Stress Disorder: when insurers say no, reviewers often say yes

Where the denial was overturned

Physician 1: The patient is a 15-year-old male who experienced a sudden onset of encephalopathy of undetermined cause, which left him with a neuropsychological deficit from which he has recovered slowly and incompletely. The patient has been followed by a neuropsychologist. His parents are requesting reimbursement for cognitive rehabilitation therapy the patient received from April 2004 to August 2004. The Health Plan has denied this request indicating the therapy at issue is considered experimental for treatment of the patient’s medical condition.Review of the clinical evidence reveals the cause of the patient’s acute encephalopathy was undetermined, and the patient had residual deficits requiring treatment. Cognitive rehabilitation therapy is a medically reasonable and appropriate therapy for treatment of patients such as this patient.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s representative has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.

Where the denial was upheld

Findings: The physician reviewer found that An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center Services.At issue in this case is whether the Residential Treatment Center (RTC) services at issue and requested services were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A) to treat the enrollee’s mental health or substance use disorder. “Medically necessary treatment of a mental health or substance use disorder” is defined in Health and Safety Code section 1374.72(a)(3)(A) as follows:(A) For purposes of this section, “medically necessary treatment of a mental health or substance use disorder” means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progr…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly individual therapy.At issue in this case is whether weekly individual therapy is medically necessary to treat the patient’s medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. “Medically necessary treatment of a mental health or substance use disorder” means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for stress disorder was denied, the published record says the denial is worth fighting.