Family Counseling denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient’s parent has requested authorization and coverage for (1) in-person family therapy, once a week (in addition to the approved individual therapy, once a week), or (2) in-person family therapy, twice monthly (in addition to the approved individual therapy, once a week). The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (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).

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for family therapy. The researchers provide 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. For dimension 1, with regard to risk of harm, the records support a score of 1. The patient has a low risk of harm.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for family therapy every 2-3 weeks.The Researchers provide 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.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for intensive in-home family treatment sessions four times a week for 9 to 12 months. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to persistent and ongoing suicidal ideation with thoughts of wanting to hang herself and a history of superficial cutting. The patient had been hospitalized multiple times for suicidal ideation and was noted to be impulsive with poor judgment.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to multiple hospitalizations.

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