders are
excluded.
The requested service or procedure for the treatment of a mental health condition
must be reviewed against the language in the enrollee's benefit document. When
the requested service or procedure is limited or excluded from the enrollee’s
benefit document, or is otherwise defined differently, it is the terms of the
enrollee's benefit document that prevails.
Inconsistent or Inappropriate Services or Supplies – 2001, 2007, 2009 &
2011
Services or supplies for the diagnosis or treatment of Mental Illness that, in
the reasonable judgment of the Mental Health/Substance Use Disorder
Designee, are any of the following:

Not consistent with generally accepted standards of medical practice for
the treatment of such conditions.

Not consistent with services backed by credible research soundly
demonstrating that the services or supplies will have a measurable and
beneficial health outcome, and are therefore considered experimental.

Not consistent with the Mental Health/Substance Use Disorder Designee’s
level of care guidelines or best practice guidelines as modified from time
to time.

Not clinically appropriate for the member’s Mental Illness or condition
based on generally accepted standards of medical practice and
benchmarks.
Additional Information
The lack of a specific exclusion that excludes coverage for a service does not
imply that the service is covered.
The following are examples of services that are inconsistent with the Level of
Care Guidelines and Best Practice Guidelines (not an all inclusive list):

Services that deviate from the indications for coverage summarized in this
document.
Other Specified and Unspecified Disorders
Coverage Determination Guideline
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Page 4 of 9

The use of “Other Specified” when the presenting signs, symptoms and
functional impairments demonstrate evidence to support the full criteria of
a DSM classified condition.

The use of an “Other Specified” diagnosis when a “provisional” diagnosis
is more appropriate.

Use of an “Other Specified” diagnosis when all general medical conditions
and substance induced conditions have not been ruled out.

Use of an “Other Specified” diagnosis when there has been sufficient
opportunity to gather data or clarify inconsistent or contradictory
information.
Please refer to the enrollee’s benefit document for ASO plans with benefit
language other than the generic benefit document language.
PART II: CLINICAL BEST PRACTICES
1. When establishing a diagnosis, consider the following:
1.1.
An “Other Specified” or “Unspecified” diagnosis is not the same as a
“provisional diagnosis.” A “provisional diagnosis “ (a.k.a. “working
diagnosis”) is given when there is limited information that prevents a
clinician from establishing a firm principal DSM diagnosis. A
“provisional diagnosis” is applied when:
1.1.1. There is a strong presumption that the full criteria of a DSM
classified disorder will ultimately be met, but not enough information
is available to make a firm diagnosis (i.e., a full history is needed to
establish if full criteria are met) (DSM-5, p. 23, 2013).
1.1.2. Differential diagnosis is dependent exclusively on the duration of
the illness (i.e., remission cannot be confirmed until 6 months has
lapsed) (DSM-5, p. 23, 2013).
1.2.
Carefully differentiate symptoms that support an “Other Specified” or
“Unspecified” diagnosis from those that:
1.2.1. Support a “provisional diagnosis”; or
1.2.2. Meet the full criteria for a specific disorder.
2. Further assessment should confirm whether the member’s symptoms
continue to warrant an “Other Specified” or “Unspecified” diagnosis (e.g.,
there, is uncertainty about whether the symptoms are substance induced or
due to a general medical condition, there is insufficient opportunity to
complete data collection, or there is inconsistent or contradictory information).
Coverage for an “Other Specified” may be indicated when:
2.1.
The member’s diagnosis meets the DSM definition of a “Other
Specified Disorder” or “Unspecified Disorder”;
Other Specified and Unspecified Disorders
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2.2.
The member’s diagnosis does not meet the full criteria for a specific
disorder;
2.3.
There will be further assessment to confirm whether the member’s
symptoms continue to warrant an “Other Specified” diagnosis due to:
2.3.1. Uncertainty about whether the symptoms are substance induced or
due to a general medical condition,
2.3.2. Insufficient opportunity to complete data collection, or
2.3.3. Inconsistent or contradictory information.
2.4.
Coverage for “Other Specified” may be reviewed against the Coverage
Determination Guideline of the specific condition that coincides with
the “Other Specified” (e.g., Major Depressive Disorder will be used to
review a diagnosis of “Other Specified Depressive Disorder”).
2.5.
When treating an “Other Specified” or “Unspecified” disorder, consider
using evidence-based practices which are recommended for the
specific condition which is most like the “Other Specified” or
“Unspecified” disorder.
PART III: ADDITIONAL RESOURCES
Clinical Protocols
Optum maintains clinical protocols that include the Level of Care Guidelines and
Best Practice Guidelines which describe the scientific evidence, prevailing
medical standards and clinical guidelines supporting our determinations
regarding treatment. These clinical protocols are available to Covered Persons
upon request, and to Physicians and other behavioral health care professionals
on ubhonline
Peer Review
Optum will offer a peer review to the provider when services do not appear to
conform to this guideline. The purpose of a peer review is to allow the provider
the opportunity to share additional or new information about the case to assist
the Peer Reviewer in making a determination including, when necessary, to
clarify a diagnosis
Second Opinion Evaluations
Optum facilitates obtaining a second opinion evaluation when requested by an
enrollee, provider, or when Optum otherwise determines that a second opinion is
necessary to make a determination, clarify a diagnosis or improve treatment
planning and care for the member.
Referral Assistance
Other Specified and Unspecified Disorders
Coverage Determination Guideline
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Optum provides assistance with accessing care when the provider and/or
enrollee determine that there is not an appropriate match with the enrollee’s
clinical needs and goals, or if additional providers should be involved in delivering
treatment.
PART IV: DEFINITIONS
Diagnostic and Statistical Manual of the American Psychiatric Association
(DSM) A manual produced by the American Psychiatric Association which
provides the diagnostic criteria for mental health and substance use disorders,
and other problems that may be the focus of clinical attention. Unless otherwise
noted, the current edition of the DSM applies.
Mental Illness Those mental health or psychiatric diagnostic categories that are
listed in the current Diagnostic and Statistical Manual of the American Psychiatric
Association, unless those services are specifically excluded under the Policy.
Other Specified Disorder The “Other Specified Disorder” category allows the
clinician to communicate the specific reason that the presentation does not meet
the criteria for any specific category within a diagnostic class. This is done by
recording the name of the category, followed by the specific reason
Provisional Diagnosis A provisional diagnosis (a.k.a. a “working diagnosis”) is
given when there is limited information that precludes a firm principal DSM
diagnosis.
Unspecified Disorder The “Unspecified Disorder” is given when the clinician
cannot specify the reason that the criteria are not met within a diagnostic class
until there is sufficient evidence to do so based on the member’s clinical
presentation. When the clinician determines that there is evidence to specify the
nature of the clinical presentation, the “Other Specified Diagnosis” or a specific
disorder diagnosis can be given.
PART V: REFERENCES
1. American Psychiatric Association: Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric
Association, 2013.
2. Generic UnitedHealthcare Certificate of Coverage, 2001
3. Generic UnitedHealthcare Certificate of Coverage, 2007
4. Generic UnitedHealthcare Certificate of Coverage, 2009
5. Generic UnitedHealthcare Certificate of Coverage, 2011
PART VI: CODING
The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this guideline are
for reference purposes only. Listing of a service code in this guideline does not imply that the
service described by this code is a covered or non-covered health service. Coverage is
determined by the benefit document.
Other Specified and Unspecified Disorders
Coverage Determination Guideline
Confidential and Proprietary, © Optum 2016
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Limited to specific CPT and HCPCS codes?
DSM-5 Codes
300.9
314.01
296.89
□ YES x
NO
ICD-10 Codes
F41.8
F90.8
F31.89
Applicable Diagnoses
Other Specified Anxiety Disorder
Other Specified ADHD
Other Specified Bipolar and
Related Disorder
311
F32.8*
Other Specified Depressive
F32.89
Disorder
312.89
F91.8
Other Specified Disruptive,
Impulse-Control, and Conduct
Disorder
300.15
F44.89
Other Specified Dissociative
Disorder
307.59
F50.8*
Other Specified Feeding or
F50.89
Eating Disorder
300.9
F99
Other Specified Mental Disorder
300.3
F42*
Other Specified ObsessiveF42.8
Compulsive Disorder
298.8
F28
Other Specified Schizophrenia
Spectrum and other Psychotic
Disorder
309.89
F43.8
Other Specified Trauma and
Stressor-Related Disorder
292.89
F19.121; F19.221; F19.921 Other Specified Substance
Intoxication (mild, moderate,
severe)
292.81
F19.10; F19.20; F19.20
Other Specified Substance Use
Disorder (mild, moderate,
severe)
292.0
F19.239
Other Specified Withdrawal
*Original codes and new codes will both be listed in document for a 90-day period. After this
period has passed, the original codes will be removed.
Limited to place of service (POS)?
□
YES
x NO
Limited to specific provider type?
x
YES
□
Limited to specific revenue codes?
□
YES
x NO
NO
PART VII: HISTORY
Revision Date
10/12
Name
L. Urban
Revision Notes
Version 1-Final
Other Specified and Unspecified Disorders
Coverage Determination Guideline
Confidential and Proprietary, © Optum 2016
Optum is a brand used by United Behav ioral Health and its affiliates
Page 8 of 9
10/13
10/14
10/2015
5/2016
10/2016
L. Urban
L. Urban
L. Urban
L. Urban
L. Urban
Version 3-Final
Version 3-Final
Version 4-Final
Version 5-Final
Version 5-Final Revised
The enrollee's specific benefit documents supersede these guidelines and are used to make coverage determinations.
These Coverage Determination Guidelines are believed to be current as of the date noted.
Other Specified and Unspecified Disorders
Coverage Determination Guideline
Confidential and Proprietary, © Optum 2016
Optum is a brand used by United Behav ioral Health and its affiliates
Page 9 of 9