How to Appeal a Anthem Blue Cross Blue Shield Intensive In-home Behavioral Health Services Denial

What Anthem Blue Cross Blue Shield requires for coverage

Anthem Blue Cross Blue Shield considers Intensive In-home Behavioral Health Services medically necessary when the following criteria (from CG-BEH-14) are met:

• {'category': 'Initial Authorization - ALL must be met (A, B, and C)', 'criteria_A_severity_of_illness': ['Specific psychiatric symptoms or disturbances of mood or behavior linked to functional impairment and risk of serious harm', 'Specific deficits directly related to intensive in-home behavioral health services exist', 'Member and significant others demonstrate motivation, capability to benefit, and participation in treatment', 'Symptoms expected to improve with services based on achievable goals', 'Risk for behavioral or functional regression without intensive in-home behavioral health services', 'Demonstrated evidence of significant variability in the day-to-day capacity of the member to cope', 'Need for direct monitoring less than daily but more than weekly'], 'criteria_B_diagnosis': 'Licensed medical professional must document a psychiatric diagnosis per DSM or ICD consistent with behavioral health disturbance', 'criteria_C_treatment_plan': ['Identifies specific behavioral, psychological, family-based, or community-based impairments/symptoms interfering with normal functioning', 'Specific individual age-appropriate goals documented which can be objectively measured based on standardized assessments', 'Specific timeline documented including intensity (visits/week, hours/visit) and duration (typically 1-6 months)', 'Services delivered by appropriately licensed/certified providers within scope of practice']}
• {'category': 'Continuation of Services', 'criteria': ['Member must continue meeting Severity of Illness criteria', 'AND demonstrate ONE of: (A) Measurable progress documented not less often than every 4 weeks, member/significant others cooperative with treatment, meeting treatment plan goals, symptoms at risk for relapse without continued services; OR (B) Treatment plan being re-evaluated and amended with achievable goals by licensed professional']}

Covered procedure codes

H0004	Behavioral health counseling and therapy, per 15 minutes
H0006	Alcohol/drug services; case management
H0023	Behavioral health outreach service (planned approach to targeted population)
H0036	Community psychiatric supportive treatment, face-to-face, per 15 minutes
H2015	Comprehensive community support services, per 15 minutes
H2019	Therapeutic behavioral services, per 15 minutes
H2020	Therapeutic behavioral services, per diem

How to appeal this denial

Frame your appeal around the specific criterion you satisfy. Quote the CG-BEH-14 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Anthem Blue Cross Blue Shield either approve the claim or identify the precise criterion they believe you fail. CareCost Appeals assembles this automatically: it cites the policy, pulls verified clinical evidence, and applies your state and federal appeal rights.

Source: Anthem Blue Cross Blue Shield medical policy CG-BEH-14 — view the published policy.