A member 21 years of age or older must meet all of the following conditions of medical necessity:

1. (A) demonstrate symptomatology consistent with a diagnosis listed in the current edition of the DSM, and that such symptomatology requires and will respond to therapeutic intervention;
2. (B) be cleared for treatment in a nonmedical, nonsurgical treatment environment;
3. (C) require 24-hour medical, psychiatric, and nursing services that can appropriately be provided only at an acute level-l of hospital care;

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-5

Provider Manual Series (130 CMR 425.000)

Transmittal Letter Date

Psychiatric Inpatient Hospital Manual

PIH-23 06/16/17

1. (D) have a psychiatric condition that results in serious dysfunction, such as increased suicidal gestures, assaultiveness, or sudden inability to provide self-care, that endangers the member or others; and
2. (E) present conditions that can reasonably be expected to improve to the extent that psychiatric inpatient hospital services will no longer be needed or further regression of the member’s condition will be prevented.