Minnesota Administrative Rules

5221.6700 POST-TRAUMATIC STRESS DISORDER.

Subpart 1.

Scope.

A.

Pursuant to Minnesota Statutes, section 176.83, subdivision 5, paragraph (b), clause (8), this part establishes standards and procedures for treatment of patients with a compensable mental impairment of post-traumatic stress disorder (PTSD) as defined in Minnesota Statutes, section 176.011, subdivision 15, paragraph (d). This part does not affect any determination of liability for an injury under Minnesota Statutes, chapter 176, and does not expand or restrict a health care provider's scope of practice.

B.

This part applies to all outpatient treatment provided for PTSD after May 4, 2020, regardless of the date of injury.

C.

This part does not apply to treatment of an injury after a payer has denied primary liability for the injury. However, if primary liability is later accepted or determined, this part does apply to treatment initiated after primary liability has been established.

D.

References to days and weeks in this part means calendar days and weeks unless otherwise specified.

E.

Parts 5221.6050, subparts 1, item C; 2; 4; 5; 6, items A and C; and 7, items A and D, and 5221.8900 apply to the treatment standards established in this part. The departures listed in part 5221.6050, subpart 8, do not apply to this part.

Subp. 2.

Definitions.

A.

The definitions in this subpart apply to this part.

(1)

"Condition" means the symptoms, physical signs, clinical findings, and functional status that characterize the patient's complaint, illness, or injury related to a current claim for compensation.

(2)

"Contraindication" means a condition that makes the use of a particular psychological treatment or medication inadvisable because of an increased risk of harm to the patient, including the risk of self-harm by the patient.

(3)

"Evidence-based" means a practice that integrates research validated by peer-reviewed scientific literature with clinical expertise in the context of patient characteristics, culture, and preferences.

(4)

"Functional status" means the ability of an individual to engage in activities of daily living or other social, recreational, and vocational activities.

(5)

"Mental health care provider" means a currently licensed health care provider who has experience treating patients with PTSD and whose practice primarily involves mental health treatment.

(6)

"Modality" means the application or use of a therapeutic agent or regimen.

(7)

"Narrative exposure therapy" means a treatment for trauma disorders in which a patient establishes a coherent, chronological narrative of the patient's life story, with a focus on the patient's traumatic experiences.

(8)

"Trauma-focused psychotherapy" means a therapy that uses cognitive, emotional, and behavioral techniques to process a traumatic experience and in which the trauma focus is a central component of the therapeutic process.

B.

Unless otherwise defined in this subpart, the definitions of the psychotherapy treatment modalities in subpart 5 are as provided in Appendix A - Description of Treatments and Strength of Recommendations - of the American Psychological Association's Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder in Adults, which is incorporated by reference in subpart 12.

Subp. 3

Diagnosis and initial evaluation.

A.

The diagnosis of PTSD must be made by a licensed psychologist or psychiatrist according to the most recently published edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association, as required by Minnesota Statutes, section 176.011, subdivision 15, paragraph (d). As of May 4, 2020, the most current edition is the fifth edition (DSM-5), which is incorporated by reference in subpart 12.

B.

A mental health care provider must complete an initial evaluation that includes a determination of:

(1)

the patient's functional status;

(2)

the patient's relevant family history;

(3)

the patient's history of mental health conditions and treatment, if any;

(4)

whether there is an acute risk that the patient will harm self or others, and any potential need for hospitalization;

(5)

whether the patient has any comorbid physical or psychiatric disorders, including substance and other addictions, previous untreated or unresolved trauma, personality disorder, depression, anxiety, serious mood disorder, and psychosis;

(6)

whether the patient would benefit from psychotherapy treatment under subpart 5, after considering any contraindications; and

(7)

any appropriate referrals for treatment for any risks or comorbid physical or psychiatric disorders identified under subitems (4) and (5), psychotherapy treatment under subpart 5, and treatment with medication under subpart 9.

Subp. 4.

Treatment plan.

A.

Prior to providing psychotherapy treatment under subpart 5, a mental health care provider must:

(1)

engage and collaborate with the patient to establish a plan for treatment that does the following:

(a)

specifies the treatment modality or modalities described in subpart 5, item A, that will be provided;

(b)

determines if treatment will be conducted using telehealth, which requires patient agreement;

(c)

assesses the patient's current level of symptoms and functional status;

(d)

develops a specific set of goals for the treatment based on the patient's functional status;

(e)

establishes a timetable for achieving the treatment goals within the prescribed number of psychotherapy sessions;

(f)

prescribes the duration and frequency of treatment, subject to subparts 5, 6, and 8;

(g)

addresses the patient's plan for return to work, including any restrictions necessary for the patient's initial return to work, in compliance with parts 5221.0410 and 5221.0420. The mental health care provider establishing the treatment plan may collaborate with the patient's other treating health care providers to address planning a return to work; and

(h)

provides for any necessary referrals that were not made under subpart 3, item B, subitem (7);

(2)

provide education about PTSD and its treatment; and

(3)

provide any motivational interviewing needed to prepare the patient for trauma-focused psychotherapy.

B.

The assessment described in item A, subitem (1), unit (c), must be conducted using a tool validated in peer-reviewed scientific literature for the assessment of PTSD symptoms and functional status. When available, assessment tools must be based on the most recently published edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association. Examples of acceptable assessment tools for the DSM-5 are the PTSD Symptom Scale - Interview for DSM-5 (PSS-I-5), the PTSD Scale - Self Report for DSM-5 (PS-SR5), the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and the PTSD Checklist for DSM-5 (PCL-5).

C.

The assessment required by item A, subitem (1), unit (c), provides the baseline for determining the progress of the treatment as described in subpart 5, item C.

D.

If the mental health care provider establishing the treatment plan in item A is not the same provider who completed the initial evaluation in subpart 3, item B, the provider must review and consider that initial evaluation before establishing a treatment plan under this subpart.

Subp. 5.

Psychotherapy treatment.

A.

The following trauma-focused psychotherapy treatment modalities are indicated for the treatment of PTSD singularly, concurrently, or simultaneously:

(1)

cognitive behavioral therapy (CBT);

(2)

cognitive processing therapy (CPT);

(3)

cognitive therapy (CT);

(4)

prolonged exposure therapy (PE);

(5)

brief eclectic psychotherapy (BEP);

(6)

eye-movement desensitization and reprocessing (EMDR);

(7)

narrative exposure therapy (NET); and

(8)

any other treatment modality recommended by the treating mental health care provider that is an evidenced-based, trauma-focused psychotherapy treatment modality, subject to the requirements of subpart 7.

B.

All psychotherapy treatment modalities under item A must be provided by a mental health care provider who is trained to treat PTSD with the modality or modalities they are using to treat the patient. The provider must retain documentation of the training. Treatment for PTSD under item A is not indicated more than two times per week, except to provide emergency treatment as defined in part 5221.6040, subpart 5.

C.

At least once every two weeks while a patient is receiving psychotherapy treatment under this subpart, the psychotherapy provider must:

(1)

evaluate the severity of the patient's PTSD symptoms and changes in the patient's functional status using an assessment tool described in subpart 4, item B, and the provider's clinical observations of the patient;

(2)

review:

(a)

the treatment plan, including goals; and

(b)

the patient's adherence to the plan;

(3)

make any necessary adjustments to the treatment plan; and

(4)

complete and submit to the patient a report of work ability. Part 5221.0410, subpart 6, items B, C, and D, apply to the provider's completion of the report of work ability. The provider completing the report may collaborate with the patient's other treatment health care providers regarding the patient's return to work.

Subp. 6.

Duration of psychotherapy treatment.

A.

A period of psychotherapy treatment begins with the first time a modality is initiated under this part, and ends 16 weeks later. Additional modalities added during the 16 weeks do not extend a period of psychotherapy treatment. Subject to the requirements of this part, there is no limit to the number of periods of psychotherapy treatment a patient may receive.

B.

An additional period of treatment is indicated only if the provider determines the patient continues to meet the criteria for PTSD described in the most recently published edition of the Diagnostic and Statistical Manual of Mental Disorders, and the requirements of items C to E are satisfied.

C.

A complete psychological assessment is indicated for a patient who does not complete a period of psychotherapy treatment and continues to meet the criteria for PTSD, or who continues to meet the criteria for PTSD after the conclusion of a period of treatment. This assessment is not necessary if a complete psychological assessment has already been completed within the previous year, or if one or more of the indications for an additional period of treatment described in item E apply.

D.

The psychological assessment required by item C must include the use of objective testing such as the most current version of the Minnesota Multiphasic Personality Inventory. The goal of the assessment is to determine if the patient has any new or unresolved comorbid psychological conditions that are preventing the successful treatment of PTSD. If identified, these comorbidities must be addressed or treated prior to the patient resuming psychotherapy treatment for PTSD or, if appropriate, addressed or treated concurrently with an additional period of treatment for PTSD.

E.

An additional period of psychotherapy treatment is indicated in the following circumstances, without the need for a complete psychological assessment:

(1)

the patient's treatment has been interrupted or delayed because of a need for treatment of a different medical or psychological condition, including treatment of comorbidities;

(2)

previous treatment for PTSD did not meet the accepted standard of practice;

(3)

there is documentation in the medical record or other report, pursuant to subpart 10, of all of the following during the current period of treatment:

(a)

the patient has adhered to the treatment plan, as described in subpart 4;

(b)

a decrease in the patient's PTSD symptoms;

(c)

improvement in the patient's functional status; and

(d)

further decrease in the patient's PTSD symptoms and continued improvement in the patient's functional status are anticipated with additional treatment;

(4)

the patient has returned to work and is in need of additional treatment related to an exacerbation of PTSD symptoms caused by the patient's work activities; or

(5)

with the approval of the commissioner or a compensation judge, after a medical request is filed, in rare cases with exceptional circumstances.

Subp. 7.

Prior notification.

A.

The provider must give prior notice to the payer of each additional 16-week period of psychotherapy treatment. The provider must also give prior notice of any psychotherapy treatment with a modality other than those indicated in subpart 5, item A, subitems (1) to (7). The prior notice may be made orally or in writing, must be provided at least seven working days before the treatment begins, and must include:

(1)

the basis for the additional period of treatment, if applicable;

(2)

the psychotherapy treatment modality or modalities that will be used; and

(3)

the anticipated length of the treatment.

B.

The payer must respond within seven working days of receipt of the notification in item A by either approving the treatment, denying the treatment, scheduling a medical examination under Minnesota Statutes, section 176.155, or requesting additional information including an updated treatment plan. If the provider does not receive a response from the payer within the seven working days, the payer has deemed to have given authorization. If the payer authorizes treatment, it may not later deny payment for the authorized treatment. A payer must respond within seven working days of receiving additional information, if requested. Payers may delegate their obligations under this subpart to their certified managed care plan, if applicable.

C.

If treatment is denied, the provider or the employee may file with the commissioner a medical request under part 5221.6050, subpart 7, item C. If treatment is denied or if a medical examination under Minnesota Statutes, section 176.155, is scheduled, a provider may proceed with the proposed treatment subject to a later determination of compensability by the commissioner or compensation judge. If the employer has contracted with a certified managed care plan, the plan's dispute resolution process must be completed before a medical request is filed pursuant to Minnesota Statutes, section 176.1351.

Subp. 8.

Change of provider.

A.

A patient must not change the mental health care provider who is providing the patient with psychotherapy treatment under subpart 5 more than once within the first 60 days of the patient's first period of psychotherapy treatment. After the first 60 days of psychotherapy treatment under subpart 5, the patient must not change the patient's provider except as provided by part 5221.0430. For purposes of this part, the requirements of part 5221.0430, subparts 2 to 4, governing the change of a patient's primary care provider also apply to the change of a patient's mental health care provider when a treatment plan established under subpart 4 has been initiated.

B.

Treatment received prior to the change of provider under item A is not included in the 16-week duration limit for a period of psychotherapy treatment described in subpart 6, item A.

Subp. 9.

Treatment with medication.

A.

If a patient is not receiving psychotherapy treatment under subpart 5, a health care provider must evaluate whether the patient would benefit from psychotherapy treatment before prescribing medication for PTSD. The provider must communicate the evaluation to the patient. Treatment of PTSD with medication is indicated as provided in this subpart.

B.

The following medications are indicated for the initial treatment of PTSD:

(1)

selective serotonin reuptake inhibitors (SSRIs), such as sertraline, paroxetine, or fluoxetine;

(2)

selective norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine; and

(3)

antihypertensive medication, if there is peer-reviewed scientific literature demonstrating that the medication is effective treatment for PTSD.

C.

If the medications in item B are contraindicated for the patient, produce undesirable side effects, or do not decrease the severity of PTSD symptoms, the following medications are indicated for treatment of PTSD:

(1)

serotonin antagonist and reuptake inhibitors (SARIs), such as trazodone, mirtazapine, or nefazodone; or

(2)

other medications if prescribed or recommended by a licensed psychiatrist, a psychiatric mental health advanced practice registered nurse (PMH-APRN), or any other health care provider after consultation with one of the providers in this subitem.

D.

The following requirements must be met while treating PTSD:

(1)

medication must be prescribed at the lowest clinically effective dose, as determined by the prescribing health care provider but not to exceed the manufacturer's maximum daily dosage;

(2)

medication is indicated only for the shortest duration needed, as determined by the prescribing health care provider;

(3)

generic medications are indicated for the treatment of PTSD; and

(4)

the initial prescription of a medication indicated in items B and C for treatment of PTSD is limited to no more than three months of the medication per prescription. Subsequent refills of the same medication are limited to no more than six months of medication per refill.

E.

Benzodiazepines are not indicated for treatment of PTSD.

Subp. 10.

Documentation.

A health care provider must clearly document the following information in the patient's medical record or other report:

A.

the diagnosis and initial evaluation under subpart 3;

B.

the treatment plan under subpart 4;

C.

the biweekly evaluation under subpart 5, item C, including any work restrictions;

D.

the basis for any additional periods of psychotherapy treatment under subpart 6, including any psychological assessments or indications for additional periods of treatment without assessment and determinations that the patient continues to meet DSM criteria;

E.

the evaluation of potential psychotherapy treatment performed prior to prescribing medication under subpart 9, item A; and

F.

any medications prescribed under subpart 9, including the basis for any medications prescribed under subpart 9, item C.

Subp. 11.

Patients currently receiving treatment.

For a patient receiving treatment for PTSD prior to May 4, 2020, a payer must provide written notice of the requirements of this part to the patient, the patient's attorney of record, and the patient's treating health care providers before denying payment based on this part. A payer must not deny payment based on failure to comply with this part until 90 days after the written notice has been provided.

Subp. 12.

Incorporation by reference.

A.

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and any updates, including errata and coding updates, is incorporated by reference. DSM-5 is copyrighted by the American Psychiatric Association and is not subject to frequent change. It is published by American Psychiatric Publishing, Inc. (APPI), and may be purchased from them by calling 800-368-5777 or by ordering online at the APPI website. It is available through the Minitex interlibrary loan system and from other bookstores and online retailers.

B.

The Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder in Adults and its appendices, adopted by the American Psychological Association as APA Policy on February 24, 2017, and any updates, are incorporated by reference. It is not copyrighted and is not subject to frequent change. It is available online at http://www.apa.org/ptsd-guideline/.

Statutory Authority:

MS s 176.83

History:

44 SR 1266

Published Electronically:

October 19, 2021