Appeal type: Medical necessity
Decision: Upheld

Mental Health/attention deficit hyperactivity disorder/ADHD
Home health Care/Other/936 Units of Caregiver Family Advocacy and Support Services
The health plan denied the requested 936 Units of Caregiver Family Advocacy and Support Services as not medically necessary. The health plan's determination is upheld.

According to the records provided to the reviewer, the patient is a young boy. A letter by his psychiatrist describes that the patient has been diagnosed with attention deficit disorder (ADHD), impulsive and aggressive behavior, and a tic disorder. Current medication comprises of Ritalin 5 milligrams (mg) twice daily (BID), in the morning and at noon. The dose is being titrated upwards. He is described as having "significant problems with hyperactivity at home, poor social interactions and aggressiveness." His physician recommended that provision of services continue, but his letter did not recommend an increase in units/hours of Caregiver Family Advocacy and Support Services. He is approved for 1248 units; an additional 936 units are being requested.
An undated, unsigned letter (possibly from the agency providing the Caregiver Family Advocacy and Support Services) describes that the patient has high intellectual ability, but that he is performing at below average level at school. He struggles with time management and organization, and is emotionally erratic. An e-mail from his school describes that he has missed 19 days of school and has been late for school on 20 days. It is not mentioned whether he has an Individualized Education Plan (IEP) in place at school.
An undated letter from his mother describes that she has multiple chronic health conditions including back pain, gastrointestinal issues and hypotension. The patient has two younger siblings who also have ADHD.
At issue in this review is whether the requested additional 936 Units of Caregiver Family Advocacy and Support Services are medically necessary for the patient.

The reviewer recommends to uphold, in whole, the health plan's determination of medical necessity.

In the reviewer's opinion the requested health service/treatment of 936 Units of Caregiver Family Advocacy and Support Services is not medically necessary for this patient.
The patient is already approved for 1248 units of Caregiver Family Advocacy and Support Services. [1] The reviewer requested additional records to include details regarding use of the current allocation of units and an explanation/plan of care for the requested additional 936 units of Caregiver Family Advocacy and Support Services. This information was not received.
According to a letter by his psychiatrist he has been diagnosed with attention deficit disorder (ADHD), impulsive and aggressive behavior, and a tic disorder. Current medication comprises Ritalin 5 mg BID, in the morning and at noon. The dose is being titrated upwards. Levi is already approved for 1248 units of Caregiver Family Advocacy and Support Services. The reviewer requested additional records to include details regarding use of the current allocation of units and an explanation/plan of care for the requested additional 936 units of Caregiver Family Advocacy and Support Services. This information was not received. The need for an additional 936 units of Caregiver Family Advocacy and Support Services does not appear to be medically necessary. There is no explanation of how the additional units would be used.
School attendance appears to be an issue for Levi; if he does not already have a 504 plan or an Individualized Education Plan, the reviewer suggests that one be implemented.