*** This policy was implemented in the absence of National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) coverage criteria. This policy applies to all Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + MedicareSM (HMO-POS D-SNP), Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services. ***

Description of Procedure

Intensive Outpatient Programs (IOP) provide time-limited, multidisciplinary, multimodal structured treatment in an outpatient setting. IOP is intended to provide treatment on an outpatient basis, and does not include boarding/housing and is intended to provide treatment interventions in a structured setting, with patients returning to their home environments or community-based-setting outside of program hours, intensive outpatient programs do not include treatment in a locked unit or restricted access setting.

Programming consists of evidence-based, psychosocial interventions and education for substance use, mental health and eating disorder diagnoses.

Policy Statement

Coverage will be provided for an Intensive Outpatient Program when it is determined to be medically necessary when the medical criteria and guidelines shown below are met.

Benefit Application

Please refer to the member’s individual Evidence of Coverage (EOC) for benefit determination. Coverage will be approved according to the EOC limitations if the criteria are met.

Coverage decisions will be made in accordance with:

• The Centers for Medicare & Medicaid Services (CMS) national coverage decisions;
• General coverage guidelines included in original Medicare manuals unless superseded by operational policy letters or regulations; and
• Written coverage decisions of local Medicare carriers and intermediaries with jurisdiction for claims in the geographic area in which services are covered.

Benefit payments are subject to contractual obligations of the Plan. If there is a conflict between the general policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular Evidence of Coverage (E.O.C.), the E.O.C. always governs the determination of benefits.

Indications for Coverage

1. Must be under the care of a physician who certifies the need for intensive outpatient services,
2. Must have a need for a minimum of 9 (nine) hours per week of services as evidence in a plan of care,
3. Members must also require comprehensive, structured, multimodal treatment requiring medical supervision and coordination, provided under an individualized plan of care, because of a mental disorder (including SUD) which severely interferes with multiple areas of daily life, including social, vocational, and/or educational functioning,
   A, Services must include Multimodal active treatment described by:
   • Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, mental health counselors, marriage and family therapists, clinical nurse specialists, certified alcohol and drug counselors);
   • Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if required, must be a component of the physician’s treatment plan for the individual;
   • Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients (including patients with SUD). These include principal illness navigation services provided by auxiliary staff, including peer support specialists;
   • Drugs and biologicals that cannot be self-administered and are furnished for therapeutic purposes (subject to limitations specified in 42 CFR 410.29);
   • Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the patient’s diagnosed condition and for progress toward treatment goals;
   • Family counseling services for which the primary purpose is the treatment of the patient’s condition. These include counseling services for caregivers;
   • Patient training and education, to the extent the training and educational activities are closely and clearly related to the individual’s care and treatment of his/her diagnosed psychiatric condition. These services include caregiver training services furnished for the benefit of the patient; and
   • Medically necessary diagnostic services related to mental health treatment (including SUD).
4. IOP patients must be able to cognitively and emotionally participate in the active treatment process and be capable of tolerating the intensity of an IOP program.

**See special notes section for additional information regarding medical necessity requirements

When Coverage Wil Not be Approved

The following services are non covered and non-appealable by the provider as they are excluded from coverage:

• Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care;
• Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; or
• Patients who are otherwise psychiatrically stable or require medication management only.
• Services to hospital inpatients;
• Meals, self-administered medications, transportation; and
• Vocational training.

The following services are appealable when reasonable and necessary denial is applied:

• Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of an IOP; or
• Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization.

Billing/ Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in the section does not guarantee reimbursement.

Applicable codes: 90832, 90834, 90837, 90845, 90846, 90847, 90853, 90880, 96112, 96116, 96130, 96132, 96136, 96138, G0410, G0411, 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90880, 90899, 96112, 96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96161, 96164, 96167, 96202, 96203, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 97550, 97551, 97552, G0023, G0024, G0129, G0140, G0146, G0176, G177, G0140, G0411, G0451

The Plan may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Providers should include a comprehensive substance use or mental health history in the members bio-psychosocial assessment. The provider is required to coordinate care with the member’s primary care provider (PCP) to address all medical issues. The provider and patient will develop an individualized treatment plan, which will include:

• Problems
• Needs
• Strengths
• Skills
• Priority formulation
• An outline of short-term, measurable treatment goals and activities designed to achieve those goals

Treatment plans must include individualized, time-measurable outcomes as well as toxicology testing as part of the initial assessment and monitoring process as indicated in the assessment.

Special Notes

Members admitted to an IOP do not require 24-hour per day supervision as provided in an inpatient setting, must have an adequate support system to sustain/maintain themselves outside the IOP, and must not be an imminent danger to themselves or others.

Patients admitted to an IOP generally have an acute onset or decompensation of a covered Axis I mental disorder

There are no specific limits on the length of time that services may be covered. As long as the evidence shows that the patient continues to show improvement in accordance with his/her individualized treatment plan and the frequency of services is within accepted norms of medical practice, coverage may be continued.

If a patient reaches a point in his/her treatment where further improvement does not appear to be indicated, evaluate the case in terms of the criteria to determine whether with continued treatment there is a reasonable expectation of improvement.

Adults and adolescents with psychiatric symptoms will receive nine to 19 hours per week of structured programming through psychiatric IOP when their psychiatric symptoms are no longer severe enough to be considered a danger to themselves or others and when they no longer need 24-hour nursing supervision.

Adults with a substance use disorder will receive nine to 19 hours per week of structured programming.

References

1. Medicare Benefit Policy Manual Chapter 6 – Hospital Services Covered Under Part B, Section 70.4:Intensive Outpatient Services; Effective 12/21/2023 via Medicare Benefit Policy Manual accessed on 08/18/2025
2. CMS MLN Billing Requirements for Intensive Outpatient Program Services with New Condition Code 92 effective date 1/1/2024 MM13496 - Billing Requirements for Intensive Outpatient Program Services with New Condition Code 92 accessed on 08/18/2025
3. Blue Cross NC Corporate Policy: Psychiatric Intensive Outpatient Programs, effective date 03/2024 via Psychiatric Intensive Outpatient Programs | Providers | Blue Cross NC accessed on 08/18/2025

Policy Implementation/Update Information

Creation Date: August 21, 2025, Newly created policy for MA Behavioral Health

Approval Dates

Medical Coverage Policy Committee: August 21, 2025

Physician Advisory Group Committee:

Quality Improvement Committee:

Policy Owner: Amy Russo, LPN
Medical Policy Coordinator