In order to qualify for admission
to an RTC, a
TRICARE authorized independent mental
health provider shall recommend that the child be
admitted to the RTC. The child must be diagnosed as suffering from
a mental disorder, according to the criteria listed in the current
edition of the
Diagnostic and Statistical Manual of Mental
Disorders (DSM). Benefits are limited for certain mental
disorders, such as specific learning disorders (see
Section 3.6).
No benefits are payable for “Conditions Not Attributable to a Mental
Disorder”, or International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM)
V codes, or International
Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
Z codes.
Co-occurring mental
and SUDs are common and assessment should proceed as soon as it
is possible to distinguish the substance related symptoms from other independent
conditions. In order for treatment of a mental disorder
to be medically or psychologically necessary, the patient must,
as a result of a diagnosed mental disorder, be experiencing both
physical or psychological distress
and an
impairment in his or her ability to function in appropriate occupational,
educational or social roles. It is generally the degree to which
the patient’s ability to function is impaired that determines the
level of care (if any) required to treat the patient’s condition.