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 3.16).
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 3.10);
5.2.6 Specific mental health coverage
descriptions are outlined in eating disorder treatment (see
Section 3.15), specific learning disorder
(see
Section 3.6), Attention Deficit Hyperactivity
Disorder (ADHD) (see
Section 3.7), and Gender Dysphoria (GD) and
gender-affirming health care for dates of service on or after July
1, 2022 (see
Section 1.3);
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) procedure 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 3.18);
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 procedure codes 90867, 90868,
and 90869), is proven.
5.2.14 Spravato™ (esketamine) nasal
spray (HCPCS J3490) (CPT codes G2082-83) for the treatment of treatment-resistant
depression and other U.S. 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.