Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of a 16-year-old male enrollee requested transportation services to a residential treatment facility in Utah for treatment of the enrollees diagnoses of bipolar disorder, attention deficit hyperactivity disorder (ADHD) and mood disorder.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient was reported to have threatened family members and laid hands on his four-year-old sibling. The sheriff was called.  The enrollee was status post three days in juvenile hall after striking his mother in the head and having been arrested for assault and battery. The enrollee had stated that he wanted to return to juvenile hall and join a gang, and it was felt that his mother needed protection.  Subsequently, it was reported that the patient had yanked his mothers head back while driving at 60 mph with the four other children in the car. The patient had been continuing to vandalize and show destructive behavior of property. The patient's residential treatment center application indicated that his moods were labile and unpredictable with worsening rageful/violent episodes towards family.  The patient had refused or was unavailable for evaluation.  The patient was on Seroquel 75 mg which improved sleep but not behavior.  His past medication trials included clonidine, Wellbutrin, Strattera, and Vyvanse. The patient selectively took medications and refused to participate in treatment. Based on the patients progressively increasing mood lability, and threatening and violent behavior towards his family, his parents hired a transport company to take him to a residential treatment facility out of state. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention. The patient was demonstrating progressively increasing mood lability, and threatening and violent behavior towards his mother and siblings. In addition, the enrollees physician felt that without intervention the patient would likely develop antisocial personality disorder. The patient was only partially compliant with his medication regimen and did not participate in treatment. The patient showed violent and aggressive behavior. He laid hands on his mother while operating a car at high speed, putting his and his familys lives in jeopardy, and placing the patient's health in serious jeopardy. The unpredictable nature of the patients moods and behavior would be considered an immediate danger to himself or others. The patients behavior was unpredictable, erratic, violent, aggressive, and threatening, and represented a potential danger to self and others as it could not be predicted when the next episode would occur. Due to this nature and the threat to self and others an immediate prevention of these potential situations was vital. In sum, the transportation services provided did meet prudent layperson criteria for emergency care. Further, criteria for urgently needed services were met. The patients behavior and mood were degenerating and required rapid intervention to halt the worsening of his perilous behaviors. The patient, his mother, siblings, and others outside of his home may have been placed in a dangerous position if the patients mother would have transported her son to the residential facility independently. Based on the documentation submitted for review a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. Further, there was evidence that the patients mental condition was deteriorating. In sum, based on the patients clinical presentation he did meet prudent layperson criteria for urgently needed transportation services.