Cognitive Therapy denials in California external review

What the reviewers wrote

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 The patient has requested authorization and coverage for weekly in-person cognitive behavioral therapy (CBT) for one year and/or prescription management appointments once every two weeks for one year, or in the alternative for a shorter duration. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, 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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for (1) comprehensive assessment incorporating multiple settings (e.g., home, school) by a board certified behavior analyst (BCBA), (2) cognitive behavior therapy for 60 minutes per session once a week for eight weeks, and (3) occupational therapy for one weekly 60 minute session, for 12 weeks. The submitted documentation does not support the medical necessity of the requested services. In this case, the patient’s parent reports diagnoses of autism, attention deficit hyperactivity disorder (ADHD), and anxiety. However, the submitted records only documented a diagnosis of ADHD, apart from notes indicating that the patient’s mother reported that the patient had the possibility of an autism diagnosis following a second opinion.

Findings: The physician reviewer found that the patient’s parent has requested authorization and coverage for auditory processing disorder testing to include: (1) evaluation of central auditory function, with report initial 60 minutes, (2) evaluation of central auditory function, additional 15 minutes, (3) comprehensive audiometry threshold evaluation and speech recognition, (4) evoked otoacoustic emissions, limited, and (5) tympanometry and acoustic reflex testing. Testing patients with diagnoses that affect cognition, such as attention deficit hyperactivity disorder (ADHD), can affect the results of a central auditory processing disorder (CAPD) evaluation or render it invalid. Without complete treatment for ADHD, including physician-recommended medication therapy, it is likely that the untreated symptoms of ADHD for this patient would impact the reliability of a CAPD evaluation.

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 Therapy, then check the rights and deadlines that apply to your plan.