Dialectical Behavior 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 therapy that includes eye movement desensitization and reprocessing (EMDR), dialectical behavior therapy (DBT), and cognitive behavior therapy (CBT). 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. The composite score is then used to determine the level of care needed.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a six-month Dialectical Behavior Therapy (DBT) program. Findings: The physician reviewer found that The submitted documentation does not support that the requested services are medically necessary. DBT is typically used for individuals with a diagnosis of borderline personality disorder. DBT is used to help individuals with emotion regulation issues, instability of affect, and interpersonal problems. In this case, the most recent progress notes from the patient’s psychiatrist and her therapist indicated that the patient appeared to be functioning well. These notes do not indicate that the patient was experiencing any suicidal ideation. The patient reported that her mood was stable. Her impulse control was noted to be good.

The parent of an enrollee has requested authorization and coverage for individual dialectical behavior therapy (DBT) twice a week. A Cochrane review of therapeutic interventions for addressing self-harm in children and adolescents concluded that there have been relatively few investigations into interventions for children and adolescents who engage in self-harm. The review concluded that there is little evidence on which to draw conclusions on the effectiveness of interventions for self-harm in this population. While there were some very limited positive findings regarding DBT-A (DBT for adolescents), mentalization, and therapeutic assessment, the review concluded that these approaches require further evaluation before any definitive conclusions about their use in clinical practice can be made.

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