Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ongoing cognitive processing therapy (CPT).Cognitive processing therapy (CPT) is a specific treatment approach developed for post-traumatic stress disorder (PTSD), which requires specialized training. In their 2017 clinical practice guidelines for the treatment of PTSD, the American Psychological Association (APA) strongly recommends the following approaches: cognitive behavioral therapy (CBT), CPT, cognitive therapy, and prolonged exposure therapy. According to the Veterans Administration (VA) National Center for PTSD, `Although CPT was originally developed as a 12-session protocol, it is now administered over a variable number of sessions, depending on patient needs. This change stemmed from a study by Galovski et al. (2012) which found that ending therapy based on patient progress yielded better results than using a proscribed number of sessionsby the end of the study, 92% of the participants who had variable length CPT no longer had a diagnosis of PTSD.` Per APA guidelines for PTSD, individuals post-trauma reactions show great variability, ranging from those that are highly resilient--with little or no emotional distress-- to those that are relatively mild and short-term, to those that are major, chronic, and highly debilitating. In their 2012 study, Galovski and colleagues concluded that it is possible that living with PTSD for extended periods of time (irrespective of current age of the client) may result in more diffuse distress, overall role impairment, and subsequent deficits in functioning. A chronic PTSD clinical presentation may present additional challenges in therapy, requiring a longer course of treatment. Elevated depression prior to therapy also emerged as a significant predictor of length of treatment. The presence of elevated depression prior to treatment may portend a longer road to recovery. Their study found that continuing the course of CPT is warranted if resolution of PTSD and depressive symptoms has not been fully achieved by the end of the standard 12-session protocol.In this case, the patient had suffered with symptoms for years prior to treatment. He had comorbid depression and a history of substance abuse, which started after the trauma. Also, the surgeries the patient underwent to address the medical sequelae of his rape may have led to re-traumatization, based on the nature of the surgeries themselves, the recovery periods, and the history of homophobia and poor medical care he reported experiencing after the initial trauma. The patients therapist has indicated in her clinical notes that she is providing CPT, along with other approaches, including CBT, gradual exposure therapy, and dialectical behavioral therapy (DBT) based approaches, as well as crisis management and safety monitoring. Given patient's prior traumatic experiences with the health care system and his reluctance to seek care, as well as the complexity and severity of his symptoms, a long-term course of therapy, including a CPT approach, is clinically warranted and supported by PTSD treatment guidelines. The patient would be at risk of relapse of depressive symptoms and anxiety without continued treatment. Under these circumstances, ongoing cognitive processing therapy (CPT) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.