Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested out of network mental health services on an emergent or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation reveals this patients developmental task of identity formation was compromised by a serious mood disorder. Upon presentation, the patient was depressed and unable to self-soothe. He had multiple static risk factors. His progressive clinical deterioration demanded intensive specialty services, and the combination of both psychotherapy and pharmacotherapy represented a trusted combination that was reasonably expected to improve the patients condition and prevent a more serious episode of illness. Current psychiatric practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which multiple sessions per week may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Considering these factors, the patient met criteria for a psychiatric emergency medical condition, as the healthcare team was unable to definitively determine that he did not pose an imminent danger to self during the disputed timeframe. Given the specifics of this a prudent layperson would have acted reasonably in seeking medical attention. However, this conceptualization would only apply to the services provided by the therapist, and the primary psychiatrist.  The patient was receiving timely psychiatric care for the emergent condition.  There was no documentation in the medical record justifying an immediate need for subsequent visits which appear to be non-urgent and consultative in nature. Further, with regard to the genetic testing at issue, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well become a valuable tool in the treatment armamentarium for those diagnosed with mental illness. However, despite its promise, gene testing is neither ready for mainstream clinical application nor utilized in the clinical management of psychiatric emergencies. According to the American Academy of Child and Adolescent Psychiatry, the limited positive preliminary results in the literature require replication in studies involving large groups of patients before they can be established as clinically useful. In sum, the initial services provided met prudent layperson criteria for emergency care. However, the subsequent services, and the disputed genetic testing did not meet prudent layperson criteria for emergent or urgently needed services.  Final Result: The reviewer determined that a portion of the services at issue met prudent layperson criteria for emergent or urgently needed services. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in 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.