Eye Movement Desensitization And Reprocessing 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: An enrollee has requested authorization and coverage for Eye Movement Desensitization and Reprocessing (EMDR) Therapy.At issue in this case is whether the requested Eye Movement Desensitization and Reprocessing (EMDR) Therapy is medically necessary to treat the patient’s mental health or substance use disorder, as defined in Health and Safety Code section 1374.72(a)(3)(A).California Health and Safety Code section 1374.72(a)(3)(A) states that, “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 th…

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to an eye movement desensitization and reprocessing (EMDR) specialist. Findings: The physician reviewer found that EMDR is specifically indicated for the treatment of patients with post-traumatic stress disorder (PTSD). Based on the available documentation, this patient’s presentation does not support a diagnosis of PTSD. In addition, there is a lack of documentation of symptoms consistent with PTSD. Bereavement is distressing, particularly that after a child’s death. However, this is not considered an exposure to an actual or threatened death, injury or violence, which is required for a PTSD diagnosis per the American Psychiatric Association (APA).

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 Eye Movement Desensitization And Reprocessing, then check the rights and deadlines that apply to your plan.