Minnesota Administrative Rules
Agency 151 - Labor and Industry Department
Chapter 5221 - FEES FOR MEDICAL SERVICES
Part 5221.6700 - POST-TRAUMATIC STRESS DISORDER
Universal Citation: MN Rules 5221.6700
Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1. Scope.
A. Pursuant to Minnesota
Statutes, section
176.83. subdivision 5.
paragraph (b). clause (8). this part establishes standards and procedures for
treatment of patients with a compensable mental impairment of post-traumatic
stress disorder (PTSD) as defined in Minnesota Statutes, section
176.011.
subdivision 15. paragraph (d). This part does not affect any determination of
liability for an injury under Minnesota Statutes, chapter 176. and does not
expand or restrict a health care providers scope of practice.
B. This part applies to all outpatient
treatment provided for PTSD after the effective date of this part, regardless
of the date of injury.
C. This part
does not apply to treatment of an injury after a payer has denied primary
liability for the injury. However, if primary liability is later accepted or
determined, this part does apply to treatment initiated after primary liability
has been established.
D. References
to days and weeks in this part means calendar days and weeks unless otherwise
specified.
E. Parts
5221.6050. subparts 1, item C: 2:
4: 5: 6. items A and C: and 1. items A and P. and 5221.8900 apply to the
treatment standards established in this part. The departures listed in part
5221.6050. subpart 8. do not apply
to this part.
Subp. 2. Definitions.
A. The definitions
in this subpart apply to this part.
(1)
"Condition" means the symptoms, physical signs, clinical findings, and
functional status that characterize the patients complaint, illness, or injury
related to a current claim for compensation.
(2) "Contraindication" means a condition that
makes the use of a particular psychological treatment or medication inadvisable
because of an increased risk of harm to the patient including the risk of
self-harm by the patient.
(3)
"Evidence-based" means a practice that integrates research validated by
peer-reviewed scientific literature with clinical expertise in the context of
patient characteristics, culture, and preferences.
(4) "Functional status" means the ability of
an individual to engage in activities of daily living or other social
recreational, and vocational activities.
(5) "Mental health care provider" means a
currently licensed health care provider who has experience treating patients
with PTSD and whose practice primarily involves mental health
treatment.
(6) "Modality" means the
application or use of a therapeutic agent or regimen.
(7) "Narrative exposure therapy" means a
treatment for trauma disorders in which a patient establishes a coherent
chronological narrative of the patients life story, with a focus on the
patients traumatic experiences.
(8)
"Trauma-focused psychotherapy" means a therapy that uses cognitive, emotional
and behavioral techniques to process a traumatic experience and in which the
trauma focus is a central component of the therapeutic process.
B. Unless otherwise defined in
this subpart, the definitions of the psychotherapy treatment modalities in
subpart 5 are as provided in Appendix A - Description of Treatments and
Strength of Recommendations - of the American Psychological Associations
Clinical Practice Guideline for the Treatment of Postraumatic Stress Disorder
in Adults, which is incorporated by reference in subpart 12.
Subp. 3. Diagnosis and initial evaluation.
A. The diagnosis of
PTSD must be made by a licensed psychologist or psychiatrist according to the
most recently published edition of the Diagnostic and Statistical Manual of
Mental Disorders by the American Psychiatric Association, as required by
Minnesota Statutes, section
176.011.
subdivision 15. paragraph (d). As of the effective date of this part, the most
current edition is the fifth edition (DSM-5). which is incorporated by
reference in subpart 12.
B. A
mental health care provider must complete an initial evaluation that includes a
determination of:
(1) the patients functional
status:
(2) the patients relevant
family history:
(3) the patients
history of mental health conditions and treatment if any:
(4) whether there is an acute risk that the
patient will harm self or others, and any potential need for
hospitalization:
(5) whether the
patient has any comorbid physical or psychiatric disorders, including substance
and other addictions, previous untreated or unresolved trauma, personality
disorder, depression, anxiety, serious mood disorder, and psychosis:
(6) whether the patient would benefit from
psychotherapy treatment under subpart 5. after considering any
contraindications: and
(7) any
appropriate referrals for treatment for any risks or comorbid physical or
psychiatric disorders identified under subitems (4) and (5). psychotherapy
treatment under subpart 5. and treatment with medication under subpart
9.
Subp. 4. Treatment plan.
A. Prior to
providing psychotherapy treatment under subpart 5. a mental health care
provider must:
(1) engage and collaborate
with the patient to establish a plan for treatment that does the following:
(a) specifies the treatment modality or
modalities described in subpart 5. item A. that will be provided:
(b) determines if treatment will be conducted
using telemedicine. which requires patient agreement:
(c) assesses the patients current level of
symptoms and functional status:
(d)
develops a specific set of goals for the treatment based on the patients
functional status:
(e) establishes
a timetable for achieving the treatment goals within the prescribed number of
psychotherapy sessions:
(f)
prescribes the duration and frequency of treatment subject to subparts 5, 6,
and 8:
(g) addresses the patients
plan for return to work, including any restrictions necessary for the patients
initial return to work, in compliance with parts
5221.0410 and
5221.0420. The mental health care
provider establishing the treatment plan may collaborate with the patients
other treating health care providers to address planning a return to work:
and
(h) provides for any necessary
referrals that were not made under subpart 3, item B, subitem (7);
(2) provide education about PTSD
and its treatment: and
(3) provide
any motivational interviewing needed to prepare the patient for trauma-focused
psychotherapy.
B. The
assessment described in item A. subitem (1). unit (c), must be conducted using
a tool validated in peer-reviewed scientific literature for the assessment of
PTSD symptoms and functional status. When available, assessment tools must be
based on the most recently published edition of the Diagnostic and Statistical
Manual of Mental Disorders by the American Psychiatric Association. Examples of
acceptable assessment tools for the DSM-5 are the PTSD Symptom Scale -
Interview for DSM-5 (PSS-I-5), the PTSD Scale - Self Report for DSM-5 (PS-SR5),
the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and the PTSD
Checklist for DSM-5 (PCL-5).
C. The
assessment required by item A. subitem (1). unit (c), provides the baseline for
determining the progress of the treatment as described in subpart 5. item
C.
D. If the mental health care
provider establishing the treatment plan in item A is not the same provider who
completed the initial evaluation in subpart 3. item B. the provider must review
and consider that initial evaluation before establishing a treatment plan under
this subpart.
Subp. 5. Psychotherapy treatment.
A. The
following trauma-focused psychotherapy treatment modalities are indicated for
the treatment of PTSD singularly, concurrently, or simultaneously:
(1) cognitive behavioral therapy
(CBT);
(2) cognitive processing
therapy (CPT);
(3) cognitive
therapy (CT);
(4) prolonged
exposure therapy (PE):
(5) brief
eclectic psychotherapy (BEP):
(6)
eye-movement desensitization and reprocessing (EMDR)
(7) narrative exposure therapy (NET):
and
(8) any other treatment
modality recommended by the treating mental health care provider that is an
evidenced-based. trauma-focused psychotherapy treatment modality, subject to
the requirements of subpart 7.
B. All psychotherapy treatment modalities
under item A must be provided by a mental health care provider who is trained
to treat PTSD with the modality or modalities they are using to treat the
patient. The provider must retain documentation of the training. Treatment for
PTSD under item A is not indicated more than two times per week, except to
provide emergency treatment as defined in part
5221.6040. subpart 5.
C. At least once every two weeks while a
patient is receiving psychotherapy treatment under this subpart, the
psychotherapy provider must:
(1) evaluate the
severity of the patients PTSD symptoms and changes in the patients functional
status using an assessment tool described in subpart 4. item B. and the
providers clinical observations of the patient:
(2) review:
(a) the treatment plan, including goals:
and
(b) the patients adherence to
the plan:
(3) make any
necessary adjustments to the treatment plan: and
(4) complete and submit to the patient a
report of work ability. Part
5221.0410. subpart 6. items B. C.
and P. apply to the providers completion of the report of work ability. The
provider completing the report may collaborate with the patients other
treatment health care providers regarding the patients return to
work.
Subp. 6. Duration of psychotherapy treatment.
A. A period of psychotherapy treatment begins
with the first time a modality is initiated under this part, and ends 16 weeks
later. Additional modalities added during the 16 weeks do not extend a period
of psychotherapy treatment. Subject to the requirements of this part, there is
no limit to the number of periods of psychotherapy treatment a patient may
receive.
B. An additional period of
treatment is indicated only if the provider determines the patient continues to
meet the criteria for PTSD described in the most recently published edition of
the Diagnostic and Statistical Manual of Mental Disorders, and the requirements
of items C to E are satisfied.
C. A
complete psychological assessment is indicated for a patient who does not
complete a period of psychotherapy treatment and continues to meet the criteria
for PTSD. or who continues to meet the criteria for PTSD after the conclusion
of a period of treatment. This assessment is not necessary if a complete
psychological assessment has already been completed within the previous year,
or if one or more of the indications for an additional period of treatment
described in item E apply.
D. The
psychological assessment required by item C must include the use of objective
testing such as the most current version of the Minnesota Multiphasic
Personality Inventory. The goal of the assessment is to determine if the
patient has any new or unresolved comorbid psychological conditions that are
preventing the successful treatment of PTSD. If identified, these comorbidities
must be addressed or treated prior to the patient resuming psychotherapy
treatment for PTSD or. if appropriate, addressed or treated concurrently with
an additional period of treatment for PTSD.
E. An additional period of psychotherapy
treatment is indicated in the following circumstances, without the need for a
complete psychological assessment:
(1) the
patients treatment has been interrupted or delayed because of a need for
treatment of a different medical or psychological condition, including
treatment of comorbidities:
(2)
previous treatment for PTSD did not meet the accepted standard of
practice:
(3) there is
documentation in the medical record or other report, pursuant to subpart 10. of
all of the following during the current period of treatment:
(a) the patient has adhered to the treatment
plan, as described in subpart 4:
(b) a decrease in the patients PTSD
symptoms:
(c) improvement in the
patients functional status: and
(d)
further decrease in the patients PTSD symptoms and continued improvement in the
patients functional status are anticipated with additional treatment:
(4) the patient has returned to
work and is in need of additional treatment related to an exacerbation of PTSD
symptoms caused by the patients work activities: or
(5) with the approval of the commissioner or
a compensation judge, after a medical request is filed, in rare cases with
exceptional circumstances.
Subp. 7. Prior notification.
A. The provider must give prior notice to the
payer of each additional 16-week period of psychotherapy treatment. The
provider must also give prior notice of any psychotherapy treatment with a
modality other than those indicated in subpart 5. item A. subitems (1) to (7).
The prior notice may be made orally or in writing, must be provided at least
seven working days before the treatment begins, and must include:
(1) the basis for the additional period of
treatment, if applicable:
(2) the
psychotherapy treatment modality or modalities that will be used: and
(3) the anticipated length of the
treatment.
B. The payer
must respond within seven working days of receipt of the notification in item A
by either approving the treatment, denying the treatment, scheduling a medical
examination under Minnesota Statutes, section
176.155, or
requesting additional information including an updated treatment plan. If the
provider does not receive a response from the payer within the seven working
days, the payer has deemed to have given authorization. If the payer authorizes
treatment it may not later deny payment for the authorized treatment. A payer
must respond within seven working days of receiving additional informatioa if
requested. Payers may delegate their obligations under this subpart to their
certified managed care plaa if applicable.
C. If treatment is denied, the provider or
the employee may file with the commissioner a medical request under part
5221.6050, subpart 7, item C, If
treatment is denied or if a medical examination under Minnesota Statutes,
section
176.155, is
scheduled, a provider may proceed with the proposed treatment subject to a
later determination of compensability by the commissioner or compensation
judge. If the employer has contracted with a certified managed care plaa the
plans dispute resolution process must be completed before a medical request is
filed pursuant to Minnesota Statutes, section
176.1351.
Subp. 8. Change of provider.
A. A patient must not change
the mental health care provider who is providing the patient with psychotherapy
treatment under subpart 5 more than once within the first 60 days of the
patients first period of psychotherapy treatment. After the first 60 days of
psychotherapy treatment under subpart 5. the patient must not change the
patients provider except as provided by part
5221.0430. For purposes of this
part, the requirements of part
5221.0430, subparts 2 to 4,
governing the change of a patients primary care provider also apply to the
change of a patients mental health care provider when a treatment plan
established under subpart 4 has been initiated.
B. Treatment received prior to the change of
provider under item A is not included in the 16-week duration limit for a
period of psychotherapy treatment described in subpart 6, item A.
Subp. 9. Treatment with medication.
A. If a patient is not
receiving psychotherapy treatment under subpart 5, a health care provider must
evaluate whether the patient would benefit from psychotherapy treatment before
prescribing medication for PTSD. The provider must communicate the evaluation
to the patient. Treatment of PTSD with medication is indicated as provided in
this subpart.
B. The following
medications are indicated for the initial treatment of PTSD:
(1) selective serotonin reuptake inhibitors
(SSRIs), such as sertraline, paroxetine, or fluoxetine:
(2) selective norepinephrine reuptake
inhibitors (SNRIs), such as venlafaxine: and
(3) antihypertensive medication, if there is
peer-reviewed scientific literature demonstrating that the medication is
effective treatment for PTSD.
C. If the medications in item B are
contraindicated for the patient, produce undesirable side effects, or do not
decrease the severity of PTSD symptoms, the following medications are indicated
for treatment of PTSD:
(1) serotonin
antagonist and reuptake inhibitors (SARIs), such as trazodone, mirtazapine, or
nefazodone: or
(2) other
medications if prescribed or recommended by a licensed psychiatrist a
psychiatric mental health advanced practice registered nurse (PMH-APRN), or any
other health care provider after consultation with one of the providers in this
subitem.
D. The
following requirements must be met while treating PTSD:
(1) medication must be prescribed at the
lowest clinically effective dose, as determined by the prescribing health care
provider but not to exceed the manufacturers maximum daily dosage:
(2) medication is indicated only for the
shortest duration needed, as determined by the prescribing health care
provider:
(3) generic medications
are indicated for the treatment of PTSD: and
(4) the initial prescription of a medication
indicated in items B and C for treatment of PTSD is limited to no more than
three months of the medication per prescription. Subsequent refills of the same
medication are limited to no more than six months of medication per
refill.
E.
Benzodiazepines are not indicated for treatment of PTSD.
Subp. 10. Documentation.
A health care provider must clearly document the following information in the patients medical record or other report:
A. the diagnosis and initial evaluation under
subpart 3:
B. the treatment plan
under subpart 4:
C. the biweekly
evaluation under subpart 5, item C, including any work restrictions:
D. the basis for any additional periods of
psychotherapy treatment under subpart 6. including any psychological
assessments or indications for additional periods of treatment without
assessment and determinations that the patient continues to meet DSM criteria:
and
E. the evaluation of potential
psychotherapy treatment performed prior to prescribing medication under subpart
9, item A: and
F. any medications
prescribed under subpart 9, including the basis for any medications prescribed
under subpart 9, item C.
Subp. 11. Patients currently receiving treatment.
For a patient receiving treatment for PTSD prior to the effective date of this part, a payer must provide written notice of the requirements of this part to the patient, the patient's attorney of record, and the patient's treating health care providers before denying payment based on this part. A payer must not deny payment based on failure to comply with this part until 90 days after the written notice has been provided.
Subp. 12. Incorporation by reference.
A. The Diagnostic and
Statistical Manual of Mental Disorders, fifth edition (DSM-5), and any updates,
including errata and coding updates, is incorporated by reference. DSM-5 is
copyrighted by the American Psychiatric Association and is not subject to
frequent change. It is published by American Psychiatric Publishing, Inc.
(APPD. and may be purchased from them by calling 800-368-5777 or by ordering
online at the APPI website. It is available through the Minitex interlibrary
loan system and from other bookstores and online retailers.
B. The Clinical Practice Guideline for the
Treatment of Posttraumatic Stress Disorder in Adults and its appendices,
adopted by the American Psychological Association as APA Policy on February 24,
2017, and any updates, are incorporated by reference. It is not copyrighted and
is not subject to frequent change. It is available online at
http://www.apa.org/ptsd-guideline/.
Disclaimer: These regulations may not be the most recent version. Minnesota may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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