Psychotherapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for ongoing psychotherapy treatment, every two weeks. 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.

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement and prospective authorization and coverage for psychotherapy services. 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychotherapy services. The patient is variously diagnosed with major depression, recurrent, generalized anxiety disorder, obsessive compulsive disorder (OCD), BPAD unspecified, with impulsivity, risky behavior, and paranoid thinking. He also has a reported seizure disorder. By his own report, the patient had abused alcohol but had been sober for several months before receipt of the services at issue. He also reported having strained family relationships and stress at home. Upon referral from a Licensed Clinical Social Worker (LCSW) therapist to services elsewhere, the therapist wrote that the patient’s OCD had improved, that he had decreased impulsivity, and that he had no suicidal or homicidal ideation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested twice weekly therapy visits for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that the medical literature does not define the frequency or duration for the amount of psychotherapy required for each patient. However, it is generally accepted that patients in crisis require more frequent sessions than patients who are stable. The medical literature also supports that in unrestricted therapies, each additional psychotherapy session has a diminished effect. An article by colleagues, they report, “Our findings suggest that, at least in unrestricted therapies, the average rate of change during psychotherapy can be expected to diminish with each additional session irrespective of the length of treatment.

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