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Over 50 million Americans have a mental illness. Despite this overwhelming number, the denial of health insurance coverage for mental health treatment continues to be extremely common, despite federal and state parity laws that are supposed to ensure fairness. 

On January 26, 2022, our client was admitted to a residential treatment program for teens and young adults. He entered treatment with a history of anxiety, mood instability, poor judgment and decision-making, substance use, and increased depressive symptoms. He had a history of high-risk behaviors, including alcohol use and drug use, and significant family discord. His mental health was declining rapidly, and he became unable to manage his overall functioning. Given all the above factors, his outpatient treatment team concluded he had an increased likelihood of self-harm and recommended residential treatment.

Upon admission to the facility, our client was diagnosed with major depressive disorder, severe, generalized anxiety disorder, cannabis use disorder, moderate, and attention-deficit/hyperactivity disorder. He was taking several prescribed psychiatric medications including, Prozac, Focalin, Trazodone, Neurontin, and Abilify.

On January 27, 2022, the facility requested preauthorization as required by the benefit plan within 24 hours of admission. Anthem denied the preauthorization request on the grounds that the requested treatment was not medically necessary. The request was sent for a peer-to-peer review.  The peer-to-peer review upheld the denial. The facility requested an expedited appeal and once again Anthem upheld the denial of residential treatment on the grounds that the requested treatment was not medically necessary.

Despite Anthem’s denial, our client’s treatment team believed residential treatment was clinically appropriate and medically necessary. The client remained in residential treatment. His treatment consisted of psychiatric evaluation and ongoing assessment, and medication management with the facility’s board-certified psychiatrist.

He participated in ongoing psychological assessments, five individual therapy sessions weekly, weekly family therapy sessions, as well as various psycho-educational, experiential, process, and other group therapy sessions three to four times daily.  He was exposed to 12-step programs while in residential treatment. 24/7 care was also provided to monitor his symptoms.

Once the team at Kantor & Kantor got involved and reviewed the denial letters, it was clear that Anthem’s denial was wrong and not supported by the record. Kantor & Kantor filed an appeal with Anthem, but Anthem upheld their denial. Recognizing that Anthem’s denial was improper, Kantor & Kantor acted quickly and filed a request for an independent external review with the California Department of Managed Healthcare (“DMHC”). As a result of Kantor & Kantor’s efforts the DMHC recently overturned Anthem’s denial finding our client’s residential treatment was medically necessary and directed Anthem to issue payment immediately.

At Kantor & Kantor we work to put an end to the stigma surrounding mental illness and substance use disorders and we advocate for treatment and recovery. We are willing to stand up to the insurance companies when they deny treatment and we understand that living with a mental illness or substance use disorder is different for everyone.

If you or someone you know has been denied healthcare benefits or access to treatment, please call Kantor & Kantor for a free consultation or use our online contact formWe understand, and we can help.