Issued and entered June 11, 2003 by Linda A. Watters, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On March 13, 2003, XXXXXXXXXXXXXX (Petitioner), filed a request for external review with the Commissioner of the Office of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act (PRIRA), MCL 550.1901 et seq. After an assessment of the material submitted, the Commissioner accepted the request for external review.

A determination on medical issues was required. The Commissioner assigned the case to the Maximus Center for Health Dispute Resolution (CHDR), an independent review organization (IRO). The Commissioner directed CHDR to provide the opinion and recommendation of a medical expert. On June 3, 2003, the IRO completed its review and sent it to the Office of Financial and Insurance Services (OFIS).

II
FACTUAL BACKGROUND

Petitioner is a member of HealthPlus of Michigan (HPM). She has a history of depression, anxiety, job stress, relationship concerns, social isolation and suicidal ideation without a plan. Petitioner began seeing her current psychologist Dr. XXXXXXXXX, a limited license psychologist, in December 1996 when he was with XXXXXXXXXXXXXXXXXXXXX, an affiliated facility. In XXXXXXXXXXX he went into private practice. For continuity of care, HPM authorized 6 counseling sessions in XXXX, 20 counseling sessions in 2XXX and 20 sessions in XXXX. HPM claims it has taken efforts to direct Petitioner to an affiliated provider. Letters dated XXXXXXXXXXXX, XXXXXXXXXXXXXXXX, XXXXXXXXXX, XXXXXXXXXXXXX and XXXXXXXXXXXXXX document HPM’s efforts to re-direct Petitioner to an affiliated provider. On XXXXXXXXXX HPM denied the Petitioner’s request for continued behavioral health services from Dr. XXXXXXXXX.

On XXXXXXXXXXXXX, HPM sent Petitioner a letter authorizing four visits with Dr. XXXXXXXXX to transition the Petitioner from a non-affiliated provider to an affiliated provider for the XXXX contract year. Petitioner requested authorization to continue to receive outpatient behavioral health services from Dr. XXXXXXXXX. HPM denied the request and determined 1) a psychiatric evaluation was needed to ensure the Petitioner’s behavioral health needs were being met appropriately, and 2) If continued therapy is medically necessary, an affiliated provider could provide the services. Petitioner exhausted HealthPlus’ internal grievance process and received their final adverse determination letter dated March 13, 2003.

III
ISSUE

Did HealthPlus of Michigan properly deny authorization for continued behavioral health services from a non-affiliated provider?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner argues authorization for services with a non-affiliated provider should be allowed to continue. She believes:

• it is necessary in order to maintain continuity of care, and
• it would be detrimental at this time to change counselors since she has been working with Dr. XXXXXXXXX for the last several years.

HPM’s ARGUMENT

In its March 19, 2003, final adverse determination letter, HPM denied authorization and coverage for continued behavioral health services from a non-affiliated provider because the Petitioner has received services for three years with no change in her condition. 1) HPM wants the Petitioner to submit to a psychiatric evaluation to determine if her behavioral health needs are being met appropriately, and 2) if the evaluation finds these services are medically necessary, the services can be provided by an affiliated provider. Petitioner has refused a psychiatric evaluation. She believes her current behavioral health provider is the person most capable of providing an evaluation to HPM.

HPM denied the Petitioner’s request to continue receiving services from the non-affiliated provider for the following reasons:

1. HPM is concerned that Petitioner’s needs are not being met since there has not been a change in her condition for over three years.
2. Since there has been no change HPM questions if the services are still medically necessary.
3. Her current counselor is not a fully licensed psychologist and does not meet HPM’s minimum requirements for a credentialed provider.
4. The services if needed can be provided by an affiliated provider.

HPM had the case reviewed by Dr. XXXXXXXXXXXX, a board certified psychiatrist. He determined based upon treatment plans provided by Dr. XXXXXXXXX:

• The member had been diagnosed with depression
• The goals were unclear
• Her condition appears to be without change
• The length of treatment provided by Dr. XXXXXXXXX appears to be excessive
• A psychiatric evaluation is warranted in order to ensure the member’s behavioral health needs are appropriately being met.

In addition, Petitioner’s primary care physician (PCP) has been monitoring her Zoloft and Klonopin medications for two years. HPM believes the lack of change in her condition since she has been seeing her current behavioral health provider indicates a psychiatric evaluation is needed before further treatment is authorized.

IRO RECOMMENDATION

A practicing physician, board certified in psychiatry reviewed this case. The physician is also a Senior Attending Psychiatrist and a Clinical Associate Professor of Psychiatry at a large academic medical center and is familiar with the medical management of patients with the member’s condition.

The expert found:

• A history of major depression disorder, recurrent, moderate
• A treatment plan date September 18, 2002, noted she achieved a significant decrease in her depressive symptoms
• She was taking Zoloft and Klonopin which was being monitored by her PCP; she has not been evaluated by the psychiatrist who prescribed it in two years
• The psychologist she is seeing is not fully licensed and does not meet HealthPlus’ criteria for participation in their panel as a network provider
• The plan wants a psychiatric evaluation to ensure Petitioner’s needs are being met

Based upon the available documentation the expert determined the Petitioner has improved and appears to be stable. He concluded HPM’s recommendation of an evaluation by an affiliated psychiatrist and transition to an affiliated psychotherapist for treatment is a prudent and timely approach to reassessing the member’s treatment goals and clinical status.

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents presented by the parties in this case, as well as the findings of the IRO. The focus of this analysis is whether HealthPlus of Michigan properly denied Petitioner authorization for additional outpatient counseling visits with a non-affiliated provider.

HPM’s Benefit Rider CD states in pertinent part:

Section 1. Covered Services
Only services that are Medically Necessary according to generally accepted standards of practice as determined by an HealthPlus Medical Director are Covered Services under this Rider.

Section 1.5
MENTAL HEALTH SERVICES when authorized in advance by HealthPlus or its designee, and when under the direction or care of an HealthPlus preferred Provider to whom HealthPlus has given prior authorization for services, including:

1. Hospital inpatient care.
2. Intermediate care, including:
   1. Day treatment program.
3. Outpatient care.

HPM is a Health Maintenance Organization (HMO). It is reasonable for a HMO to require its members to consult with affiliated providers. HMOs can require affiliated providers to meet certain requirements to be credentialed. In this case, the non-affiliated provider does not meet HPM’s requirements to be credentialed. A HMO can also limit services to those that are medically necessary, appropriate, and conform to professionally accepted standards of care.

HPM believes a psychiatric evaluation is necessary to evaluate Petitioner’s behavioral health needs. The Commissioner agrees and finds that it is reasonable to require this evaluation to assess and confirm the Petitioner’s diagnosis and course of treatment before continuing to pay for services when there has been no change in approximately three years. The Commissioner also finds that if behavioral health services are medically necessary, HPM can refuse to authorize payment to a non-affiliated provider. The Commissioner finds HPM’s final adverse determination in this matter is valid.

V
ORDER

The Commissioner upholds HealthPlus of Michigan’s adverse determination. HPM is not required to continue to authorize outpatient counseling services from a non-affiliated provider.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.