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

Nature of Statutory Criteria/Case Summary: The enrollee is diagnosed with major depressive disorder (MDD). On 1/6/19, his patient health questionnaire (PHQ-9) score was 16. On 1/9/19, the patients generalized anxiety disorder (GAD-7) score was 16. On 1/15/19, the patients provider noted deterioration in the patients mood. The patient was noted to be more tearful, especially with social discomfort. The patient demonstrated an increase in obsessive thoughts, reduced motivation associated with decreased frequency in his activities of daily living, and is isolating himself from others. The patient reported a depressed mood and hopelessness. At issue in this case is whether individual outpatient psychotherapy once a week is medically necessary for the treatment of this patients medical condition. The National Institute for Health and Clinical Excellence reports that psychotherapy is an evidence-based treatment for MDD, either alone or in combination with psychiatric medication management. The aim of treatment is to obtain significant improvement or remission. The duration of treatment may be reduced if remission has been achieved or increased when a patient is making progress. In one study, after treatment with psychotherapy, 62% of patients no longer met the criteria for MDD. Further, the American Psychiatric Association reports that use of a depression-focused psychotherapy is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder. Patients receiving psychotherapy should be carefully and systematically monitored on a regular basis to assess their response to treatment and assess patient safety. When determining the frequency of psychotherapy sessions for an individual patient, the provider should consider multiple factors, including the specific type and goals of psychotherapy, symptom severity, co-occurring disorders, cooperation with treatment, availability of social supports, and the frequency of visits necessary to create and maintain a therapeutic relationship, ensure treatment adherence, and monitor and address depressive symptoms and suicide risk. This patient reported an increase in depressive and anxiety symptoms. The patients provider noted the patient had been stable and responding to weekly therapy, but deteriorated due to the change in frequency of psychotherapy. The medical evidence supports the requested treatment in this clinical setting. Therefore, individual outpatient psychotherapy once a week is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in psychosomatic medicine 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.