coTenacious Therapy

Individual TherapyMedical necessity means that therapy is needed to treat a mental health condition that is causing significant emotional distress, symptoms, or difficulty functioning in daily life. Treatment is considered medically necessary when it is expected to help improve, stabilize, or prevent worsening of those symptoms and functioning.Examples of areas that may be affected include:Work or school performanceRelationships and family functioningSleep, concentration, or moodAbility to manage stress or emotionsSafety, self-care, or daily responsibilitiesInsurance companies generally require that therapy:Addresses a diagnosable mental health conditionUses clinically appropriate treatment methodsHas clear treatment goals and measurable progressIs provided at a level and frequency appropriate to the person’s needsFamily TherapyFamily therapy is considered medically necessary when family relationships, communication patterns, or caregiver dynamics are directly affecting the identified client’s mental health symptoms, recovery, or daily functioning.Family sessions may help:Reduce conflict or stress that worsens symptomsImprove communication and emotional supportStrengthen coping strategies within the family systemSupport treatment goals and recoveryImprove safety, stability, and functioning at homeIn family therapy, the focus remains on supporting the identified client’s treatment needs and improving outcomes related to their mental health condition.Therapy that does not meet medical necessity criteriaAccording to insurance companies, there are some services that are not medically necessary. This does not mean these services are unhelpful or unimportant, only that insurance plans will not pay for them.Services provided forPersonal growth or self-improvementGeneral life stress without functional impairmentWellness or maintenance without active symptomsSocialization or companionshipConvenience of the client or providerSupportive counseling without a treatment objectiveEducational, vocational, or recreational purposes aloneRelationship counseling when no mental health diagnosis or functional impairment is presentCustody evaluations, court-ordered evaluations without treatment focus, or administrative requestsTherapy that is duplicative of another provider’s servicesMaintenance treatment where sustained improvement is not expected and treatment is primarily to preserve prior gains without active symptoms requiring treatmentAccording to provider guides“The goals of treatment are not primarily for providing support… or primarily self-improvement.”“Not primarily for the convenience of the patient or Healthcare Provider.”“Treatment is not duplicative of services being provided by another clinician for the same reasons/diagnoses.”“The condition has not stabilized to the point where maintenance treatment is appropriate.”Services must be “directed at a medical problem/diagnosis.”Medical necessity is not met when treatment is not expected to improve symptoms, functioning, or prevent deterioration.

Our blog is a great place to read more about this but fundamentally, CoTenacious Therapy has made the difficult decision to leave insurance networks due to decreasing and unpredictable reimbursement, increasing audits and clawbacks, growing administrative burdens, restrictions on clinical care, and concerns about the increasing consolidation of provider data and healthcare infrastructure within the insurance industry. We know this change may significantly impact some clients, and we are committed to helping our clients understand their out-of-network benefits, explore your options for payment, and advocate for better behavioral health coverage with insurance companies.