Gen Anxiety Disorder Outpatient

COVERAGE
OPTUM DETERMINATION
By United Behavioral Health
GUIDELINE
Outpatient Treatment of Generalized Anxiety

Disorder
Guideline Number: BHCDG492012 Product:
Approval Date: January, 2011 2001 Generic UnitedHealthcare COC/SPD
Revised Date: August, 2012 2007 Generic UnitedHealthcare COC/SPD
Table of Contents: 2009 Generic UnitedHealthcare COC/SPD
Instructions for Use 1 2011 Generic UnitedHealthcare COC/SPD
Plan Document Language 2 May also be applicable to other health plans
and products
Indications for Coverage 2
Related Medical Policies:
Coverage Limitations and Exclusions 10
Level of Care Guidelines
Definitions 11
American Academy of Child and Adolescent
References 11
Psychiatry, Practice Parameter for the
Coding 12 Treatment of Children and Adolescents with
Anxiety Disorders, 2007
Canadian Psychiatric Association, Clinical
Practice Guideline for the Management of
Anxiety Disorders, 2006
National Institute for Health and Clinical
Excellence, Management of Anxiety in Adults
in Primary Secondary and Community Care,
2007
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
enrollees 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
Optums understanding of current best practices in care, it does not constitute medical advice.
Outpatient Treatment of Generalized Anxiety Disorder Page 1 of 13
Coverage Determination Guideline

Confidential and Proprietary, Optum 2012
Oputm is a brand used by United Behavioral Health and its affiliates
PLAN DOCUMENT LANGUAGE
Before using this guideline, please check enrollees specific plan document and
any federal or state mandates, if applicable
INDICATIONS FOR COVERAGE
Key Points
According to the DSM, the essential feature of Generalized Anxiety Disorder (GAD) is
excessive anxiety and worry occurring more days than not in a number of activities or
settings for at least 6 months. Excessive anxiety has significantly impaired the members
functioning in a number of areas of the members life (Diagnostic and Statistical Manual,
Fourth Edition (DSM-IV-TR), 2000).
Outpatient treatment is indicated when the presenting symptoms support a diagnosis of GAD.
The goals of outpatient treatment are to control the presenting symptoms, monitor and
manage response to treatment including medication management, and to assist the member
and the family/support network with maintaining treatment gains. Factors that may preclude
the need for outpatient care include the following:
o The member is at imminent risk of harm to self or others and would be more
safely treated in a more intensive level of care (Optum Level of Care Guidelines
(LOCGs), 2012).
o The members psychological, social, occupational or other area of functioning is
impaired or is deteriorating and cannot be managed in a traditional outpatient
setting (DSM-IV-TR, 2000).
o A co-occurring behavioral health or medical condition complicates treatment to
the extent that a more intensive level of care is indicated (LOCGs, 2012).
Optum maintains that outpatient treatment of GAD should be consistent with nationally
recognized scientific evidence as available, and prevailing medical standards and clinical
guidelines (Certificate of Coverage (COC), 2007, 2009 & 2011).
Best Practices for the treatment of GAD outlined in this guideline address:
o Assessment and Diagnosis
o Treatment Planning
o Psychotherapy
o Pharmacotherapy
o Maintenance and Follow-Up
The requested Outpatient Treatment 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 outpatient service or procedure is limited
or excluded from the enrollees benefit document, or is otherwise defined
differently, it is the terms of the enrollee's benefit document that prevails.
Benefits include the following services provided in an outpatient treatment
setting:
Diagnostic evaluations and assessment

Treatment planning
Referral services
Medication management
Individual, family, therapeutic group and provider-based case
management services
Crisis intervention
Best Practices for the treatment of GAD in an Outpatient Treatment setting:
Assessment and Diagnosis
The assessment should include an inquiry as to:
o The focus of anxiety (e.g., finances, marriage, children, health, job)
o Persistence and intensity of anxiety.
o Associated symptoms that may include (International
Psychopharmacology Algorithm Project (IPAP), 2006):
Depression and suicidality
Restlessness (e.g., keyed up or on edge)
Insomnia, sleep disturbance or fatigue
Difficulty concentrating (e.g. mind going blank)
Irritability
Somatic symptoms
Pain
Substance use
o Treatment history and response
o Family history
o Social and cultural factors
Assessment scales may be considered for use as tools in identifying the
presence and severity of anxiety symptoms. These may include
(Canadian Psychiatric Association (CPA, 2006):
o The Adult Manifest Anxiety Scale (AMAS),
o The Anxiety Disorders Interview IV (ADIS-IV for children and
adults)
o Beck Anxiety Inventory (for adults and adolescents)
o Endler Multidimensional Anxiety Scales

o The Multidimensional Anxiety Questionnaire (for children and
adults)
o State-Trait Anxiety Inventory (15 years and older)
o The Generalized Anxiety Disorder 7 question screening (GAD-7)
o Measuring response to therapy may be considered periodically
using the Hamilton Anxiety Rating Scale (HARS) clinician-rated
tool. Once the members score is <7 and the member no longer
meets DSM criteria for GAD, the member has likely achieved
remission.
As part of evaluating comorbidity and completing differential diagnosis, the
assessment should determine whether the anxiety is (American Academy
of Child and Adolescent Psychiatry (AACAP), 2007):
o Confined to a GAD Axis I diagnosis, unrelated to another disorder
(e.g., social anxiety, adjustment disorder, PTSD)
o Causing significant impairment in psychological, social,
occupational or other important areas of functioning.
o Due to the direct physiological effects of a substance, medical
condition, and does not occur during a mood disorder, psychotic
disorder or a pervasive developmental disorder.
o Overlapping with or better described as Panic Disorder, Social
Phobia, Obsessive Compulsive Disorder, Anorexia Nervosa,
Somatization Disorder, Posttraumatic Stress Disorder,
Hypochondriasis, Major Depressive Disorder, Attention-
Deficit/Hyperactivity Disorder, Separation Anxiety and Bipolar
Disorder.
o If identified, comorbid conditions should be addressed in the
treatment plan. (DSM list Differential Diagnosis)
Treatment Planning
The provider and the member should document clear, reasonable and
objective treatment and recovery goals that stem from the patients
diagnosis, address the patients symptoms, and take into account the
members preferences (LOCGs, 2012).
The treatment plan should include objectives, actions and timeframes to
include (LOCGs, 2012):
o Monitoring the members motivation and readiness to change as
well as the members strengths and other psychosocial resilience
factors such as the members family/support network.

o Developing an advance directive, a recovery plan, and a plan for
managing relapse.
o A plan to achieve symptom reduction and rapid stabilization will be
achieved.
o A plan to manage existing co-occurring behavioral health and
medical conditions.
o A plan as to how the member will manage his/her condition
including the use of psycho-education, peer support services and
community resources.
o A plan to assess changes in the members GAD or co-occurring
conditions and update the treatment plan in response to changes in
the members condition.
o Developing a relapse prevention plan.
The provider should contact the members family and/or social support
network, with the members documented consent to regularly participate in
the members treatment planning when such participation is essential and
clinically appropriate (LOCGs, 2012).
o Parents/guardians of child and adolescent members should be
contacted and should participate in the members treatment unless
clinically contraindicated. Optimally, the members family and/or
social support group should participate in treatment when the
member is a child or adolescent (AACAP, 2007).
The provider should contact the members outside providers and primary
care practitioner, with the members documented consent, if the member
was in treatment prior to admission to obtain information about the
members presenting condition and its treatment (LOCGs, 2012).
The provider and the member should collaborate to update the treatment
plan as changes are observed (LOCGs, 2012)
Pharmacotherapy
Pharmacotherapies used to treat GAD include SSRIs, SNRIs, TCAs,
anticonvulsants, benzodiazepines, buspirone, atypical antipsychotics and
hypnotics (IPAP, 2006).
Considerations when choosing the most appropriate agent include
(National Institute for Health and Clinical Excellence (NICE), 2007):
o Age of the member
o Previous treatment response
o Risk of overdose or misuse

o Tolerability
o Interactions and side effects
First-line treatments include escitalopram, paroxetine, sertraline, or
venlafaxine xr (CPA, 2006).
Antidepressants are also first line treatments and effective in treating
ruminative worry and accompanying depressive symptoms (IPAP, 2006).
If response to therapy with a first line agent is inadequate, dosing should
be optimized and compliance assessed before switching or augmenting
(CPA, 2006).
Reassessment of suicidality, comorbidity, insomnia, substance abuse and
treatment adherence should occur when there is partial or no response
and when any change in medication occurs (IPAP, 2006).
o If there is no response after 8-12 weeks, or if the member is unable
to tolerate a first line agent, another first line agent should be
substituted before considering a second line agent.
o If an SSRI was chosen as a first line agent, a switch to a second
SSRI or SNRI should occur prior to choosing a second line agent.
Second-line treatments include benzodiazepines (alprazolam, lorazepam
and diazepam), bupropion xl, buspirone and imipramine (CPA, 2006).
o Although benzodiazepines are considered a second line treatment,
they can be used at anytime on a short-term basis if agitation or
anxiety is severe however, monitoring for possible misuse,
especially with the elderly is necessary.
Treatment resistant individuals should be assessed for comorbid medical
and psychiatric conditions that may be affecting response to therapy
(CPA, 2006).
o In these individuals, third-line treatments such as olanzapine,
risperidone, hydroxyzine, mirtazapine, and trazodone are
adjunctive options for the treatment of GAD if no comorbidities are
present.
o For members prescribed olanzapine and risperidone, metabolic
syndrome is a risk and should be monitored.
Psychotherapy
Cognitive Behavioral Therapy (CBT) or Exposure Therapy alone, or in
combination are typically recommended as first-line psychotherapies for
GAD, and are shown to be more effective than non-specific therapies
(IPAP, 2006).
o Consider interventions that target features of the condition such as:

Intolerance of uncertainty and imperfection;
Symptoms such as restlessness, irritability or difficulties with
concentration;
Poor problem-solving approaches; and/or
Maladaptive thoughts and beliefs such as the belief that
worry is a useful way to deal with problems.
There is no evidence to show that combined therapy is more effective than
monotherapy however, when either pharmacotherapy or psychotherapy is
used alone and not producing improvement, combined therapy should be
useful (IPAP, 2006).
The provider should educate the member and family/support network
about GAD, its treatment, and self-management.
Maintenance and Follow-Up
For members receiving CBT, response to therapy should be evaluated on
an ongoing basis (NICE, 2007).
If referrals are made to other providers, regular and effective
communication and management should continue between providers to
include primary care (NICE, 2007).
Efficacy and side effects of medications should be reviewed within 2
weeks of starting treatment, then again at 4, 6, and 12 weeks (NICE,
2007).
o At the end of 12 weeks, efficacy and progress should be assessed
and alternative interventions explored.
o If pharmacotherapy is going to progress beyond 12 weeks, the
member should be assessed every 8-12 weeks.
o Pharmacotherapy should be continued as long as necessary as
long as there are no detrimental side effects or misuse.
o It is recommended that GAD be treated with pharmacotherapy for at
least 1 year after a good response is achieved.
o If pharmacotherapy is discontinued, it should be tapered gradually
(10%-20% per week) and psychotherapy may be useful during this
time.
Treatment Discontinuation
Documentation of on-going discharge planning (beginning at the initiation
of treatment) should include the following elements (LOCGs, 2012):
o Criteria for discharge

o Identification of barriers to completion of treatment and
interventions to address those barriers
o Identification of support systems
o Development of a relapse prevention plan
Factors to assess when considering termination include (LOCGs, 2012):
o Level of risk that symptoms will worsen
o Frequency and severity of past episodes
o Presence of symptoms of co-occurring disorders
o Member preference
Treatment goals have been successfully completed, and remaining
recovery goals can be self-managed or managed with peer support. An
appropriate termination plan has been developed which includes referral
to appropriate and necessary peer support and other community
resources as required, as well as instructions for resuming services should
the need arise in the future (LOCGs, 2012).
The member refuses further treatment or repeatedly does not adhere with
recommended treatment despite the deployment of motivational
enhancement interventions, peer support and other community support
services. In such cases, the provider explains to the member and to the
family/social supports as appropriate, the risks of discontinuing treatment.
The member should be offered alternative referrals and instructions for
resuming services should the need arise in the future (LOCGs, 2012).
The members condition has responded to pharmacotherapy, and the
members primary care provider has agreed to take over medication
management (LOCGs, 2012).
Treatment is otherwise no longer necessary (LOCGs, 2012).
A discharge summary is to be completed at the end of the treatment
episode that includes the following elements (LOCGs, 2012):
o Reason for treatment episode
o Summary of the treatment goals that were achieved
o Specific follow up activities/aftercare plan
o Aftercare plan that addresses safety, risk and crisis planning
State and federal mandates supersede the generic Certificate of Coverage
and compliance with applicable legislation is required.
The outpatient treatment of GAD must be reviewed against the language in the
enrollee's benefit document. When the outpatient treatment of GAD is limited or

excluded from the enrollees benefit document, or is otherwise defined differently,
it is the terms of the enrollee's benefit document that prevails.
In Some Situations Optum May Offer:
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 Evaluation: Optum facilitates obtaining a second opinion
evaluation when requested by an enrollee, provider, or when United
Behavioral Health otherwise determines that a second opinion is necessary to
make a determination, clarify a diagnosis or improve treatment planning and
care for the enrollee.
Referral Assistance: Optum provides assistance with accessing care when
the provider and/or enrollee determine that there is not an appropriate match
with the enrollees clinical needs and goals, or if additional providers should
be involved in delivering treatment.
Covered Health Service(s) UnitedHealthcare 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) UnitedHealthcare 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 this 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.
The Mental Health/Substance Use Disorders Designee 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. These clinical protocols (as revised
from time to time), are available to Covered Persons upon request, and to
Physicians and other behavioral health care professionals on ubhonline.
COVERAGE LIMITATIONS AND EXCLUSIONS
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 Optum, 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 Optums level of care guidelines or best practice
guidelines as modified from time to time.
Not clinically appropriate for the members 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 the
previous section such as:
o A mis-match between the presenting symptoms, and the type
and/or duration of treatment.

o A treatment plan that has not been modified when there has been
partial or no response to an adequate trial of treatment.
The use of psychological or neuropsychological testing when a diagnostic
or treatment planning question can be answered by means of a standard
interview and behavior rating scale assessment.
The member is at imminent risk of harm to self or others and would be
more safely treated in a more intensive level of care.
Services arent coordinated when more than one practitioner is delivering
treatment.
The treatment plan that doesnt address co-occurring behavioral health
and medical conditions including substance disorders.
Services continue even though treatment goals have been completed.
Services continue despite repeated failures to adhere with recommended
treatment despite the deployment of motivational enhancement
interventions, peer support and other community resources.
Please refer to the enrollees benefit document for ASO plans with benefit
language other than the standard benefit document language.
DEFINITIONS
Cognitive Behavioral Therapy (CBT) A classification of therapies that are
predicated on the idea that behavior and feelings are caused by thoughts.
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-related
disorders, and other problems that may be the focus of clinical attention. Unless
otherwise noted, the current edition of the DSM applies.
Generalized Anxiety Disorder Generalized anxiety disorder is characterized by
chronic feelings of excessive worry and anxiety that have been present for at
least 6 months and have impaired functioning in several areas of an individuals
life. These feelings are often accompanied by physical complaints such as
elevated blood pressure, increased heart rate, and muscle tension, sweating,
and shaking.
Mental Health/Substance Use Disorder Designee The organization or
individual, designated by Optum, that provides or arranges Mental Health
Services and Substance Use Disorder Services for which Benefits are available
under the policy.
Outpatient Treatment Outpatient care consists of visits provided in an
ambulatory setting for the purpose of assessing and treating a mental health
condition.

Standardized Behavioral Rating Scales A standardized tool used as part of an
assessment to collect and evaluate information about symptoms, behaviors, and
functioning.
REFERENCES
1. Generic UnitedHealthcare Certificate of Coverage, 2001
5. Level of Care Guidelines, 2012
6. Psychological and Neuropsychological Testing Guidelines, 2012
7. American Academy of Child and Adolescent Psychiatry, Practice Parameter
for the Treatment of Anxiety Disorders, 2007.
http://www.aacap.org/galleries/PracticeParameters/JAACAP_Anxiety_2007.p
df
8. Canadian Psychiatric Association, Clinical Practice Guideline for the
Management of Anxiety Disorders, 2006. http://ww1.cpa-
apc.org/Publications/CJP/supplements/july2006/anxiety_guidelines_2006.pdf
9. International Psychopharmacology Algorithm Project, Generalized Anxiety
Disorder Algorithm, 2006. http://www.ipap.org/
10. National Institute for Health and Clinical Excellence, Management of Anxiety
in Adults in Primary Secondary and Community Care, 2007.
http://www.nice.org.uk/CG22
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.
Limited to specific CPT and HCPCS codes?
x YES NO
90801-90815, 90845-90899 Outpatient
Limited to specific diagnosis codes?

x YES NO
300.02 Generalized Anxiety Disorder
Limited to place of service (POS)?

x YES NO
Outpatient
Limited to specific provider type?

YES x NO

Limited to specific revenue codes?
x YES NO
HISTORY
Revision Date Name Revision Notes

10/22/12 L. Urban Version 2-Final
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.


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COVERAGE

Outpatient Treatment of Generalized Anxiety

INSTRUCTIONS FOR USE

Coverage Determination Guideline

The requested Outpatient Treatment service or procedure for the treatment of a

Coverage Determination Guideline

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