Individual Psychotherapy 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 individual psychotherapy services (as needed, referring one to two times per week, at a minimum). 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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for therapy services (including one hour, weekly, in-person, individual therapy; one hour, weekly, in-person, family therapy; one hour, weekly, in-person, parent therapy; and one hour, weekly, 1:1 skills coaching). 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).

Where the denial was upheld

The enrollee is requesting authorization and coverage for individual therapy sessions at the frequency of once per week. The enrollee is a male who identifies as a female with a diagnosis of gender dysphoria. The enrollee also struggles with depression, anxiety, and relational problems. The enrollee reports attending couples’ counseling with her wife, and having her wife’s support to proceed with vaginoplasty. Despite these emotional stresses, the enrollee reports having good relations with her therapists and prefers to be seen more often. The therapist indicates the enrollee feels she needs more support, and created a treatment plan for psychotherapy.

The patient is a 46-year-old male who first presented in outpatient care in September 2003 with an approximate two-month history of anxiety and depression, attendant with insomnia, depressed mood, loss of energy, decreased attention and concentration, and sense of panic and agitation. He noted this as secondary to several stressors including long work hours, suffering a pay cut with no cost of living increase, job promotion but uncertainty as well, refinancing his house, and his two young children being very active. The patient has been diagnosed with generalized anxiety disorder as well as major depression. He was prescribed a combination of Paxil, Trazodone, Imipramine, Lorazepam, and Celexa, the latter being the most recently added medication, as well as Klonopin. He was also seen in couples therapy in October 2003.

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