The panel examined the medical necessity definitions for the five Regional Behavioral Health Authorities (RBHAs) that serve children in the public sector and found that the language in all five definitions overlapped considerably. It should also be noted that none of these definitions make any specific reference to children and/or families. The panel felt that the absence of such references illustrates a lack of attention to children and families' unique needs. In addition, we strongly recommend a consistent medical necessity definition across regions. Medical necessity should not differ by location.

Community Partnership of Southern Arizona, the RBHA that serves Pima, Cochise, Graham, Greenlee and Santa Cruz counties, defines medical necessity as follows.

"Medical Necessity" pertains to all covered services provided to members by the RBHAs or their subcontracted providers.

"Medically Necessary" means those covered services provided by practitioners within the scope of practice to prevent disease, disability and/or other adverse health conditions or their progression and to promote progress towards the highest possible level of health and self sufficiency.

"Level of Care Criteria" means written standards that describe the indications for medically necessary covered services. For behavioral health services these criteria include that the services:

1. Are reasonable expected to benefit the person's mental or physical health,
2. Are necessary and appropriate to the person's present condition,
3. Are designed to assist persons to manage their illness to the extent possible and to live, learn and work in their communities.

For covered, medically necessary services that are equally effective, the least costly and/or least restrictive service should be utilized.

The panel was displeased that Community Partnership of Southern Arizona's definition for medical necessity includes a separate, more restrictive definition specifically for mental health services. The broad medical necessity definition covers services that "prevent disease, disability and/or other adverse health conditions." Mental health services, however, must meet three separate criteria, one being that services must be "necessary and appropriate to the person's present condition" and assumes that "there is no equally effective service that is less restrictive or less costly."

The panel was pleased to note that this medical necessity definition incorporates the importance of optimizing functioning to the highest level and preventing the progression of illness, which allows for a broader interpretation and is more humane. The panel was especially pleased with the amount of attention that was given to the third premise, which focuses on integration into the community in a meaningful way and optimizing health.

The EXCEL Group, the RBHA that serves Yuma and LaPaz counties, defines medical necessity as follows.

"Medically Necessary" means those covered services provided by qualified service providers within the scope of their practice. Medically necessary services are provided to prevent disease, disability and other adverse health conditions or their progression, or to prolong life.

"Level-of-Care Criteria" are standards that describe the indications for medically necessary covered services. For behavioral health services, these criteria include the following:

The medically necessary service
i.    is reasonably expected to benefit the person's mental or physical health; and

ii.   is necessary and appropriate to the person's present condition; and

iii.  there is no equally effective service that is less restrictive or substantially less costly.

This definition has almost the exact same language as the one used by the Community Partnership of Southern Arizona, with one small improvement (please see the comments on that definition, page 8 However, the EXCEL Group definition adds that services are "provided to prevent disease, disability...or their progression." The inclusion of "progression" allows for a broader interpretation for covered services and is more humane. Sadly, in this definition mental health services again have their own specific section, and requires consumers to meet not only separate, but stricter criteria than for general health services.

Northern Arizona Regional Behavioral Health Authority, the RBHA that serves Coconino, Mohave, Yavapai, Navajo, and Apache Counties, defines medical necessity as follows.

"Medically necessary covered services," as defined by AHCCCS and DBHS, are services that include all of the following:

1. Are provided by qualified practitioners within the scope of their practice;
2. Prevent disease, disability and other adverse health conditions or their progression and to promote progress toward the highest possible level of health and self-sufficiency;
3. Are reasonably expected to benefit the eligible member's present condition; and
4. Are designed to assist eligible members to manage their illness to the extent possible and to live, learn and work in their own communities.

Again, this definition echoes much of the language of the others. However, this one incorporates the importance of optimizing functioning to the highest level and preventing the progression of illness, which, as mentioned before, allows for a broader interpretation and is more humane. The panel was especially pleased with the amount of attention that was given to the fourth premise, which focuses on integration into the community in a meaningful way and optimizing health

Pinal Gila Behavioral Health Association, the RBHA that serves Pinal and Gila Counties, defines medical necessity as follows.

"Medically Necessary" means those covered services provided by qualified service providers within the scope of their practice. Medically necessary services are provided to prevent diseases, disability and other adverse health conditions or their progression, and to promote progress towards the highest possible level of health and self-sufficiency.

Again, this definition uses much of the same language as Community Partnership of Southern Arizona and The EXCEL Group (see comments, page 10). It does, however, include the concept of preventing the "progression" of diseases, disabilities and other adverse health conditions. In addition, this definition includes "progress towards the highest possible level of health and self sufficiency," which illustrates attention to optimizing and improving the level of functioning. While this definition is short and somewhat vague, it does incorporate these two crucial elements.

ValueOptions, the RBHA that serves Maricopa County, defines medical necessity as follows.

Medically necessary covered services shall be provided by practitioners within the scope of their practice to prevent disease, disability, and/or other adverse health conditions or their progression and to promote progress towards the highest possible level of health and self-sufficiency. Medically necessary covered services:

1. are reasonably expected to benefit the person's mental or physical health;
2. are necessary and appropriate to the person's present condition;
3. are designed to assist persons to manage their illness to the extent possible and to live, learn and work in their own communities.

The panel was pleased that ValueOptions defines medically necessary services as those that "promote progress towards the highest possible level of health and self-sufficiency." In keeping with this commitment to treating the entire individual, rather than simply the illness, the definition's third premise is that medically necessary services "are designed to assist persons to manage their illness to the extent possible and to live, learn and work in their own communities." This language emphasizes a "system of care" model that values integrating the youth into the community. It is also less restrictive in that services are not required to "cure" the disorder, and incorporates the desire for positive, meaningful treatment outcomes. The panel also was pleased by the inclusion of "prevention" in the definition.

While there is a minimum medical necessity definition with which all RBHAs must comply, the panel is concerned about the tremendous regional variation in the quality of these definitions. Medical necessity should not differ by location.

The panel strongly recommends that the state of Arizona adopt one comprehensive definition for medical necessity that all five RBHAs must follow, and we further recommend that the following premises should be added to this statewide definition. (This language is borrowed from Arkansas' medical necessity definition for children served by Medicaid, one of the very few child-specific medical necessity definitions in the country.)

Medically necessary services:

• Provide anticipatory guidance to parents/guardians of children with respect to mental health and emotional development;

• Reflect enrollee and their family's choice, active participation in treatment planning and are designed to achieve outcomes desired by the enrollees and their families;

• Are individualized, specific and consistent with symptoms of the confirmed diagnosis of the illness or condition under treatment;

• Are appropriate to meet the enrollee's needs as determined from information provided by the individual's family and primary service provider, as well as any other providers, programs, and agencies that have conducted relevant evaluations of the individual;

• Are offered in the most integrated settings appropriate to the enrollee's needs and developmental level;

• Affirmatively ensure access to and promote appropriate utilization of services (including overcoming barriers cause by inability to obtain transportation);

• Are designed to enable the child to live at home or in a homelike settings, and address both the needs of the child and the related needs of the family; and

• Designed (when relevant) to prevent the need for involuntary treatment or institutionalization.

We further recommend inclusion of language noting the importance of the cultural appropriateness of the assessments and care provided to children in Arizona. This topic was not addressed sufficiently in any of the medical necessity definitions or level-of-care criteria sets reviewed, despite the tremendous cultural diversity among Arizona residents.