Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 36-year-old female enrollee has requested reimbursement and prospective authorization and coverage for outpatient mental health services provided from 12/17/14 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that according to the documentation submitted for review, the patient presents with major depressive disorder and posttraumatic stress disorder with pathology steeped in psychodynamic and characterological theory. Psychodynamic psychotherapy is a trusted intervention in the treatment armamentarium for those afflicted with major depressive disorder. Per the American Psychiatric Association (APA) clinical practice guideline, Psychodynamic psychotherapy may be brief but usually has a longer duration than other psychotherapies, and its aims extend beyond immediate symptom relief. These goals are to modify underlying psychological conflicts and deficits, which increase the patients vulnerability to depressive affect and the development of major depressive disorder.  Although not an evidence-based therapy for posttraumatic stress disorder akin to cognitive processing therapy or prolonged exposure, per the VA/DoD clinical practice guideline, psychodynamic psychotherapy is recognized as having some benefit with fair evidence that it can improve health outcomes for those diagnosed with PTSD.  Thus, contemporary practice standards and evidence-based treatment guidelines support the appropriateness of the intervention in this particular case. However, in the absence of treatment records such as a psychiatric evaluation, psychological assessment with testing, interpretative summary, progress notes, objective rating scales and treatment plan updates, the reasonableness of the intervention, in particular the duration and frequency of the therapy, cannot be determined. According to APA guidelines It can be useful to establish an expected duration of psychotherapy at the start of treatment. Communicating this expectation may help mobilize the patient and focus treatment goals, yet there are few data available on the optimal duration of specific depression-focused psychotherapies.The optimal frequency of psychotherapy has not been rigorously studied in controlled trials.Regardless of the type of depression-focused psychotherapy that is selected, the clinician should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of clinician and patient rated scales at regular intervals. If 48 weeks of treatment do not yield at least moderate improvement (=20% diminution in symptoms), the clinician should thoroughly review and reappraise the treatment plan. In this case, the absence of treatment records does not make it possible to assert with any degree of confidence that the disputed therapy is improving the patients condition and/or preventing a more serious episode of illness. In the absence of any additional clinical documentation supporting the treatment plan from 4/15/15, the disputed service cannot be considered medically necessary after an eight-week interval, which correlates with a date of 6/15/15. As such, the outpatient mental health services provided from 12/17/14 through 6/15/15 was medically necessary, but not thereafter. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.