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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for radically open dialectical behavior therapy (RO-DBT) services. The enrollees provider indicates RO-DBT involves the clients acquiring coping and social skills they are missing to deal with their mental illness and life circumstances. It involves attending once a week skills class, weekly individual therapy, a weekly diary card to track behavior, 24 hour phone coaching to generalize the skills to everyday life, and a weekly consultation group. The provider indicates the enrollee made progress, but decided to end treatment earlier than recommended The record indicates the enrollee primarily presented with vacillating motivation, moderate drinking behavior, shame and guilt, and a lack of ability to forgive and move forward from past experiences. The enrollees issues were treated with interventions of self-inquiry recommendations and chain analysis during individual sessions, as well as skills classes, group therapy, diary tracking card, phone coaching, and a consultation group. There are three core transacting features relative to RO-DBT including: 1. receptivity and openness to new experience and disconfirming feedback to learn; 2. flexible-control in order to adapt to changing environmental conditions, and; 3. intimacy and social-connectedness based on premises that species survival required capacities to form long lasting bonds and work in groups.  These are managed by providing the client with context-appropriate emotional expression strategies. Although, the clinical outcomes data remains scarce, there has been early quantitative data to show improvements in social connectedness, experience of pleasure, eating disorder symptomology, lack of withdrawal, and reductions in perfectionistic and obsessive tendencies.  This enrollees diagnosis of unspecified depressive disorder, can describe a host of possible patterns of subthreshold depressive symptomology that impacts a enrollees life and causes impairment or significant distress in social, occupational, or other important areas of functioning, and typically includes either a conglomerate of depressive and anxiety symptoms, or recurrent brief depression/minor depressive disorder. The ambiguity of the diagnosis, in this case, lends to the lack of the necessary framework to delineate the specific symptom set that may have been resistant to other treatment protocols or results in the medical necessity of RO-DBT. Depression can often be managed via psychopharmacology, or through various evidenced-based practices and interventions that have high success rates.  The enrollees issues, as described in the record, and interventions provided do not appear specialized beyond what could have been offered through alternative depression treatment. Final Result: The reviewer determined that the requested services are 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.