How to Write a Medical Necessity

like taking a bone
For people who may already have read this post I have written an update.

I left out crucial information regarding the need to get a written referral from your doctor if you are referred to a psychotherapist or think you need one. His written referral should include his clinical rational. This is the heart of any medical necessity.  For people who may already have read the post, I apologize for leaving out something so important.

This is my 2015 Blog for Mental Health for today
You have no rights if you have no legal recourse for exercising them.
One way you can exercise your right to access psychiatric services under the Affordable Care Act is to understand that all of your medical care in the managed care system hinges on a statement of medical necessity.
A concise medical necessity is a narrative description of the patient’s condition, abilities, limitations, as well as the relative success or failure of previous treatment protocols. It should be well researched with plenty of verified sources.
If you have Medicaid through the Affordable Care Act then you should know that individual Medicaid programs vary according to each State’s statutes.
States have the option of implementing a State specific program(s) through the State Medicaid Plan and waiver programs.
There are some general rules that apply to all State Medicaid programs.
  1. Beneficiaries are eligible for services when they are furnished;
  1. Services are furnished by licensed, qualified, Medicaid-approved staff;
  2. To the extent required by the State, services are medically necessary;
    To the extent required by the State, Medical necessity and medical rationale are documented and justified in the medical record (remember, each State adopts its own medical necessity definition);
    Here is a link to a profile of each state’s Medicaid program and the services their programs offer.
    Medically necessary services defined: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
    I’m going to use California’s definition of Medical necessity as a model.
    This is from the online Criteria Manual for the State of California.
    Your Statement of Medical Necessity should include the following information:
    1. A Statement of the specific services required to treat a patient with a specific Axis 1. Diagnosis.
    2. The specific Axis 1. diagnosis and its symptoms.
    3. The focus of the treatment; IE to Significantly diminish the impairment or to prevent significant deterioration in an important area of life functioning.
    4. The service provided must correct or ameliorate the mental illnesses discovered by the screening services provided by your care providers.

    In my case the diagnosis of Dissociative Identify Disorder was made after several sessions with my psychiatrist and screening for DID by a Kaiser case manager.

    A brief word about the multiaxial diagnosis.
    The Axis 1. Diagnosis is the primary diagnosis. schizophrenia, Bi-Polar illness, dissociative disorders, Post Traumatic Stress Disorder and major depression are examples of serious Axis 1 disorders.
    Axis 2 disorders are primarily disorders of personality. I frankly don’t understand the difference. The suffering of someone with Borderline Personality Disorder is terrible. My opinion is that there is a whiff of moral judgment here.
    But for the purpose of getting what you need, it is important to know that only the Axis 1 diagnosis is the one that matters.

    The biggest structural problem that people with mental illnesses have is the cost of psychotherapy, the lack of long-term structured treatment settings and the utter apathy of HMO treatment providers to the destruction this causes in the lives of their patients.

    If your goal is to get psychotherapy that is ongoing and paid for by your health plan then write your letter. Be polite. Be complete. And offer source links to verify your case.
    Here is what I wrote to the director of Kaiser’s Behavioral Health Program in 2011:
    “Dear Dr. Bigstuff;
    “I have researched dozens of well-regarded sources, including textbooks designed for students of psychotherapy, and they all say the same thing; that the only treatment for my illness is psychotherapy and that this treatment takes place in stages over the course of at least five years. My only chance of returning to a productive life, a life worth living, is to continue in psychotherapy which I cannot afford and which Kaiser claims it doesn’t provide.
    I have established the medical necessity of psychotherapy provided the documented agreement among mental health professionals that Dissociative Disorders are not responsive to short-term behavioral interventions or to medications. The only recommended treatment for Dissociative Identity Disorder is intensive psychotherapy.
    It is clear that Kaiser should pay for the recommended treatments for the illnesses diagnosed by its psychiatrists, especially if there are no alternatives.
    Please see the following sources:
    The Mayo Clinic
    Unspeakable Truths
    Re-traumatizing the Victim
    Mental Health America
    Guidelines for Treating Dissociative
    Identity Disorder in Adults, Third
    My Therapy has been covered by Kaiser since 2011.
    Do find a good case manager who is also a powerful advocate.
    Do involve your family in as much of your treatment as possible; a mental health system that doesn’t include family therapy is absurd.
    Don’t take no for an answer.
    Stigma silences. That is what it is designed to do.

    Blog for Mental Health 2015

4 thoughts on “How to Write a Medical Necessity

  1. This is a great post, Rob. People need to know the HOW as well as the WHAT. In so many tragic cases, people know/knew WHAT they needed but didn’t know HOW to get it. It’s great that you have what it takes to be your own advocate! I get bogged down in depression and often can’t muster the energy to get out of the hole.

    Liked by 1 person

    1. Thank you for liking the post. It needs a follow up.

      I have a good therapist and an alternate who has clinical skills. He is extremely objective in the way he approaches clinical issues. When he thinks that our treatment is not going well he calls in the therapist for a case conference. He will give her a list of clinical concerns and a menu of strategies. I think he frightens the counselors at Kaiser. He’s a Freudian. He’s the one that wrote “Our Lives Matter”.


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