Individual Psychotherapy Session (Standard)
What is this procedure?
Standard individual psychotherapy session (45 minutes) with a licensed mental health professional for treatment of mental health conditions. Used for depression, anxiety, trauma, personality disorders, and other psychiatric conditions.
Does this require prior authorization?
Step Therapy / Pre-Requirements
Subject to similar visit limits and re-authorization requirements as extended sessions (90837). Plans may cap at 20-30 total mental health sessions per calendar year across both standard and extended codes. Some plans distinguish between psychiatry sessions and therapy sessions with different caps.
Common Reasons This Gets Denied
Based on insurer policy analysis and claims data patterns. Frequency indicates how often this reason appears.
Total mental health visit limit exceeded
Denial occurs when combined standard (90834) and extended (90837) sessions exceed plans total mental health visit cap. Many plans pool all mental health visits (therapy, psychiatry, psychology) under single annual limit.
How to prevent this
Verify plans total mental health visit policy and whether standard/extended therapy sessions count separately or combined. Track cumulative visit count across all mental health CPT codes. Request re-authorization before limits reached with updated clinical documentation. For ongoing treatment needs, discuss alternative arrangements (less frequent sessions, group therapy options, or medication management focus).
No psychiatric diagnosis or vague indication
Authorization denied if no specific DSM-5 psychiatric diagnosis documented, or indication is non-medical (life coaching, career counseling, relationship advice without psychiatric component).
How to prevent this
Diagnosis documentation critical. Examples: Major Depressive Disorder with anxiety features (F32.1, F41.9), PTSD with dissociative symptoms (F43.10), Generalized Anxiety Disorder (F41.1). Avoid: "counseling for stress," "career transition support," or "relationship issues." Frame mental health condition medically with specific diagnostic criteria met.
Different provider type not covered or approval status unclear
Authorization may be denied if provider type (social worker, counselor) not covered under plan, or if clinician licensing status unclear. Some plans restrict coverage to Ph.D. psychologists or psychiatrists only.
How to prevent this
Verify provider credentials and licensing state. Ensure provider is in-network or verify out-of-network coverage policy. Document credentials: Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), etc. For out-of-network providers, submit verification of licensure and credentials with authorization request.
Documentation Checklist
Gather these documents before submitting your authorization request. Click items to check them off.
Specific DSM-5 psychiatric diagnosis
RequiredDiagnosis code and criteria description. Medical diagnosis required; avoid life coaching or non-medical counseling framing.
Functional limitation and psychiatric impact
RequiredHow psychiatric symptoms specifically limit functioning (work disability, relationship impairment, safety concerns).
Treatment plan with specific interventions
RequiredTherapy modality, goals, and expected duration. Clinical justification for ongoing treatment.
Provider credentials and licensing status
RequiredVerify provider type covered by plan (psychiatrist, psychologist, LCSW, LMFT, LPC). Document licensure state.
Progress documentation and total mental health visit tracking
RequiredTrack combined standard (90834) and extended (90837) sessions for total mental health visit limits. Document progress toward treatment goals.
Medical Necessity Tips
What clinical evidence supports approval
- Specific DSM-5 psychiatric diagnosis required
- Document functional impairment and treatment plan
- Provide progress notes showing response to treatment
- For medication management combined with therapy, clarify distinction between psychiatric visits and therapy visits
- Track total mental health visit count toward plan limits (standard and extended combined)
Related Procedures
What to Do If Denied
If your individual psychotherapy session (standard) is denied, you have the right to appeal. Most denials are overturned on appeal when proper documentation is provided.
Had this procedure? Share your experience.
Help other patients by anonymously reporting your insurance outcome. No personal information collected.
Report Your ExperienceThis information is for educational purposes only and is not medical, legal, or financial advice. Coverage decisions depend on your specific plan, insurer, and clinical circumstances. Always verify with your insurance company and healthcare provider.
Look up another procedure: