Cognitive Behavioral Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly therapy that includes eye movement desensitization and reprocessing (EMDR), dialectical behavior therapy (DBT), and cognitive behavioral therapy (CBT). 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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly psychotherapy including cognitive behavioral therapy (CBT), or in the alternative, psychotherapy including CBT every two weeks. Research provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using this, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include (1) risk of harm; (2) functional status; (3) medical, addictive, and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.

Where the denial was upheld

A female enrollee has requested authorization and coverage for eye movement desensitization and reprocessing (EMDR) for two hours per day for 90 days, or at any frequency or duration, cognitive behavioral therapy (CBT) twice per week, or at any frequency and duration, and residential treatment center (RTC) level of care with dual diagnosis. In review and consideration of additional documentation provided, the requested services including EMDR for two hours per day for 90 days, or at any frequency or duration, CBT twice per week, or at any frequency and duration, and RTC level of care with dual diagnosis are not medically necessary for treatment of this patient’s behavioral health issues. There is no new information to show that the patient’s condition warrants these treatment interventions.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mental health services, more frequently (weekly or bi-weekly) for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patient’s cases. In a letter from a treating provider, the notation indicates that the patient is receiving and utilizing CBT and supportive therapy while continuing to assess the patient’s need for increased sessions. The provider noted that this current plan was discussed with the patient’s parent. The medical necessity of increasing the sessions to weekly or bi-weekly is not demonstrated by the submitted records. Instead, the treating provider is suggesting less intervention for treatment of this patient.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Cognitive Behavioral Therapy, then check the rights and deadlines that apply to your plan.