State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave.

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1 Earl Ray Tomblin Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave. Elkins, WV October 5, 2012 Rocco S. Fucillo Cabinet Secretary ---- for Dear Ms. ----: Attached is a copy of the Findings of Fact and Conclusions of Law on your hearing held September 11, Your hearing request was based on the Department of Health and Human Resources denial of Medicaid authorization for your daughter s continued services at In arriving at a decision, the State Hearing Officer is governed by the Public Welfare Laws of West Virginia and the rules and regulations established by the Department of Health and Human Resources. These same laws and regulations are used in all cases to assure that all persons are treated alike. Eligibility for Medicaid services is based on current policy and regulations. Some of these regulations state as follows: All inpatient admissions, with the exception of those related to labor and delivery, are subject to medical necessity review and certification of admission by the Bureau for Medical Services Utilization Management Agency. Inpatient services that do not contribute meaningfully to the treatment of an illness or injury are not covered. (WVDHHR Hospital Services Manual Chapters and 510.4) Information presented during the hearing reveals that the medical documentation submitted for review does not demonstrate medical necessity for continued benefits at a Psychiatric Residential Treatment Facility. It is the decision of the State Hearing Officer to uphold the action of the Department in denying Medicaid authorization for services at Sincerely, Pamela L. Hinzman State Hearing Officer Member, State Board of Review cc: Erika H. Young, Chairman, Board of Review Stacy Broce, Bureau for Medical Services

2 WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES BOARD OF REVIEW IN RE: ----, Claimant, v. ACTION NO: 12-BOR-1432 WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES, Respondent. DECISION OF STATE HEARING OFFICER I. INTRODUCTION: This is a report of the State Hearing Officer resulting from a fair hearing for This hearing was held in accordance with the provisions found in the Common Chapters Manual, Chapter 700 of the West Virginia Department of Health and Human Resources. This fair hearing was convened telephonically on September 11, 2012, on a timely appeal filed March 29, 2012, and received by the Hearing Officer on June 18, The hearing was originally scheduled for August 7, 2012, but was continued at the Claimant s request. The hearing was rescheduled for August 23, 2012, at which time the parties conducted a pre-hearing conference and the Claimant s representative requested a continuance. II. PROGRAM PURPOSE: The 1965 Amendments to the Social Security Act established, under Title XIX, a Federal-State medical assistance program commonly known as Medicaid. The Department of Health and Human Resources administers the Medicaid Program in West Virginia in accordance with Federal Regulations. The Bureau for Medical Services is responsible for development of regulations to implement Federal and State requirements for the program. The Department of Health and Human Resources processes claims for reimbursements to providers participating in the program. III. PARTICIPANTS: ----, Claimant s mother/custodial parent Dr , Claimant s step-father ----, Certified Psychologist - 1 -

3 Nora McQuain, RN, Director of the Office of Facility-Based and Residential Care, Bureau for Medical Services, WVDHHR Linda Kennedy, Program Manager, Office of Facility-Based and Residential Care, Bureau for Medical Services, WVDHHR Dr. ----, Psychiatrist Reviewer, APS Healthcare ----, Behavioral Health Clinical Manager, APS Healthcare ----, Director of Socially Necessary Services, APS Healthcare Presiding at the hearing was Pamela L. Hinzman, State Hearing Officer and a member of the State Board of Review. IV. QUESTION TO BE DECIDED: The question to be decided is whether the Department was correct in its decision to deny services at a Psychiatric Residential Treatment Facility. V. APPLICABLE POLICY: WVDHHR Hospital Services Manual Chapters 510.4, and VI. LISTING OF DOCUMENTARY EVIDENCE ADMITTED: Department s Exhibits: D-1 WVDHHR Hospital Services Manual Chapter D-2 Hearing Request documents sent to Board of Review D-3 Statement of Assurance dated April 26, 2010 D-4 Psychiatric Evaluations from ---- dated May 11, 2011, and May 10, 2010 D-5 Psychosocial Assessment from ---- dated June 10, 2011 D-6 Physician Review Summaries D-7 Initial Denial Notification dated February 29, 2012 Claimant s Exhibits: C Discharge Summary dated February 25, 2012 C-2 Neuropsychological Evaluation (dated 2006) C-3 Adoption Assistance Agreement signed by ---- (formerly ----) on September 18, 1997 C-4 Psychosocial Assessment dated May 31, 2012 C-5 Receptive Vocabulary Assessment dated April 13, 2011 C-6 Letter to , Esq., from ---- dated April 20, 2012 C-7 Electronic Mail Transmission from ----to ---- dated April 20, 2012 C-8 Treatment Plan Review dated January 8, 2012 C-9 Treatment Plan Review dated February 9, 2011 C-10 Treatment Plan Review dated February 10, 2012 C-11 Treatment Plan Review dated March 10,

4 C-12 Treatment Plan Review dated April 10, 2012 C-13 Treatment Plan Review dated May 10, 2012 C-14 Treatment Plan Review dated June 10, 2012 C-15 Treatment Plan Review dated July 9, 2012 C-16 Medication, Precaution and Nutrition Orders for ---- VII. FINDINGS OF FACT: 1) The Claimant, age 16, is a West Virginia Medicaid recipient and is currently receiving services at ----, hereinafter ----, a Psychiatric Residential Treatment Facility (PRTF) in ) Nora McQuain, RN, Director of the Office of Facility-Based and Residential Care for the Department s Bureau for Medical Services, cited Department policy and testified that all psychiatric inpatient facility and PRTF admissions are subject to medical necessity review. 3) ----, Behavioral Health Clinical Manager with APS Healthcare, testified that the Department received a request for continued authorization of PRTF services at ----, with a service start date of December 31, Ms indicated that the reviewing psychiatrist determined that medical necessity criteria for ongoing services was not met; however, the Claimant was approved for a 30-day continued stay to facilitate transition to another facility. The Department then received a follow-up request from ---- for prior authorization review with a start date of January 30, At that time, the Department requested any additional information from the facility for physician review. Additional information was submitted; however, the request was again denied based on failure to meet medical necessity criteria. Ms stated that because the Claimant is an adolescent ---- exercised its right to a peer-to-peer review between a nurse practitioner at the facility and the Department psychiatrist. The review failed to alter the Department s decision. 4) On February 29, 2012, APS Healthcare, sent an Initial Denial Notification (D-7) to ----, explaining that the request for continued services was denied. The letter states, in pertinent part: The service requested does not meet medical necessity and has been denied based upon the following: The clinical information submitted for prior authorization by the provider does not demonstrate medical necessity for the requested service

5 5) Dr. ----, Psychiatrist Reviewer with APS Healthcare, testified that he denied the request for continued services at ---- because the stay is not appropriate for the Claimant s diagnosis or symptoms, and there is no need for direct care. Dr s Physician Review Summary dated January 15, 2012 (D-6) states that diagnostic information submitted in conjunction with the continued authorization request indicates the Claimant has an Axis I diagnosis of other specified pervasive developmental disorders, current or active state; unspecified hyperkinetic syndrome; and conduct disorder, childhood onset type. The Claimant has an Axis II diagnosis of mild mental retardation. Dr s report states: ---- is a 15yrs [sic] who was admitted to /7/2010 with impulsive behaviors, anger and aggression. She has very supportive parents but they are unable to care for her due to her aggressive behavior. It states in her progress summary that although ---- continues to have issues with impulsivity and emotional outburst [sic] that she has made a lot of progress in her ability to voice her frustrations. It also states that they have been working for 6 months to find placement and have sent out numerous referral packets. Step down placements will not accept her due to her aggressive behavior or her IQ is too low for their requirement ---- recently completed her first home pass in two years. It was noted issues arose during this time which reinforced that ---- is not ready to return home. Considering ---- [sic] noted progress yet continued aggressiveness, her length of stay and continued difficulty finding placement, a physician review is requested for continued medical necessity. Patient has had a number of previous psychiatric treatments: ---- Acute Treatment 1/27/10 to 2/7/10 and from 4/8/10 to 4/9/10, ---- from 9/105 [sic] to 1/26/06, ---- Group home 12/6 to 1/29/09 and - ---group home 1/30/09 to 5/7/10. I will approve 30 more days to finalize transfer plans. I see little reason for continued long term care because she has had many years without much improvement. Placement is a problem but long term psychiatric residential care seems to have been exhausted. Dr s Physician Review Summary dated February 8, 2012, (D-6) again found that the request for continued PRTF care did not meet medical necessity criteria and the doctor wrote, As unfortunate as it may be, there is no need for continued medical care at this facility. It should be noted that documentation submitted by ---- for Dr s review included Exhibits D-4 and D-5: Psychiatric Evaluations dated May 11, 2011 and May 10, 2010, and a Psychosocial Assessment dated June 10, Exhibit D-5 indicates that the - 4 -

6 Claimant has made some progress in regard to angry outbursts and self-harming behavior, but continues to become easily agitated and reacts impulsively. The Psychiatric Evaluation dated May 11, 2011 (D-4) states that the Claimant continues to be impulsive and lack insight into her behaviors. She does not comply with simple daily living skills without direct prompts and assistance. She desires immediate gratification, to the point that she is at very high risk to put herself in dangerous situations unknowingly. For these reasons, ---- continues to need residential level of care. The document states that the Claimant has a difficult time developing and practicing appropriate life skills. Her motivation towards gaining insight into this area has been minimal. Exhibit D-4 indicates that the Claimant had physically assaulted a peer, and that her unstable moods during the reporting period appeared to be a result of her environment and not her medications. The Claimant s Psychiatric Review of Systems (ROS) in Exhibit D-4 addresses her aggressive behavior, and states that she has suicidal ideation, has made homicidal threats (including a desire to kill infants), exhibits selfinjurious behaviors and has engaged in animal cruelty. Dr testified that while the Claimant needs some type of care, direct medical care at the PRTF level is not a medical necessity, as the facility is not treating her illness. 6) ----, the Claimant s mother/custodial parent, testified that she planned to transfer her daughter to another facility, however she has faced numerous challenges in finding a facility that will accept her for admission and/or locating a program that accepts West Virginia Medicaid. Ms testified that the Claimant was recently denied entry to a program at University, as her need for comprehensive psychiatric treatment was beyond the scope of that program. Ms submitted Exhibit C-1, a Discharge Summary from ---- dated February 25, 2012, which states that the Claimant has made much progress since admission. She has met her treatment plan goals and is at maximum benefit for continued treatment at The summary states that the Claimant is able to talk about her emotions more effectively and verbalize her needs. The Claimant s self-harming and aggressive behaviors have declined and she has found alternative ways to manage her frustration. Psychologist who has not treated the Claimant, but has reviewed her medical documentation testified that he believes the Claimant will have serious behavioral issues throughout her life, and that psychological issues are driving her suicidal, homicidal and self-injurious behaviors. Mr pointed out the Claimant s additional diagnoses of Intermittent Explosive Disorder and Oppositional Defiant Disorder, and indicated that the Claimant has many different diagnoses that complicate her situation. The Department s Psychologist, however, contended that the Claimant could not have a diagnosis of Intermittent Explosive Disorder due to the hierarchy of psychiatric diagnoses listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). Mr testified that he does not believe the Claimant is safe outside of the hospital setting. He stated that the Claimant may have made progression in some behavioral areas, but in some ways not

7 The Claimant s mother questioned the Department s decision about why the PRTF level of care is not appropriate for her daughter. She stated that her daughter has had recent suicide attempts, which included yanking a television cord from the wall and wrapping it around her neck. The Department s psychiatrist maintained that the Claimant s issues cannot be treated in any kind of long-term care PRTF, and that there is no medically necessary reason for her to continue to receive services at , Behavioral Health Clinical Manager for APS Healthcare, added that documentation has suggested the Claimant s aggression is attributed to her continued placement. 7) WVDHHR Hospital Services Manual Chapter (D-1) states, in pertinent part: All inpatient admissions, with the exception of those related to labor and delivery, are subject to medical necessity review and certification of admission by the Bureau for Medical Services Utilization Management Agency. (See Attachment 2 for further information). General requirements by category of provider are as follows: 1. Acute inpatient. Admissions to both general and critical access acute care facilities are subject to medical necessity review and preadmission certification. Retrospective review is available for admissions occurring on weekends and holidays, or at times when the utilization management agency review process is unavailable. Additionally, retrospective review is permitted for admissions of Medicaid members whose eligibility has been determined retroactively. Retrospective review must be requested within 12 months of discharge date. 2. Admissions to Medicare certified distinct part psychiatric and rehabilitation units of acute care facilities are subject to both preadmission and continued stay review. 3. Psychiatric inpatient facility and PRTF admissions are subject to admission and continued stay review by the Bureau s utilization management contractor. 4. Inpatient Medical Rehabilitation Facility admissions are subject to both admission and continued stay review by the Bureau s utilization management contractor. Members who are inpatients, upon reaching the age of 21, may continue to receive services through age 21, as long as they continue to meet medical necessity criteria for continued stay. 8) WVDHHR Hospital Services Manual Chapter states: - 6 -

8 Inpatient Psychiatric Residential Treatment Facility Services rendered in this setting are available only to Medicaid eligible individuals under age 21. PRTFs may only render inpatient services, which are inclusive of any medical, pharmaceutical or psychiatric professional services rendered in the facility. PRTFs are not authorized to render outpatient hospital services. These facilities are reimbursed based on costs and are subject to audit and cost settlements. 9) WVDHHR Hospital Services Manual Chapter states: Hospital Inpatient Services An inpatient admission is defined as a person who has been admitted to an inpatient facility for bed occupancy for purposes of receiving inpatient hospital facility services. Inpatient care is covered under the Medicaid Program when it is reasonable and medically necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body part. The services must be consistent with the diagnosis or treatment of the patient s condition, and must be rendered in accordance with standards of good medical practice to be considered medically necessary. Inpatient care which does not contribute meaningfully to the treatment of an illness or injury, or to improve the functioning of a malformed body part, is not covered. VIII. CONCLUSIONS OF LAW: 1) Policy stipulates that all psychiatric inpatient and PRTF admissions are subject to medical necessity review and certification of admission by the Bureau for Medical Services Utilization Management Agency. Inpatient services that do not contribute meaningfully to the treatment of an illness or injury are not covered. 2) Evidence submitted at the hearing fails to demonstrate that services provided by ---- are making a meaningful contribution to the treatment of the Claimant s illness. As a result, direct care at the PRTF level is not medically necessary. 3) While it is clear that the Claimant faces many challenges, there is insufficient evidence to demonstrate that the request for continued authorization meets eligibility criteria. Therefore, the Department acted correctly in denying Medicaid benefits for PRTF services. IX. DECISION: - 7 -

9 It is the ruling of the State Hearing Officer to uphold the Department s decision to deny Medicaid authorization of services at X. RIGHT OF APPEAL: See Attachment XI. ATTACHMENTS: The Claimant s Recourse to Hearing Decision Form IG-BR-29 ENTERED this 5th Day of October Pamela L. Hinzman State Hearing Officer - 8 -

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