Appeal type: Medical necessity
Decision: Overturned

Autistic Disorder
Mental Health Outpatient 

The patient who is in treatment with twice weekly multimodal psychotherapy for the management of a pervasive developmental disorder (autism spectrum and intellectual disability); schizoaffective disorder, bipolar type; communication disorder; generalized anxiety disorder; and, Tourette's syndrome.
The extended psychotherapy targets social skills, disruptive and inappropriate behaviors, self-care, and symptoms and behaviors related to the comorbid conditions. The patient has reportedly made progress with regard to functioning but continues to display problems with executive functions (organizing, sequencing, problem solving and decision making), communication-especially with regard to social cues and norms, inappropriate social behaviors including abnormal vocalizations and intrusions, rigidity with regard to behavior and conversation, and obsessive-compulsive related symptoms including those associated with the Tourette's syndrome. The patient has relationship problems and other functional impairments that limit her ability to function socially and within the family constellation.
Overturn in whole, the health plans determination.

The proposed outpatient mental health services and treatment are "medically necessary" for this patient.
The requested benefit of continued extended outpatient mental health visits twice a week for the DOS under review is consistent with prevailing standards of care and in keeping with evidence-based and empirical-based treatment principles and techniques that are being employed in this case, including treatment of the co-morbid conditions and ongoing issues related to executive functioning, communication, intellectual disability/developmental disorder and associated behavioral disturbances, tics and rigidity and ritual behaviors, and self-care. Moreover, the treatment was medically necessary for this patient,
 The outpatient mental health treatment and frequency and length of sessions under review is consistent with prevailing medical standards or clinical guidelines pertaining to patients with the conditions diagnosed in this case, as well as the scientific literature involving evidence-based treatments, known to benefit patients with the conditions diagnosed in this case. The patient has moderately severe symptoms of mood and anxiety and obsessive compulsive related disorders and ongoing stressors related to the developmental and communication disorders together with severe symptoms of dissociation; she has not reached a plateau with respect to symptoms or functioning, and the treatment plan focuses on maintaining progress with symptoms relief and coping skills, as well as continued attention to emotional and social functioning, and interpersonal and daily functions. The goals of treatment are reasonable and in the best interest of the patient and are consistent with prevailing standards of medical practice with regard to the intensity and frequency and duration of treatment with psychotherapy in order to address the conditions under treatment in this case. The case is complicated by the multiple conditions that impact communication, social functioning and ability to maintain self-care, and the patient has continued to benefit from the ongoing treatment as noted in the clinical summaries.