All claims for treatment of
mental disorders are subject to review in accordance with claims
processing procedures contained in the TRICARE Operations Manual
(TOM). The following services and supplies are covered:
5.1 Institutional Benefits
5.1.1 Medically or psychologically
necessary acute hospital psychiatric care (see
Section 3.1);
5.1.2 Medically or psychologically
necessary psychiatric RTC care for children and adolescents, up
to age 21 (see
Section 3.2);
5.1.3 Medically or psychologically
necessary psychiatric PHP care (see
Section 3.4);
5.1.4 Medically or psychologically
necessary psychiatric IOP care (see
Section 3.15).
Note: Institutional benefits for
SUDs are covered in
Section 3.5.
5.2 Professional Services
5.2.1 Individual psychotherapy, adult
or child (see
Section 3.11);
5.2.5 Psychological testing and assessment
(see
Section 3.9);
5.2.6 Specific mental health coverage
descriptions are outlined in eating disorder treatment (see
Section 3.14), specific learning disorder
(see
Section 3.6), and Gender Dysphoria (see
Section 1.2);
5.2.7 Administration of psychotropic
drugs. All patients receiving psychotropic drugs must be under the
care of a qualified mental health provider authorized by state licensure
to prescribe drugs (see
Section 3.12).
5.2.8 Electroconvulsive treatment
(Current Procedural Terminology (CPT) codes 90870 and 90871). Electroconvulsive
treatment is covered when medically or psychologically appropriate
and when rendered by qualified providers. However, the use of electric
shock as negative reinforcement (aversion therapy) is excluded.
5.2.10 Medication Assisted Treatment
(MAT) (see
Section 3.17);
5.2.11 Ancillary therapies (no code,
as separate reimbursement is not permitted). Includes art, music,
dance, occupational, and other ancillary therapies, when included
by the attending provider in an approved inpatient treatment plan
and under the clinical supervision of a licensed doctoral level
mental health professional. These ancillary therapies are not separately
reimbursed professional services but are included within the institutional reimbursement.
5.2.12 All providers are expected
to consult with, or refer patients to, a physician for evaluation
and treatment of physical conditions that may co-exist with or contribute
to a mental disorder.
5.2.13 Transcranial Magnetic Stimulation
(TMS) (also referred to as repetitive TMA (rTMS)) for the treatment
of major depressive disorder (CPT codes 90867, 90868, and 90869),
is proven.
5.2.14 Spravato™ (esketamine) nasal
spray (Healthcare Common Procedure Coding System (HCPCS) code J3490)
(CPT codes G2082-83) for the treatment of treatment-resistant depression
and other US Food and Drug Administration (FDA) approved indications,
which is available to providers from the FDA’s Spravato™ Risk Evaluation
and Mitigation Strategy (REMS) Program, may be cost-shared. Preauthorization
under the medical benefit is required. See
Chapter 1, Section 6.1 and TOM,
Chapter 7, Section 2.
5.2.15 Allowable services that are
necessary to diagnose and treat Attention Deficit/Hyperactivity
Disorder (ADHD) may be cost-shared.