Pyschotherapy denials: what the review data shows

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.

The patient is a 56-year-old woman with a several-year history of depression. The patient’s provider notes the patient had a positive response to individual counseling. It has been recommended that the patient receive ten weekly sessions of individual counseling. The Health Plan indicates additional individual therapy is not medically indicated.The submitted records demonstrate the patient has clearly benefited from ongoing psychotherapy. Her psychiatrist, while providing pharmacology intervention, feels continued individual therapy is medically necessary. The patient’s therapy sessions are well documented and clearly show ongoing benefit. It is clear from the submitted records that psychotherapy has been instrumental in preventing relapse and rehospitalization.

Where the denial was upheld

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.

The patient is a 39-year-old male who was previously diagnosed with borderline personality disorder, polysubstance abuse, and post-traumatic stress disorder with several inpatient hospitalizations for depression and suicidality (one from 8/27/04 to 9/16/04 and the most recent from 10/11/04 to 10/15/04). Inpatient stays have often been preceded by use of amphetamine as well as alcohol. The stays themselves are marked by the patient’s dramatics and disgruntlement. The last hospitalization ended in the patient leaving against medical advice. At that point, he was offered different options including intensive outpatient treatment, residential placement, partial hospitalization, and dialectical behavioral therapy (DBT), all of which he refused, demanding instead to leave immediately.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Pyschotherapywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.