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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly therapy.At issue is whether the requested weekly therapy is medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. If weekly therapy is upheld as not medically necessary to treat the enrollees condition, is therapy every other week medically necessary to treat the enrollees condition, as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below? If therapy every other week is upheld as not medically necessary to treat the enrollees condition, is therapy every three weeks medically necessary to treat the enrollees condition, as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below? If therapy every three weeks is upheld as not medically necessary to treat the enrollees condition, is therapy once monthly medically necessary to treat the enrollees condition, as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below? Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.According to Thase and Connolly, psychotherapy is a well-accepted adjunctive treatment to pharmacotherapy for severe depression. A recent meta-analysis by van Bronswijk and colleagues showed that psychotherapy in addition to treatment as usual was beneficial even for treatment resistant depression. The study utilized a minimum frequency of weekly therapy for 18 weeks. Assessment by the clinician should be made if the patient is decompensating or remaining depressed. According to the American Psychiatric Association, if the patient continues to be depressed and is treated with an antidepressant, an initial strategy is to increase the intensity or frequency of treatment. Moreover, while a patient is in a major depressive episode, weekly psychotherapy visits are appropriate.In this case, the patient was considered to be a moderate risk for suicide on 4/28/21. Moreover, the patient has a history of depression and anxiety which has been resistant to treatment. Per progress notes, the patient has tried antidepressants, adjunct antipsychotics, anticonvulsants, electroconvulsive therapy, as well as different therapeutic modalities. Despite this, the patient continued to have relapses into major depressive episodes, as evidenced by Patient Health Questionnaire-9 scores of greater than 24 on 4/27/21. Thus, weekly therapy is medically necessary for the treatment of the patients medical condition. Specifically, weekly therapy is medically necessary until the patient is stable and no longer in a severe major depressive episode. Weekly therapy is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, weekly therapy is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested weekly therapy is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Final Result: The reviewer determined that the requested services are medically necessary for the evaluation of the patients 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.