Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for daily 1:1 therapies, to include: (1) occupational therapy 2x/week, (2) art therapy 1x/week, and (3) movement therapy 1x/week, in addition to the approved play 2x/week, eye movement desensitization and reprocessing (EMDR) 1x/week, and family therapy 1x/week. Findings:  The physician reviewer found that At issue in this case is whether the daily 1:1 therapies, to include: (1) occupational therapy 2x/week, (2) art therapy 1x/week, and (3) movement therapy 1x/week, in addition to the approved play 2x/week, EMDR 1x/week, and family therapy 1x/week are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below. 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.The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder (PTSD) states that treatment planning should consider a comprehensive treatment approach which includes consideration of the severity and degree of impairment of the child's PTSD symptoms and that treatment of children with PTSD symptoms should include education of the child and parents about PTSD.and trauma-focused psychotherapy including cognitive-behavioral therapy, psychodynamic psychotherapy, and/or family therapy. The AACAP practice parameter also states, Trauma-focused psychotherapies should be considered first-line treatments for children and adolescents with PTSD and notes that among trauma-focused psychotherapies, trauma-focused cognitive behavior therapy (TF-CBT) has the most empirical support for the treatment of childhood PTSD. Ford and Greene state that TF-CBT is the most extensively researched model of PTSD psychotherapy and is a conjoint child and parent psychotherapy model for children who are experiencing significant emotional and behavioral difficulties related to traumatic life events. It can be used with children as young as three years of age who have experienced a single trauma or multiple traumas. Brent and colleagues also found evidence for child-parent psychotherapy (CPP) in treating young children with PTSD. Conversely, there is a lack of studies utilizing movement therapy or occupational therapy in the treatment of PTSD in ages 018 years. Additionally, there is a lack of controlled trials utilizing art therapy in the treatment of PTSD in children. For these reasons, the requested daily 1:1 therapies, to include: occupational therapy 2x/week, art therapy 1x/week, and movement therapy 1x/week in addition to the approved play therapy 2x/week, EMDR 1x/week, and family therapy 1x/week are not medically necessary to treat the patients mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A). The requested daily 1:1 therapies are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the daily 1:1 therapies are not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested daily 1:1 therapies are 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.Final Result: The reviewer determined that the requested services 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 sub-specialty 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.