Individ Counsel 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’s parent has requested authorization and coverage for family therapy once per week and/or individual therapy services twice per week, or in the alternative, individual therapy services once per 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). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization for residential treatment center (RTC) services (ASAM 3.5) that include treatment for compulsive sexual behaviors with a multidisciplinary team which includes certified sex addition therapists (CSAT). For Dimension 1, In this case, the patient will be going into RTC treatment following prior detoxification. The patient is experiencing or anticipated to imminently experience mild to moderate signs and/or symptoms of intoxication that can be addressed in any level of care as needed and thus does not require a medically managed addiction treatment program for intoxication management.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for daily 1:1 therapies, to include: (1) occupational therapy 2x/week, (2) art therapy 1x/week, and (3) movement therapy 1x/week, in addition to the approved play 2x/week, eye movement desensitization and reprocessing (EMDR) 1x/week, and family therapy 1x/week. Findings: The physician reviewer found that At issue in this case is whether the daily 1:1 therapies, to include: (1) occupational therapy 2x/week, (2) art therapy 1x/week, and (3) movement therapy 1x/week, in addition to the approved play 2x/week, EMDR 1x/week, and family therapy 1x/week are medically necessary to treat the patient’s medical condition as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below.

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