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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for individual parent-child interaction therapy (PCIT) services provided by an independent provider. At issue in this case is whether the individual PCIT services were and/or are medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374(a)(3)(A). Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.PCIT is an evidence-based approach intended to treat disruptive behavior problems in children two to seven years of age. The goals of PCIT are to encourage warm and secure parent-child relationships, increase child compliance, and decrease disruptive behaviors (Lieneman, et al.). Based on the patients challenging behaviors and age, PCIT would be an appropriate and medically necessary intervention. Per the submitted documentation, the Health Plan offered the patients parents group PCIT, but the parents declined. They were also offered individual and family therapy. In their independent medical review application/complaint form, the patients parents stated that group PCIT is not evidence-based.  Although PCIT was initially developed to work with the individual caregiver and child, PCIT has been successfully adapted to a group format. Adapting PCIT to a group strategy is considered by many to be an innovative strategy to reach more families with the additional benefit of peer support. Nieter and colleagues noted, Although PCIT is typically delivered in outpatient clinic-based settings with individual families, research has demonstrated positive outcomes when the model is applied in a group-based format. The authors reported that when comparing individual PCIT to group PCIT, significant improvements were noted in child conduct problems, parenting stress, and childrens adaptive functioning in both formats. When practiced with fidelity to the PCIT model, group PCIT includes the same didactic sessions at the beginning of treatment as individual PCIT and coaching sessions are similar in structure and content to individual PCIT. Therefore, individual PCIT services were not and are not medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374(a)(3)(A).Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent 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 a similar medical condition.