[Date]
Appeals Department
[Health plan name]
[Appeals address or fax]
Re: Expedited appeal: residential treatment for [Patient name], DOB [Date of birth], Member ID [Member ID], Reference [Denial or case reference number]
To the appeals reviewer:
I am the treating child and adolescent psychiatrist for [Patient name], a 15-year-old whom I have evaluated and treated. I am writing to appeal the plan's determination dated [Date of denial] denying residential treatment, and to request that the plan authorize residential treatment as requested.
I am requesting that this appeal be handled on an expedited basis. In my clinical judgment, applying the standard timeframe would seriously jeopardize the patient's life, health, or ability to regain maximum function. A physician's attestation that an appeal is urgent should be honored as such.
Clinical summary
[Patient name] carries a diagnosis of major depressive disorder. At present the patient reports active suicidal ideation with a plan and intent and cannot be kept safe at home despite a written safety plan and means restriction. [Add one to three sentences of specific clinical detail from your evaluation, with dates.]
The family cannot provide the continuous line-of-sight supervision that this level of risk requires; that is not a parenting failure but a practical limit that no household can meet indefinitely.
Treatment history and response
Treatment to date has included ongoing individual outpatient psychotherapy, two adequate medication trials at therapeutic doses for adequate durations, and one prior inpatient admission. [List dates, settings, medications with doses and durations, and the patient's response to each.]
The plan has proposed partial hospitalization in place of residential treatment. That level of care does not provide the degree of structure, supervision, and frequency of psychiatric contact that the clinical picture described above requires.
Why residential treatment is medically necessary
Residential treatment is required because the patient needs twenty-four-hour structure and supervision to remain safe while receiving daily, multidisciplinary treatment over a sustained period. The risk here is not confined to a crisis window; it recurs whenever structure is removed, which is exactly what a program that sends the patient home each evening cannot address.
The denial states that a lower level of care would be appropriate. The least restrictive level of care is the least restrictive level at which treatment can be delivered safely and effectively; it is not the least intensive level that is available. For the reasons set out above, a lower level of care cannot meet this patient's needs at this time.
The denial does not identify the clinical criteria on which it relies. I request a copy of the specific criteria applied to this decision, the clinical rationale of the reviewer, and the name, license, and specialty of the reviewer who made the determination. Whatever criteria the plan applies, those criteria must be consistent with generally accepted standards of care for children and adolescents, including the practice parameters and principles of care published by the American Academy of Child and Adolescent Psychiatry, which address the role of each level of care in the continuum. A child or adolescent's need for a structured setting reflects developmental stage, dependence on caregivers, and the setting in which symptoms occur; criteria written for adults, or applied without attention to those factors, do not reflect the standard of care for this population.
Applicable requirements
The plan is subject to the Mental Health Parity and Addiction Equity Act, which prohibits applying medical management standards and other non-quantitative treatment limitations to mental health benefits more stringently than they are applied to medical and surgical benefits. A denial of a medically necessary level of psychiatric care for a child, where the plan would authorize a comparable level of care for a comparable medical condition, should be examined under that standard.
Under the federal internal claims and appeals and external review requirements that apply to this plan, the member is entitled to a full and fair review of this denial, to the diagnosis and treatment codes and their meanings, and to the specific reason and criteria relied upon. Because this request involves urgent care, the plan must decide this appeal as soon as possible and no later than seventy-two hours after receipt. If the denial is upheld, the member will request independent external review, and this letter should be included in the record for that review.
Request
- Reverse the determination and authorize residential treatment as requested, beginning [Requested start date].
- Before any decision to uphold the denial, schedule a peer-to-peer review with me and ensure the reviewing physician is a board-certified child and adolescent psychiatrist. I can be reached at the number below.
- Provide the specific clinical criteria applied, the reviewer's written rationale, and the reviewer's name, license, and specialty.
- Issue a decision within seventy-two hours of receipt of this appeal.
- Include this letter and its attachments in the complete claim file for any subsequent internal or external review.
I am available to discuss this patient at any time. Delaying the treatment this patient needs carries real risk, and I ask that the plan act accordingly.
Sincerely,
[Your name]
[Credentials and board certification]
[Practice or hospital]
[Direct phone and fax]
NPI [NPI]
Enclosures: [List attached records: evaluation, progress notes, safety plan, medication history, prior discharge summaries, rating scales.]