Outpatient Psychotherapy denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 29-year-old female with bipolar disorder, type 1 with a history of past hospitalization for frank mania as well as suicidality. The patient was later stabilized on Lamictal and Depakote following failure of Lithium due to excessive weight gain and development of acne. A chart note from her psychiatrist on 10/14/04 indicates that “her mood has been somewhat difficult to control” and there “continues to be much stress in her life that is easily disruptive and can cause some transient mood instability. It appears that regular maintenance psychotherapy has been helpful.” Chart notes of the patient’s psychotherapist document that due to the extent of the patient’s illness she went from working as a teacher to being without a job. The patient has had to return to living with her mother due to a lack of funds and is finding it difficult to obtain job interviews.

A 63-year-old female enrollee has requested continued outpatient psychotherapy, at a frequency of five times per week or any other frequency greater than two sessions per week, and for outpatient psychotherapy at a frequency of five times per week, or any other frequency greater than one session per week, for treatment of her dysthymic disorder. Findings: The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those diagnosed with affective disorders, such as dysthymia. Current practice is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. “The optimal frequency of psychotherapy has not been rigorously studied in controlled trials.

Where the denial was upheld

The patient is a 39-year-old female with previously diagnosed Major Depression, Recurrent and Axis II pathology thought to be in the realm of Borderline. She has been treated with a combination of medications and psychotherapy. The patient received 141 sessions with her therapist from July 2001 to January 2005. She also saw several psychiatrists during this time and was eventually thought to be reasonably stabilized with a combination of Zoloft, Wellbutrin, and Neurontin. Neurontin was added to her regimen due to the concern of the therapist that the patient seemed sufficiently hypomanic to warrant a consideration of bipolar disorder, type II. In consultation with the psychiatrist, the operative diagnosis was changed.

A 46-year-old female enrollee has requested outpatient psychotherapy, two sessions per week for treatment of her post-traumatic stress disorder and generalized anxiety disorder. Findings: The physician reviewer found that psychotherapeutically, current practice is focused on aggressive treatment of anxiety, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Thus, it is not uncommon for transient weekly, or even twice- and thrice-weekly, sessions to be medically necessary in the treatment of anxiety disorders.

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