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

The enrollee is requesting authorization and coverage for individual therapy sessions at the frequency of once per week. The enrollee is a male who identifies as a female with a diagnosis of gender dysphoria. The enrollee also struggles with depression, anxiety, and relational problems. The enrollee reports attending couples counseling with her wife, and having her wifes support to proceed with vaginoplasty. Despite these emotional stresses, the enrollee reports having good relations with her therapists and prefers to be seen more often. The therapist indicates the enrollee feels she needs more support, and created a treatment plan for psychotherapy. Based on this note, the recommended and agreed upon amount and timeframe of initial enrollee contacts (combination of all possible treatment contacts, including individual group, medication visits, and any other treatment visits) would be one to two contacts, and planned to occur within five to six weeks. Future visits and treatment frequency is to be evaluated/adjusted based on treatment progress and will be determined with the enrollees participation at each visit. The subsequent visit was six weeks later. Although the enrollee wished to schedule the follow-up appointment sooner, the therapist was in contact with the enrollee through secure messaging. When the enrollee was seen for a follow-up appointment, the therapist noted the enrollees status of target symptoms was stable since the last visit and although the recommended treatment option was to continue with in-person appointments, there is no indication for the recommended frequency for in-person appointments. Rather, the enrollees in-person appointments were scheduled approximately on a once a month basis with frequent interactions in-between via secure messaging and outpatient telephone visit accommodations. Upon the enrollees request, the therapist scheduled an outpatient telephone visit. While there is no indication within the therapists note the enrollees in-person psychotherapy treatments should be increased to a weekly basis, the enrollee has requested weekly psychotherapy. According to standards of care, psychotherapy is highly recommended, especially when a patient is considering hormone therapy and surgery. However, standards of care do not indicate psychotherapy is an absolute requirement, and do not recommend a minimum number of psychotherapy sessions prior to hormone therapy or surgery. The reasons for this are multifaceted and the mental health professionals can facilitate the development of an individualized plan with specific goals and timelines with their patients. Although in-person is one option, standards of care also indicate online or electronic therapy has been shown to be particularly useful for people who have difficulty accessing competent in-person psychotherapeutic treatment, and is a useful modality for psychotherapy. Also emphasized are the importance and the value of establishing good rapport and relationship between the mental health professionals and the patients who present with gender dysphoria.  Based on review of standards of care, the records indicate the enrollee has a good rapport with her therapist, and the therapist is having frequent encounters with the enrollee outside of in-person visits, such as secure messaging and electronic therapy, including outpatient telephone visits. Although the enrollee is currently requesting weekly in-person psychotherapy sessions, the therapist does not indicate the enrollees clinical presentation requires weekly in-person psychotherapy. There is insufficient evidence in the record the enrollees medical condition requires weekly psychotherapy. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.