Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adjustment Disorder, Attention-Deficit Hyperactivity Disorder.
Treatment: Outpatient Mental Health Services.
The insurer denied the Outpatient Mental Health Services.
The denial is upheld. 

The patient is a male who has been treated for co-occurring attention-deficit hyperactivity disorder (ADHD) and an adjustment disorder with mixed symptoms of depressed mood and anxiety. The patient has been treated with extended sessions of psychotherapy (60-minute sessions) provided by a clinical psychologist. The patient's clinician indicates that the extra time with 60-minute sessions was necessary in order to accommodate for tangential and disorganized thought processing and other symptoms of attention-deficit hyperactivity disorder (ADHD) that made therapy sessions more difficult.

The patient's insurance plan indicates that the requested benefit of extended outpatient psychotherapy sessions is not justified based upon the diagnoses under treatment. The treating provider submitted handwritten progress notes and a letter to the patient detailing therapy goals and formulation of a plan for treatment. 

The health plan has denied a request for coverage of the therapy sessions on the basis of medical necessity and plan guidelines and policy pertaining to behavioral health services and extended outpatient psychotherapy sessions. 

The patient and his clinician are requesting coverage for the extended outpatient therapy sessions with at least 13 sessions billed during the time interval under review.

No, the proposed Outpatient Mental Health Treatment is not medically necessary for this patient.

In this case, the patient received psychotherapy services from a provider with extended sessions of 60 minutes (revenue code 90837). The health plan has appropriately denied a request for the extended psychotherapy sessions indicating that therapy with 45-minute sessions would effectively provide the necessary services to address the patient's adjustment disorder with mood and anxiety symptoms. 

The submitted documentation includes progress notes that do not justify the extended sessions. The request for extended psychotherapy sessions is based upon the co-morbid diagnosis of attention-deficit hyperactivity disorder (ADHD). The progress notes provided indicate that the patient was presently not on any medication for his attention-deficit hyperactivity disorder (ADHD), which would be standard to manage symptoms. As of the last date in question, the patient is noted to be on Vyvanse and feeling "great" and better focused, but there are no details regarding the start date of medication management. The patient's psychiatric disorders and proposed treatment are not so complex or unique that it is medically necessary that the patient receive extended psychotherapy sessions. Again, the patient's treatment for the adjustment disorder with mixed depressive disorder and anxiety is amenable to conventional treatment with the provider of clinical care.

There were no complicating features identified in this case such as current, active substance use disorder, acute general medical issues, or specified psychosocial stressors that are a focus of treatment with crisis intervention that could warrant extended psychotherapy sessions. The patient's treatment for an adjustment disorder is amenable to standard therapy sessions and extended therapy sessions are not warranted in this case scenario.