Welcome to PsychU!

Best Practice: Clinical Practice Guideline: Optum Schizophrenia Coverage Determination Guidelines

Optum is one of the nation’s leading managed behavioral care organizations. It is owned by United Health Care. Optum maintains clinical protocols that include the Level of Care Guidelines and Best Practice Guidelines, which describe the scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding treatment.

Optum adopted the guidelines of the American Psychiatric Association (APA) “Practice Guideline for the Treatment of Patients with Schizophrenia, Second Edition (2004)” and “Guideline Watch (2009): Practice Guideline for the Treatment of Patients with Schizophrenia (Dixon, et al. 2009); ”The National Institute for Health and Clinical Excellence’s Treatment and Management of Schizophrenia in Adults, 2010” (no information cited in the coverage determination guideline); Current Psychiatry, 2010; “Differential Diagnosis and Therapeutic Management of Schizoaffective Disorder”; and the “SAMHSA Evidence-Based Practices KIT, 2009”. The Optum (United Behavioral Health) “Levels of Care Guidelines, 2014” should also be used as a reference.

Optum’s “Treatment of Schizophrenia & Schizoaffective Disorder” coverage determination guideline (CDG) provides guidance and assistance to Optum reviewers (managed care staff that verify the availability of contract benefits and applies clinical guidelines to the individual patient’s medical circumstances) and providers based on reviews of best practices published as recently as 2014.

The following summary provides highlights of the Optum guideline; please refer to the full report for complete information.

Optum agrees with the definition of schizophrenia from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V): “schizophrenia includes the presence of positive symptoms along with negative symptoms; and one or more areas of functioning are well below the Optum member’s normal baseline.” Examples of positive symptoms are delusions, hallucinations, disorganized speech or behavior; and examples of negative symptoms are limited emotions, disturbances in speech, and an inability to participate in goal-directed behavior. Signs of disturbance must be evident for six months and the member meets diagnostic criteria across all five domains (cognitive impairment, mood and suicidality, positive symptoms, and negative symptoms, and aggression).

The guideline also supports the DSM-V definition of schizoaffective disorder, which is an uninterrupted  presence of major mood disorder (depressive or manic) concurrent with symptoms of schizophrenia. It is considered a subtype of schizophrenia according to the DSM-V.

The guideline presents the structure for ensuring best clinical practices are used when determining treatment for persons with schizophrenia and schizoaffective disorder: evaluation, treatment planning, pharmacotherapy, psychosocial intervention, and discharge planning.


The first phase is the evaluation of the member’s current condition. The reviewer must determine the factors that are evident that have caused the need for service (e.g., changes in the member’s symptoms, psychosocial or environmental factors, or level of functioning). Optum’s “Level of Care (LOC) Guidelines, 2014” (Optum’s Provider Express) report that the evaluation should be used as a component of the treatment plan. There are three parts to the evaluation that are recommended: standard evaluation, schizophrenia evaluation, and schizoaffective evaluation. The standard evaluation includes the events leading up to the current episode of care, active symptoms and severity, current level of functioning, current substance use and substance use history, and history of interventions.

For the schizophrenia evaluation, use of ratings scales is recommended, such as the Brief Psychiatric Rating Scale (BPRS), the Positive Symptoms Rating Scale (PSRS), and the Brief Negative Symptom Assessment (BNSA). Optum concurs with the American Psychiatric Association (APA) “Practice Guideline for the Treatment of Patients with Schizophrenia, Second Edition (2004)” that as part of the evaluation the reviewer should find out if this is a first or recurrent episode; whether if an adult member, he or she has a recovery plan and/or advance directive; what are the risk factors; and identify strength and resilience factors. Optum requires that the diagnosis of schizophrenia be accurate. There are other behavioral health or medical conditions that have similar characteristics, such as major depressive disorder or bipolar disorder with psychotic or catatonic features, schizoaffective disorder, delusional disorder, and posttraumatic stress disorder.

When evaluating if a member has schizoaffective disorder, Optum concurs with MDedge’s “Current Psychiatry, 2010,” that a history of mood and psychotic symptoms should be gathered from personal reports, reports from the member’s support network, and medical and behavioral records. It also agrees with Current Psychiatry that a family history of psychotic or mood disorders may indicate schizoaffective disorder. Psychiatrists must differentiate symptoms of other behavioral or medical conditions to produce an accurate diagnosis of schizoaffective disorder. Optum recommends the use of the Positive and Negative Syndrome Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS) to evaluate psychosis; it recommends the use of mood rating scales to evaluate the severity of a member’s mood disorder, such as the Beck-Depression Inventory (BDI-II), the Hamilton Depression Rating Scale (HDRS), and the Patient Health Questionnaire (PHQ-9).

Treatment Planning

The next phase is the treatment planning phase, where Optum believes that the provider and the member (when appropriate) work together on the treatment plan. According to Optum’s LOC Guidelines, 2014, treatment planning begins within 24 hours of intake for inpatient, residential, and partial hospitalizations; and within three days of intake for intensive outpatient and outpatient settings. The treatment plan should address a number of areas, including:

  • Specific treatments including the type, amount, frequency and duration of each treatment;
  • The expected outcome for each problem to be addressed expressed in terms that are measurable, functional, and time-framed;
  • How the member’s family and other natural resources will participate in treatment when clinically indicated;
  • How treatment will be coordinated with other providers as well as with agencies or programs with which the member is involved;
  • Use of interventions that further engage the member in treatment, promote the member’s participation in care, promote informed decisions, and support the member’s broader recovery and resiliency goals.


In agreement with the APA “Guideline Watch (2009): Practice Guideline for the Treatment of Patients with Schizophrenia (Dixon, et al. 2009)”, (Psychiatry Online) Optum recommends that pharmacotherapy should be used in conjunction with psychosocial interventions in treating schizophrenia and schizoaffective disorder. First-line pharmacotherapy (which is the initial treatment stage) should incorporate either first or second generation antipsychotics. For second-line treatment (which is a second treatment stage if in the initial stage patient did not respond to treatment), switching to a different first or second generation antipsychotic should be considered. If third-line treatment (third attempt at treatment) is necessary, then the use of atypical antipsychotic medication may be especially appropriate for members with recurrent suicidality, members who have a co-occurring substance use disorder, or when positive symptoms have persisted for more than two years. For fourth-line treatment (fourth attempt at treatment), a combination of atypical antipsychotic medication and first or second generation antipsychotics is recommended. In addition electro-convulsive therapy should be considered for treatment resistant cases. Long-acting injectables should be used in patients who have a high risk of relapse after discharge.

There are other pharmacotherapy considerations specifically for treating schizoaffective disorder. Optum concurs with the following guidelines from Current Psychiatry, 2010:

  • Second generation antipsychotics are becoming the standard for first-line treatment,
  • Eight to twelve weeks are needed to determine medication efficacy,
  • Antidepressants can be used as an adjunct to antipsychotics when depressive symptoms persist,
  • The balance between psychotic symptoms and affect/mood symptoms should be monitored in case changes occur that may bring on schizophrenia or major depression/mania.

Optum concurs with the APA Schizophrenia Practice Guideline, 2004, that considerations should be given to pregnant women and for older adults under pharmacotherapy. Pregnancy tests should be given to women of child bearing age as there may be risks to an unborn fetus and breast-fed infant due to the effects of medications. If the test results are positive for pregnancy, then additional monitoring and prenatal care should be given to reduce risks of complications. For older adults, special attention is needed for the following:

  • Reduced cardiac output and organ blood flow and reduced metabolism and fat content impact the rate of absorption resulting in prolonged drug effects and greater sensitivity to medications,
  • The starting dose should be one quarter to one half of the usual adult starting dose,
  • The presence of co-occurring medical conditions or the use of multiple medications further complicates pharmacotherapy requiring close monitoring for potential risks and interactions.

Psychosocial Intervention

In line with the APA Guideline Watch, 2009, Optum agrees that psychosocial interventions are used with pharmacotherapy to improve and stabilize the patient, facilitate the member’s engagement in treatment, decrease risk, and enhance resilience.

Optum agrees with SAMHSA that Illness Management and Recovery Oriented Interventions should be used as part of the treatment plan. This evidenced based practice is used to educate members about their condition, develop goals and skills to better manage their illness, and make informed decisions about their treatment (see SAMHSA’s Illness Management and Recovery Evidence-Based Practices (EBP) KIT, 2009). If the member’s benefit supports the recovery oriented interventions, then the following may be considered: Peer Support/Peer Delivered Services, Assertive Community Treatment, Psychiatric Rehabilitation, and Case Management.

Discharge Planning

In the CDG, discharge planning and/or treatment discontinuation considerations are discussed. At the admissions/initiation of treatment stage, a discharge plan is already being drafted by the psychiatrist and the member so when the member is actually discharged, all changes in the member’s conditions over time are documented. It also reduces risk that the factors which caused the admission will not reoccur.

Guideline Development Methodology: The Treatment of Schizophrenia & Schizoaffective Disorder coverage determination guideline was developed by a team at Optum of clinical and administrative staff that uses best practices and reviews current literature. Optum’s Behavioral Policy & Analytics Committee reviews the final draft.

Date Released: The guidelines were released by Optum, United Behavioral Health in October 2014.

Guideline Developer: Optum by United Behavioral Health

Guideline Funding Source: Optum by United Behavioral Health

The complete text of the “Treatment of Schizophrenia & Schizoaffective Disorder” may be found online at https://ProviderExpress.com.

PsychU is supported by Otsuka Pharmaceutical Development & Commercialization, Inc. (OPDC), Otsuka America Pharmaceutical, Inc. (OAPI), and Lundbeck, LLC – committed supporters of the mental health treatment community. The opinions expressed by PsychU’s contributors are their own and are not endorsed or recommended by PsychU or its sponsors. The information provided through PsychU is intended for the educational benefit of mental health care professionals and others who support mental health care. It is not intended as, nor is it a substitute for, medical care, advice, or professional diagnosis. Health care professionals should use their independent medical judgement when reviewing PsychU's educational resources. Users seeking medical advice should consult with a health care professional. No CME or CEU credits are available through any of the resources provided by PsychU. Some of the contributors may be paid consultants for OPDC, OAPI, and / or Lundbeck, LLC.