Psychotherapy Utilization Review/Medical Necessity Letter

Date: [Date of letter]

To: [Payer name], Utilization Review Department [Fax number / Portal routing if known]

Re: Request for [Authorization / Continued Authorization] – Outpatient Psychotherapy

Patient: [Patient full name], DOB: [DOB], Member ID: [Member ID], Auth/Claim Reference: [Reference number if known]

Provider and Service Information

• Treating clinician: [Clinician name], [Credentials] – [License type, State], NPI: [NPI]
• Practice: [Practice name], [Address], Phone: [Number], Fax: [Number]
• Setting: [Outpatient office / Telehealth / Community clinic]
• Service type: [Individual / Family / Group] psychotherapy
• Primary modality: [CBT / DBT / EMDR / IPT / ACT / Supportive / Exposure-based / Trauma-focused CBT / Other]
• Session length: [30 / 45 / 50 / 60 / 75 / 90] minutes

Authorization Request Summary

[Initial / Continued] authorization requested for outpatient psychotherapy. (For continuation, include: Current authorization window [dates], visits approved [n], visits used [n], visits remaining [n].) Requested frequency and duration: [Frequency and number of sessions] from [Start date] through [End date]. Primary clinical reason: [One-sentence medical necessity statement]. (If requesting a change from prior authorization, briefly state what changed and why.)

Consent and Confidentiality Statement

This letter provides a clinical summary for utilization review purposes. Detailed psychotherapy process notes are not included. [Patient provided written authorization on (date) / Disclosure limited to minimum necessary clinical information per HIPAA].

Clinical Summary

[Primary diagnosis with severity and duration]. Comorbid conditions: [List or none]. Presenting problems include [Target symptoms] causing [Functional impact summary]. Risk status: [Current risk level and protective factors]. Treatment to date: [Start date], [Number] sessions using [Key interventions], with [Response summary using objective indicators]. Requesting [Frequency/amount] due to [Clear necessity statement]. (Write 5–8 sentences; use observable and measurable data.)

Diagnosis and Clinical Formulation

• Primary diagnosis: [ICD-10 code] [Diagnosis name] [Severity specifier if applicable]
• Comorbid psychiatric diagnoses: [List with codes, or "None"]
• Pertinent medical conditions: [Conditions affecting treatment, or "None"]
• Substance use: [None / Type, frequency, last use, SUD diagnosis if applicable]
• Maintaining factors/barriers: [Key psychosocial factors, stressors, or barriers to treatment]
• Diagnostic basis: [Assessment methods used: clinical interview, standardized measures with scores/dates, collateral sources] (For continued authorization: note if diagnosis unchanged or specify changes.)

Current Clinical Presentation

Target symptoms: [Symptoms organized by domain with severity indicators, frequency, duration, triggers, and dates of onset or change]

Measurement-based care: [Scale name]: Baseline [Score] on [Date]; Most recent [Score] on [Date]; Trend: [Improving / Stable / Worsening]. (Include additional scales as applicable.)

Functional impairment:

• Work/School: [Attendance, productivity, accommodations, LOA; include dates and examples]
• ADLs: [Sleep, hygiene, meals, appointments; specific examples]
• Relationships/Social: [Conflict, isolation, communication difficulties; examples]

Risk assessment: [No current risk concerns / Suicide/Self-harm: ideation (none / passive / active), plan (yes / no), intent (yes / no), means access (yes / no), past attempts (dates), recent changes; Protective factors; Safety plan status (in place / updated on date / not indicated); Rationale for outpatient level of care]. (If patient declined risk screening, document this and mitigation steps taken.)

Treatment Provided to Date

(Include for continued authorization; for initial, include only if prior treatment history informs current request.)

• Episode dates: Started [Date]; Sessions scheduled: [n]; Attended: [n]; Missed/Canceled: [n]
• Interventions delivered: [List specific interventions with brief behavioral descriptions, e.g., cognitive restructuring for automatic thoughts, behavioral activation scheduling, in-vivo exposure to avoided situations, DBT skills modules completed, EMDR phases completed]
• Patient engagement: [Homework adherence, skill practice, session participation, attendance patterns, barriers encountered]
• Care coordination: [Communication with psychiatry/PCP, medication collaboration, case management, external letters; include dates]

Response to Treatment and Progress Toward Goals

(Required for continued authorization.)

• Goal 1: [Goal statement] — Baseline: [Measure/behavior with date]. Current: [Measure/behavior with date]. Trend: [Improving / Partial response / No meaningful change / Worsening]. (If limited progress, state clinical reason and treatment modifications made.)
• Goal 2: [Goal statement] — Baseline: [Measure/behavior with date]. Current: [Measure/behavior with date]. Trend: [As above].
• (For stabilization/maintenance goals: State what decline is being prevented and evidence of relapse risk.)

Current Treatment Plan

• Modality and interventions: [Planned modality] with [Specific interventions to be implemented]
• Frequency and duration: [Session frequency and length] for [Number of weeks/sessions], then [Step-down plan if applicable]
• Measurement plan: [Scales to be used] every [Interval]
• Risk monitoring: [Screening cadence, safety plan review schedule, means-restriction counseling if applicable]
• Collaboration: [Psychiatry / PCP / Case management coordination plans with consent status]
• Plan changes since last authorization: [What changed and why, or "No changes"] (Include for continued authorization.)

Medical Necessity Rationale

[Patient name] meets criteria for [Primary diagnosis] with current symptoms of [Key symptoms] at [Severity level], supported by [Measurement data with dates]. These symptoms cause clinically significant impairment in [Functional domains] as evidenced by [Specific quantified examples]. Current risk level is [None / Low / Moderate / High] based on [Brief rationale] with protective factors including [List].

Outpatient psychotherapy at [Requested frequency] is required to address [Specific symptom targets and functional impairments] using [Evidence-based modality]. Lower-intensity alternatives are insufficient due to [Acuity / Comorbidity / Risk level / Functional demands / Prior inadequate response to lower intensity]. The requested [Number] sessions over [Duration] is time-limited and allows delivery of [Treatment components] necessary for [Symptom reduction / Stabilization].

Expected outcomes include [Objective targets: scale score reduction, symptom frequency decrease, functional improvements]. (For continued authorization beyond original plan: Treatment has been modified by [Specific changes] to address [Barriers or limited response] and prevent stagnant care.)

Requested Services

• Service type: [Individual / Group / Family] psychotherapy
• Session length: [30 / 45 / 50 / 60 / 75 / 90] minutes
• Delivery method: [In-person / Telehealth / Hybrid]
• Frequency and total units: [Frequency] for [Total sessions] from [Start date] to [End date]
• Provider: [Clinician name, credentials]
• Stepped schedule: (If applicable: Phase 1: [Frequency] until [Clinical criteria]. Phase 2: [Step-down frequency] when [Criteria met].)

Discharge and Reassessment Criteria

• Step-down/discharge criteria: [Scale name] ≤ [Threshold] sustained for [Duration]; [Target symptom] reduced by [Percentage or frequency]; [Functional benchmarks] achieved
• Reassessment interval: Every [Number] sessions with measurement updates
• Aftercare plan: [Maintenance session frequency, medication follow-up, community resources, crisis plan]

Provider Attestation

I attest that the above information is accurate and complete to the best of my knowledge and is provided for utilization review purposes.

________________________________
[Clinician name], [Credentials]
License: [Number], [State] | NPI: [NPI]
Date: [Date signed]