Individual Therapy denials in California external review
In the California DMHC record, independent physician reviewers decided 35 published external-review cases involving Individual Therapyand overturned the plan’s denial in 71.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Individual Therapy denials
| Category | Decisions | Overturned |
|---|---|---|
| Depression | 10 | 70% |
| Anxiety | 8 | 75% |
| Bipolar Disorder | 5 | 100% |
| Post-traumatic Stress Disorder | 4 | 75% |
| Major Depressive Disorder | 4 | 100% |
| Suicidal Ideation | 3 | 66.7% |
| Anxiety Disorder | 3 | 100% |
What the reviewers wrote
Where the denial was overturned
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.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for individual therapy services, two times 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). 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. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Where the denial was upheld
The patient is a 46-year-old female with long-standing opioid dependence, sedative-hypnotic abuse, and alcohol dependence in remission, generalized anxiety disorder, and depression NOS vs. major depression. She was admitted to an intensive outpatient program through her Health Plan on 4/5/04. She continued in this program until approximately 5/26/04, having become largely abstinent of substance abuse during this time. She was later admitted to inpatient care for detoxification on 6/7/04, after having taken 36 Morphine pills on 6/3/04, noting a prior overdose six weeks prior wherein she was hospitalized for five days. She was subsequently detoxified with Suboxone, tolerating the downward taper as well, last dose administered on 6/21/04. After this time, she was transitioned to seeing a psychiatrist, who she saw from 6/22/04 to 12/3/04.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for weekly in-person individual therapy. Findings: The physician reviewer found that 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.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Therapy, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY