Appeal type: Medical necessity
Decision: Overturned

Mental Health
Mental Health: Outpatient

Diagnosis: Pervasive Developmental Disorder 
Treatment: Outpatient mental health visits with sixty-minute extended sessions. 
The insurer denied Outpatient mental health visits with sixty-minute extended sessions. 
The denial is overturned.

The patient was in treatment with multimodal psychotherapy for management of a pervasive developmental disorder (autism spectrum disorder); traumatic brain injury with associated symptoms of unspecified anxiety disorder; attention deficit hyperactivity disorder; non-verbal learning disorder; and, recurrent episodes of major depressive disorder. The extended psychotherapy (code 90837) targets social skills, disruptive and inappropriate behaviors, self-care, and symptoms and behaviors related to the comorbid conditions. The patient has reportedly made progress with regard to functioning but continues to display problems with executive function (organizing, sequencing, problem solving and decision making), communication-especially with regard to social cues and norms, inappropriate social behaviors including anger when he perceives he is being wronged by others, rigidity with regard to behavior and conversation, and obsessive-compulsive and narcissistic personality traits that put him at risk for episodes of depression or mood disturbance. The patient has relationship problems and other functional impairments that limit his ability to function socially and occupationally.
The patient was seen on an ongoing basis from 07/10/2018-04/18/2019 with multimodal psychotherapy with insight oriented and cognitive behavioral techniques, as well as ongoing efforts to address the comorbid co-morbid mental health conditions with clinically appropriate therapy and collaborative psychiatric management. Medications include Nuvigil, Prozac, Lamictal, and Lunesta at clinically appropriate dosages to address the attention deficit hyperactivity disorder (ADHD), Mood and Anxiety Disorders and associated symptoms of insomnia.
The patient receives formal psychotherapy with cognitive-behavioral, dialectical behavioral and supportive techniques as well as insight-oriented therapy that are aimed at improving sense of self and somatic experiencing. Thus, the patient receives individual psychotherapy on an ongoing basis with 60 minute sessions required in view of the patient's non-verbal disability and brain injury that impacts his processing speed. During therapy sessions, the patient requires redirection, containment and support in order to provide effective therapy. The documentation does specify that the therapy addresses the mental status findings and behavioral disturbances that including efforts to address socially inappropriate behavior/social skills, and other disturbances such as communication problems.
There are no co-occurring substance use disorders or general medical issues in this case.
There are ongoing issues with stressors and neuropsychological deficits, as noted by the patient's clinicians. The patient has persistent problems with interpersonal functioning, and ongoing symptoms of mood disturbance and anxiety that are moderately severe in the context of relationship functioning. There are no other severe symptoms reported in the clinical summary or progress notes such as severe cognitive impairment, frank mania, psychosis (delusions or hallucinations), or, suicidal/aggressive behavior. The comprehensive assessment reflects the symptoms related to the multiple disorders with fair to poor insight and judgment and motivation, and clear speech despite communication problems and the nonverbal learning disability in the context of bright normal intellectual functioning.
The requested services, outpatient mental health treatment with extended sessions, have been denied for specific dates noted below on the basis of medical necessity by the health plan. The psychotherapy has resulted in symptom relief and other improvements in functioning, as well as improved insights regarding emotional and relationship functions and with regard to ongoing interpersonal functioning, as well as self-care and social skills and managing narcissistic and obsessive-compulsive related personality traits in the context of autism spectrum disorder and brain injury.
The patient and patient's therapist are requesting coverage for the outpatient mental health treatment with extended psychotherapy sessions of 60 minutes with review of the specified dates of service (DOS).
The health plan documents, policy regarding the therapy including plan language, and health plan correspondence were reviewed. The patient's appeal documents and case summary and correspondence and information submitted by the patient's clinicians together with reference to the treatment plan and recommendations from the neuropsychological test results were reviewed. This review is NY State mandated review.
The issue under review is the medical necessity of outpatient mental health visits with sixty-minute extended sessions (code 90837).

The requested benefit of extended outpatient mental health visits for the DOS under review is consistent with prevailing standards of care and in keeping with evidence-based and empirical-based treatment principles and techniques that are being employed in this case, including treatment of the co-morbid conditions and ongoing issues related to executive functioning, communication, autism spectrum disorder/developmental disorder and associated behavioral disturbances. Moreover, the treatment is clinically appropriate and medically necessary for this patient.

The outpatient mental health treatment and frequency and length of sessions under review is consistent with prevailing medical standards or clinical guidelines pertaining to patients with the conditions diagnosed in this case, as well as the scientific literature involving evidence-based treatments, known to benefit patients with the conditions diagnosed in this case. The patient has moderately severe symptoms of mood and anxiety and obsessive compulsive and narcissistic personality traits, and ongoing stressors related to the developmental and communication disorders related to nonverbal learning disorder. The treatment plan focuses on maintaining progress with symptoms relief and coping skills, as well as continued attention to emotional and social functioning, and interpersonal and occupational functions. The goals of treatment are reasonable and in the best interest of the patient and are consistent with prevailing standards of medical practice with regard to the intensity and frequency and duration of treatment with psychotherapy in order to address the conditions under treatment in this case. The case is complicated by the multiple conditions that impact communication, social functioning and ability to maintain mood stability, and the patient continued to benefit from the ongoing treatment, as noted in the clinical summaries.
Evidence-based techniques are being appropriately provided in this case scenario. The residual symptoms and psychological issues in this case cannot be effectively addressed without the ongoing extended therapy sessions together with other possible interventions that could include ongoing involvement in peer support and/or community-based self-help support groups and the appropriate application of medication management with the use of clinically appropriate medications targeting the mood and anxiety and attention deficit disorders-as is being provided in collaborative care. The best practice in this case includes the requested services, extended outpatient psychotherapy, consistent with the scientific literature, referenced below.