What is "medical necessity" for therapy?

If you are using your insurance to cover the cost of your services, all healthcare providers (such as Framework) are required to ensure that the treatment is medically necessary. Medical necessity is determined during the intake session prior to billing the service to insurance, though insurances reserve the right to reach their own determination of medical necessity.

Medically necessary psychotherapy:

• is provided for the diagnosis, treatment, or relief mental health condition,
• is within the generally accepted standards of care in the mental health community,
• is not solely for the enjoyment or convenience of the client or provider.

In the extremely rare situations in which your therapy would fall outside of medical necessity, your therapist will inform you of this and discuss before continuing in treatment. 

Example: Individual Therapy that is Medically Necessary...

• A client is seeking treatment to help with feelings of depression, anxiety, etc. Therapy is medically necessary to help alleviate the depression, anxiety, etc. 

Example: Individual Therapy that Does Not Qualify...

• A client feels happy, satisfied, motivated, and connected to their community. There are zero mental health concerns present. The client is seeking art therapy to help them get in greater touch with their creativity. 

Example: Couples Therapy that is Medically Necessary...

• A couple recently welcomed their first child. Since the child's birth, the birthing parent has been experiencing postpartum depression, and both are sleep deprived. Both partners realize they are beginning to argue and resent one another. Therapy is medically necessary to help alleviate the stress and depression the partners are experiencing, and improve communication and mutual support of one another. 

Example: Couples Therapy that Does Not Qualify...

• An engaged couple is seeking pre-martial counseling because the church where they want to hold their ceremony requires at least 5 sessions of pre-martial counseling before they will agree to wed the couple in their church. Aside from their external requirement for pre-martial counseling, both partners feel quite happy, satisfied, and excited about their relationship.