Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for non-emergency psychiatric transportation to and from applied behavior analysis therapy. Findings:  The physician reviewer found that patient centered care (PCC) has been defined as, Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.  Patient- and family-centered care interventions are increasingly being implemented in various settings for improving the quality of health care. Patient- and family-centered care, [I]nvolves shifting away from the patient passively being the goal of interventions and disease-oriented medicine to the patient constituting an active part of the care process and patient-oriented medicine. In other words, patient- and family-centered care requires mutual power-sharing relationships that are collaborative. Patient- and family-centered care interventions have been found to be an effective method for improving the quality of health care for patients, improving healthcare outcomes, and bringing satisfaction both to the families of patients and to health-care providers.In this case, records reflect that the patient has a past psychiatric history of autism spectrum disorder, attention deficit hyperactivity disorder, and severe intellectual disability with limited verbal skills. The patient is noted to struggle with communication, aggression, self-injurious behaviors, and tantrums. The patients parents and treatment team agree that the patient requires more intensive treatment services than he was previously, or is currently, receiving. They are also in agreement that local treatment options would be preferable to the currently identified option located nearly 100 miles away, however, a local provider of the recommended services could not be identified, and the closest provider is 100 miles from the patients home. There is disagreement, however, regarding the level of care and distance of transportation. Records indicate that the patients parent does not currently agree with the treatment teams recommendations for residential treatment. The fact that the patients parents are seeking medical transport for their son implies that they believe their son will be able to tolerate the lengthy commute to and from treatment. In fact, the patients mother has reported to providers that the patient is routinely driven in a car for several hours every day after school and on weekends and seems to enjoy these car rides. The treatment team, however, does not feel that transporting him to and from Irvine daily would be beneficial for the patient and transportation  5X a week does not seem safe or sustainable based on patients function and treatment needs. While a lengthy commute to and from applied behavior analysis therapy is less than ideal and may not be wholly beneficial for the patient, the alternative  no treatment at all  also does not benefit the patient and is further from ideal than the lengthy commute. The patients parents have repeatedly stated that their son needs intensive behavioral treatment. They have also stated their preference that he continue to live at home and not be placed in residential treatment. This suggests that they place great value on their son remaining at home. They have also stated their preference that he be transported to and from an applied behavior analysis clinic 100 miles away given the lack of available nearby treatment options. Applying the patient- and family-centered care principles to this patient and his family, non-emergency psychiatric transportation to and from applied behavioral analysis therapy is medically necessary. Accordingly, the requested non-emergency psychiatric transportation to and from applied behavior analysis therapy is medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.