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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for referral to a neurologist.At issue in this case is whether the requested referral to a neurologist is medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; or to correct or ameliorate any physical or behavioral conditions.Childhood headache can be dangerous, debilitating, or both. After excluding dangerous causes, it is important to provide the patient and caregiver with a plan for headache management that includes education on lifestyle management, rescue plan, and preventive measures. Jeng states that instances in which consultation with a neurologist could be helpful would include headaches that are severe, prolonged, or intractable. In this case, per the parent's description, the patient's headaches have become worse, they are occurring daily, and they are constant. The patients headaches are also disturbing the patient at night. Per the two documented pediatric visit notes, the patient may also have had developmental regression. In the earlier visit note, the patient's pediatrician documented that the patient was able to combine 2 to 3 words, while the later note reported that the patient was unable to put words together. The patients history therefore includes raises several `red flag` headache findings which suggest the need for evaluation by a neurologist. The `red flag` findings include the age of the patient, as it is very rare for a child under 5 years of age to complain of headaches; the worsening nature of the patients headache, as the patients headaches have become more frequent over time, and they are now constant and disturbing the patient at night; apparent behavioral change, with the onset of tantrums; and apparent developmental regression.Accordingly, the requested referral to a neurologist is medically necessary to treat the patients condition in order to prevent disease, disability, and other health conditions or their progression. The requested referral is medically necessary in order to prolong life, as there could potentially be a serious underlying cause of headache. The requested referral is medically necessary in order to promote physical and mental health and efficiency, as the cause of the patients headaches needs to be determined and an appropriate treatment needs to be started. The requested referral is also medically necessary to correct or ameliorate any physical or behavioral conditions, as there is a history of apparent developmental regression and behavioral change. Therefore, under these circumstances, the requested referral to a neurologist is medically necessary to treat the patients condition for all of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; and to correct or ameliorate any physical or behavioral conditions.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 neurology with special qualification in child neurology, with subspecialty certification in neurodevelopmental disabilities, 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.