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Cognitive Behavior Therapy Case Study

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Regarding Cognitive Behavior Therapy x 50 sessions, CA MTUS Chronic Pain Medical Treatment Guidelines state that behavioral modifications are recommended for appropriately identified patients during treatment for chronic pain, to address psychological and cognitive function, and address co-morbid mood disorders (such as depression, anxiety, panic disorder, and posttraumatic stress disorder). In addition, CA MTUS Chronic Pain Medical Treatment Guidelines state that with evidence of objective functional improvement, a total of up to 6-10 visits. In addition, ODG states that Up to 13-20 visits over 7-20 weeks (individual sessions), if progress is being made and in cases of severe Major Depression or PTSD up to 50 sessions if progress is being made. In this case, the patient has received psychological treatment and psychotherapy since 2000. There is no documentation of the number sessions of psychotherapy completed to date. It is noted that the patient received 8 sessions of psychotherapy in 2015. The guidelines state that the provider …show more content…

The inventory contains 21 items rated from 0 to 3 by the taker, with a total possible score of 63 points. Beck Inventory Depression (BDI) is recommended as a first-line option psychological test in the assessment of chronic pain patients. Intended as a brief measure of depression, this test is useful as a screen or as one test in a more comprehensive evaluation. However, 11/16/15 psychiatric evaluation report described that the patient had psychological testing done, including BDI and BAI. She was noted to have severe depression and severe anxiety on both inventories respectively. There is no indication to perform repeat inventories or psychological testing. Medical necessity of BDI and BAI has not been substantiated. Recommend

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