16-006837 Pearl Harrison vs. Department Of Management Services Status: Closed Recommended Order on Wednesday, May 17, 2017.

Summary: Petitioner failed to demonstrate her entitlement, under State Employees' PPO Group Health Insurance Plan, to reimbursement for a residential psychiatric stay at an out-of-network hospital.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

A. H., ON BEHALF OF R. H.,

Petitioner,

vs. Case No. 16 - 6837

DEPARTMENT OF MANAGEMENT

SERVICES,

Respondent.

_______________________________/

RECOMMENDED ORDER

Pursuant to notice, a final hearing was held in this case

on February 23, 2017, in Jackson ville, Florida, before

Lawrence P. Stevenson, a duly designated Administrative Law

Judge of the Division of Administrative Hearings (ÐDOAHÑ).

APPEARANCES

For Petitioner: Pearl Harrison , Qualified Representative

3783 Hunt Club Road

Jacksonville, Florida 32224

For Respondent: Anita J. Patel, Esquire

Department of Management Services

4050 Esplanade W ay, Suite 160

Tallahassee, Florida 32399 - 0950

STATEMENT OF THE ISSUE S

At issue in this proceeding is whether RespondentÓs denial

of PetitionerÓs Level II appeal should be upheld or whether the

inpatient residential mental health ser vices provided to R.H. by

McLean HospitalÓs 3 East Dialectical Behavior Therapy (ÐDBTÑ)

program from September 9, 2015 , through September 22, 2015 , and

again from October 15, 2015 , through December 11, 2015, were

Ðmedically necessaryÑ and therefore covered under the terms of

the State EmployeesÓ PPO Group Health Insurance Plan.

PRELIMINARY STATEMENT

By letter dated July 29, 2016, Respondent, Department of

Management Services, Division of State Group Insurance (ÐDSGIÑ),

notified Petitioner, A.H., that it i ntended to deny his Level II

appeal, by which Petitioner challenged the decision of Blue

Cross & Blue Shield of Florida, Inc., which operates under the

trade name ÐFlorida Blue,Ñ to deny coverage for the inpatient

residential stay of his daughter, R.H., at McLean Hospital, an

affiliate of Harvard Medical School located in Belmont,

Massachusetts, from September 9, 2015 , through September 22,

2015 , and again from October 15, 2015 , through December 11,

2015. On August 22, 2016, Petitioner submitted to DSGI a

request for a formal hearing disputing DSGIÓs conclusion that

R.H.Ós inpatient residential admission was not medically

necessary. DSGI referred the matter to DOAH on November 17,

2016.

The final hearing was originally scheduled for January 4,

2017. Two c ontinuances were granted before the hearing was

rescheduled for February 23, 2017, on which date it was convened

and completed.

At the final hearing, Petitioner called no witnesses,

relying on cross - examination of DSGIÓs witnesses under a

stipulated rela xation of the scope limitation on cross -

examination. PetitionerÓs Exhibits 3 through 10, 12, 13, 17,

19, 20, and 24 through 27 were admitted into evidence.

Respondent presented the testimony of Frank Santamaria,

M.D., the care management medical director of Florida Blue and

an expert in medical necessity determinations; Barbara Center,

M.D., a psychiatrist who works for Prest & Associates, Inc., an

independent review organization, and an expert in adolescent

psychiatry and medical necessity determinations; Tara Adams,

regional clinical director for New Directions Behavioral Health

(ÐNew DirectionsÑ), a behavioral m anaged health care

organization that provides behavioral health and substance abuse

services for Florida Blue; Kelly Register, a critical inquiry

analyst for Florida Blue; Michael Shaw, the team leader for

utilization management at New Directions; and Kathy Flippo, RN,

who is DSGIÓs legal nurse coordinator and an expert in legal

nurse consulting. Respondent Ós Exhibits 1 through 14 and

16 through 1 9 were admitted into evidence.

The two - volume transcript of the hearing was filed on

March 15, 2017. The record was held open pending a ruling on

the admissibility of some of PetitionerÓs exhibit s. On

March 21, 2017, an Order on Admission of PetitionerÓs Exhibits

and Closing Record was entered. The parties timely filed their

P roposed R ecommended O rders on March 31, 2017.

Unless otherwise noted, all statutory references are to

Florida Statutes (2016).

FINDING S OF FACT

1. DSGI is the state agency respon sible for administration

of the state group insurance program, pursuant to section

110.123, Florida Statutes.

2. Petitioner, A.H., is a State of Florida employee and

was insured through the State EmployeesÓ PPO Group Health

Insurance Plan (the ÐPlanÑ). R.H., the child of A.H., was

eligible for coverage under A.H.Ós health insurance policy as of

September 1, 2015.

3. Pursuant to contract, Florida Blue acts as DSGIÓs

third - party medical claims administrator for employee health

insurance benefits.

4. New Directions is Florida BlueÓs subcontractor and

third - party administrator for mental health and substance abuse

reviews and authorizations.

5. ÐUtilization managementÑ is the process of reviewing a

service claim to determine whether the service is a cover ed

benefit under the Plan and whether the service is Ðmedically

necessaryÑ as that term is defined in the Plan. In cases

involving mental health or substance abuse services, the service

must also satisfy the more detailed and specific coverage

guidelines, titled ÐMedical Necessity Criteria,Ñ established by

New Directions. 1/

6. Consistent with general practice in the field, the

Ðmedical necessityÑ criteria of the New Directions document

observe the following levels of care, in increasing order of

intensi ty: psychiatric outpatient; psychiatric intensive

outpatient; psychiatric partial hospitalization; psychiatric

residential; and psychiatric acute residential. In the

interests of conserving medical resources and preserving patient

liberty, safety, and di gnity, every effort is made to place

patients in the least intensive level of care consistent with

effective treatment of their presenting condition.

7. R.H., a female who was 15 years old during the period

relevant to this proceeding, has been diagnosed with borderline

personality disorder and has a history of eating disorders. Her

treating psychologist in Florida, Nicolle Arbelaez Lopez, noted

that R.H. was also being treated for generalized anxiety

disorder.

8. R.H. had an inpatient admission to the R enfrew Center

in Florida for eating disorder treatment in May 2015. R.H.

transitioned to partial hospitalization over the summer,

followed by a step down to the Renfrew Center's intensive

outpatient program, then by a step up back to partial

hospitaliz ati on when her eating disorder behaviors worsened.

Though less intensive than a full residential admission,

intensive outpatient treatment and partial hospitalization allow

patients to receive comparatively intensive treatment while

remaining in their home e nvironment. 2/ R.H.Ós final discharge

from the Renfrew Center was on August 21, 2015.

9. At the time she was admitted to McLean HospitalÓs

3 East DBT program, R.H. had a recent history of engaging in

superficial cutting of her arm. On August 30, 2015, R .H.

intentionally hit herself in the hand with a hammer. R.H.Ós

mother took her to the emergency room for treatment and told the

treating personnel that R.H. had fallen down some stairs. The

hammer blow caused swelling and bruising but no broken bones.

R.H. was also continuing to purge and restrict her food intake.

10. R.H.Ós treating psychiatrist, Dr. Thania V. Quesdada,

and her psychologist, Ms. Lopez, both urged that she be admitted

to one of three nat ionally - recognized immersion DBT programs.

Her f amily chose the program at McLean Hospital.

11. DBT is a cognitive behavioral treatment that was

originally developed to treat chronically suicidal individuals

diagnosed with borderline personality disorder, though it is now

employed for treatment of othe r conditions, including eating

disorders . DBT teaches behavioral coping skills such a s

mindfulness, distress tolerance, interpersonal effectiveness ,

and emotional regulation.

12. At the hearing, DSGI did not dispute the general

efficacy of DBT treatmen t. However, DSGI did dispute whether

R.H.Ós presentation merited ÐimmersionÑ DBT, i.e., a residential

inpatient admission.

13. McLean HospitalÓs 3 East DBT program is self - pay and

requires a minimum stay of 28 days. The program does not accept

insura nce and does not assist patients with insurance

reimbursement efforts. Because of its stance on insurance, the

3 East DBT program is obviously not an in - network provider under

the Plan. Prior to admission, Petitioner was aware that the

3 East DBT program did not accept insurance.

14. R.H. was in residential treatment at McLean Hospital

from September 9, 2015 , through September 22, 2015.

15. While at McLean Hospital, R.H. engaged in restricting

and purging behaviors that led to medical instability. She was

discharged to Cambridge Eating Disorder Center on September 23,

2015. She remained at the Cambridge Center until October 15,

2015. R.H.Ós stay at the Cambridge Center was pre - certified by

New Directions and is not at issue in this proceeding.

16. On October 15, 2015, R.H. returned to McLean Hospital,

again as a residential inpatient admission. She remained at

McLean Hospital until her discharge on December 11, 2015.

17. The total billed amount for R.H.Ós two stays at McLean

Hospital was $96,950, wh ich was paid by the family out - of -

pocket.

18. Section 3 - 5 of the Plan sets forth the following under

the heading ÐMental Health and Substance Dependency ServicesÑ:

ÐPhysician office visits, Intensive Outpatient Treatment,

Inpatient and Partial Hospitaliza tion and Residential Treatment

Services are covered based on medical necessity.Ñ

19. The general definition of ÐMedically NecessaryÑ is set

forth at section 15 - 4 of the Plan:

[ s ] ervices required to identify or treat the

Illness, injury, Condition, or Ment al and

Nervous Disorder a Doctor has diagnosed or

reasonably suspects. The service must be:

1. consistent with the symptom, diagnosis

and treatment of the patientÓs Condition;

2. in accordance with standards of good

medical practice;

3. required for reasons other than

convenience of the patient or the Doctor;

4. approved by the appropriate medical body

or board for the illness or injury in

question; and

5. at the most appropriate level of medical

supply, service, or care that can be safely

provid ed.

The fact that a service, prescription drug,

or supply is prescribed by a Doctor does not

necessarily mean that the service is

Medically Necessary. Florida Blue,

CVS/Caremark, and DSGI determine whether a

service, prescription drug, or supply is

Medic ally Necessary.

20. New DirectionsÓ Medical Necessity Criteria guidelines

provided the following admission criteria for psychiatric

residential admissions:

Must meet all of the following:

1. A DSM diagnosis is the primary focus of

active, daily treatme nt.

2. There is a reasonable expectation of

reduction in behaviors/symptoms with

treatment at this level of care.

3. The treatment is not primarily social,

custodial, interpersonal, or respite care.

4. The member has documented symptoms

and/or behavi ors that are a significant

deterioration from baseline functioning and

create a significant functional impairment

in at least three (3) of the following

areas:

a. primary support

b. social/interpersonal

c. occupational/educational

d. health/medical co mpliance

e. ability to maintain safety for

either self or others

5. Must have one of the following:

a. The memberÓs family members and/or

support system demonstrate behaviors that

are likely to undermine goals of treatment,

such that treatment at a lo wer level of care

is unlikely to be successful. This lack

must be situational in nature and amenable

to change as a result of the treatment

process and resources identified during a

residential confinement.

b. The member has a documented history of

an i nability to be managed at an intensive

lower level of care.

c. There is a recent (in the last six

months) history of multiple brief acute

inpatient stays without a successful

transition to a lower level of care, and at

risk of admission to inpatient acut e care.

21. New DirectionsÓ Medical Necessity Criteria guidelines

provided the following admission criteria for eating disorder

residential admissions:

Must meet 1 - 4 and either 5, 6, or 7

1. A DSM diagnosis found in the Feeding and

Eating Disorder sect ion is the primary focus

of active, daily treatment.

2. There is a reasonable expectation of

reduction in behaviors/symptoms with

treatment at this level of care.

3. The treatment is not primarily social,

custodial, interpersonal, or respite care.

4. The member has documented symptoms

and/or behaviors that are a significant

deterioration from baseline functioning and

create a significant functional impairment

in at least three (3) of the following

areas:

a. primary support

b. social/interpersonal

c . occupational/educational

d. health/medical compliance

e. ability to maintain safety for

either self or others

5. Must have one of the following:

a. The memberÓs family members and/or

support system demonstrate behaviors that

are likely to undermin e goals of treatment,

such that treatment at a lower level of care

is unlikely to be successful. This lack

must be situational in nature and amenable

to change as a result of the treatment

process and resources identified during a

residential confinement.

b. The member has a documented history of

an inability to be managed at an intensive

lower level of care.

c. There is a recent (in the last six

months) history of multiple brief acute

inpatient stays without a successful

transition to a lower level of care, and at

risk of admission to inpatient acute care.

6. There are active biomedical

complications that require 24 - hour care,

including, but not limited to:

Adults Children/Adolescents

Pulse <40><>

Blood Pressure <90 0=""><80>

Orthostatic change s Systolic: >20 point Systolic: > 20 point

in BP drop drop

(Supine to standing) Diastolic: > 10 Diastolic: > 10

point drop point drop

Potassium < 3="" meq/l="">

Body temperature < 97="" f="" abnormal="">

temperature

Electrolytes/ serum Sign ificant Significant

chemistry deviation from deviation from

normal normal

7. Must have either a. or b.:

a. A low body weight that can reasonably

lead to instability in the absence of

intervention as evidenced by one of the

following:

i. Less than 85% of IBW o r a BMI

less than 16.5 .

ii. Greater than 10% decrease in

body weight within the last 30

days .

iii. In children and adolescents,

greater than 10% decrease in body

weight during a rapid growth

cycle.

b. Persistence or worsening of eating

disorder behav ior despite recent (with [sic]

the last three months), appropriate

therapeutic intervention in a structured

eating disorder treatment setting. If PHP

or IOP is contraindicated, documentation of

the rationale supporting the

contraindication is required. O ne of the

following must be present:

i. Compensatory behaviors

(binging, purging, laxative abuse,

excessive exercise, etc.) have

caused significant physiological

complications.

ii. Compensatory behaviors occur

multiple times daily and have

failed to re spond to treatment at

a lower level of care and acute

physiologic imbalance can

reasonably be expected.

22. New DirectionsÓ contact notes for this case indicate

that it was called by someone named ÐRachelleÑ o n behalf of

A.H.Ós family on September 3, 2015 . This person asked about the

authorization process for McLean Hospital. No witness was

presented who had direct knowledge of the contents of this

conversation. The note indicates that ÐRachelleÑ was advised

that any authorization process must be initia ted with New

Directions by McLean Hospital.

23. On September 9, 2015, the day R.H. was admitted to

McLean Hospital, Florida Blue received what its notes reference

as a Ðcritical inquiryÑ message regarding this admission. A

Florida Blue employee phoned th e number attached to the message

but discovered it was not for A.H. but for Ðsomeone at AllState

Insurance who is out of the office.Ñ (This person turned out to

be Pearl Harrison, R.H.Ós grandmother and qualified

representative in this proceeding, who had not yet obtained a

release to receive confidential medical information concerning

R.H.) . No number for A.H. could be found. Florida Blue

contacted New Directions, which confirmed that no request for

pre - authorization 3/ had been received from McLean Hosp ital or the

member.

24. R.H.Ós stays at McLean Hospital were not emergency

admissions. The term Ðmedical emergencyÑ was not specifically

defined in the 2015 Plan, but expert testimony at the hearing

established that it is a term of common meaning and u sage in the

medical community. An emergency situation is one in which there

is an immediate risk of death, serious bodily harm, or creation

of an irreversible condition. If care is not administered

immediately, the person will harm herself or someone els e.

Michael Shaw, the utilization management team leader for New

Directions, explained that emergency care is not provided at the

residential level of care, but in an inpatient setting under

lock and key.

25. The medical records indicated that R.H.Ós la st

incident of self - harming behavior occurred about a week prior to

her admission to McLean Hospital. Her injuries were superficial

and she was in no immediate danger or risk of irreversible

damage.

26. Section 7 - 1 of the Plan provides for hospital

admis sions, including the following pertinent language as to

non - emergency admissions to non - network hospitals and pre -

certification for stays at non - network hospitals:

Non - Network Hospital: Non - emergency

Admission

Every non - emergency admission to a non -

netwo rk Hospital must be pre - certified.

This means that before services are provided

Florida Blue must certify the Hospital

admission and provide the number of days for

which certification is given.

Precertification of non - network Hospital

stays is your respo nsibility, even if the

Doctor admitting you or your dependent to

the Hospital is a Network Provider. Failure

to obtain pre - certification will result in

penalties (higher out - of - pocket costs). For

more information on penalties, see ÐIf You

Do Not Pre - Cert ify Your StayÑ within this

section below.

To pre - certify your stay in a non - network

Hospital, ask your Doctor to call Florida

Blue at (800) 955 - 5692 before your Hospital

admission and provide the reason for

hospitalization, the proposed treatment or

sur gery, testing, and the number of Hospital

days anticipated.

Florida Blue will review your DoctorÓs

request for admission certification and

immediately notify your Doctor or the

Hospital if your admission has been

certified and the number of days for which

certification has been given. If the

admission is not certified, your Doctor may

submit additional information for a second

review.

If your Hospital stay is certified and you

need to stay longer than the number of days

for which certification was given, your

Doctor must call Florida Blue to request

certification for the additional days. Your

Doctor should make this call as soon as

possible.

* * *

If You Do Not Pre - Certify Your Stay: Non -

Network Hospital

1. Benefits for covered services will be

reduc ed by 25 percent of the covered

charges, not to exceed a maximum benefit

reduction of $500 IF you are admitted to a

participating Hospital (Payment for Hospital

Services or PHS Provider) [4/] that is not part

of the Preferred Patient Care (PPC) Network

and admission certification has not been

requested on your behalf or the request is

denied.

2. This Plan will not pay room and board

benefits for your first two days of

hospitalization IF your non - network Hospital

admission is denied, but you are admitted to

a non - network Hospital anyway.

3. This Plan will not pay room and board

benefits for your entire Hospital stay IF

you are admitted to a non - network Hospital

without having your Doctor call prior to the

admission.

4. This Plan will not pay room and b oard

benefits for the additional days that were

not certified IF your non - network Hospital

admission is certified but your stay is

longer than the number of days for which the

admission was certified.

27. The PlanÓs pre - certification requirement was not met.

Neither A.H. nor McLean Hospital requested pre - certification.

Mr. Shaw testified that he spoke to three different people at

McLean Hospital, all of whom stated that the 3 East DBT program

does not accept or work with insurance. Mr. Shaw was unable to

generate the paperwork needed to begin the pre - certification

process because McLean Hospital declined to share with him the

necessary clinical information about R.H. 5/

28. Although pre - certification was not obtained for R.H.Ós

stays at McLean Hospital, Florida Blue conducted a post - service

review to determine whether the claim was eligible for

reimbursement.

29. Petitioner submitted a request for a Level I appeal

pursuant to Section 12 of the Plan, under which a person denied

benefits or payment of a c laim for medical services may obtain a

review by Florida Blue. Petitioner submitted a package of

R.H.Ós medical records for review.

30. Prest & Associates, Inc., a URAC - approved independent

review organization, 6/ was retained to conduct an independent

re view of PetitionerÓs claim. Dr. Barbara Center, a staff

psychiatrist with Prest & Associates, performed a review

designed to determine the medical necessity of R.H.Ós stays at

McLean Hospital. Dr. Center is board - certified in General

Psychiatry, Child an d Adolescent Psychiatry , and Addiction

Medicine.

31. Dr. Center reviewed the claim in terms of the New

Directions criteria for psychiatric residential admissions and

for eating disorder residential admissions. She performed two

reviews, one for the adm ission starting on September 9, 2015,

and another for the admission starting on October 15, 2015.

32. Dr. Center stated that the McLean Hospital medical

records provided by Petitioner gave a detailed description of

R.H.Ós history of present illness, past psychiatric history, and

other elements of her history that were adequate for making a

medical necessity determination.

33. As to the September 9 admission, Dr. Center concluded

that medical necessity criteria were not met for either a

psychiatric reside ntial or an eating disorder residential

admission. As to the psychi atric residential criteria,

Dr. Center concluded that R.H.Ós admission failed to satisfy

criteria 3, 4, and 5.

34. Dr. Center testified that criterion 4 looks at

symptoms and behaviors that represent a significant

deterioration from the patientÓs baseline functioning in several

areas. R.H.Ós primary support structures were stable. Her

mother was clearly involved in her care and had the support of

other family members. Dr. Center state d that the medical

records showed no sign of substantial social or interpersonal

deterioration, aside from some typical difficulty in starting

high school. R.H. was having no medical instability at the time

of admission. She was not at a dangerously low body weight.

She had a recent onset of self - harming behaviors, but there was

no documentation of acute risk issues that warranted placement

in 24 - hour care.

35. As to criterion 5, Dr. Center testified that the

records showed no indication that R.H.Ós fam ily and support

system was unsupportive or unable to take her to treatment and

participate in her care. There was no documentation that R.H.

could not progress in a less intensive level of c are.

Dr. Center noted that R.H.Ós prior treatment for eating

dis orders had been at varying levels of care and that R.H. had

not had multiple brief acute inpatient stays.

36. Criterion 3 is a diagnosis of exclusion, meaning that

if there is no apparent medical necessity for the residential

placement, then the reason mu st be Ðprimarily social, custodial,

interpersonal or respite care.Ñ Dr. Center found in the records

no support for a 24 - hour residential placement. She noted that

R.H.Ós self - injury was of a recent onset and that McLean

Hospital had ruled out any immedia te prospect of self - injury or

serious threat to other people. Cutting is not uncommon among

adolescents and does not rise to the level of requiring

residential care. Mental health providers distinguish between

self - injurious behaviors and suicidal ideati on, and McLean

Hospital did not describe R.H. as suicidal.

37. Dr. Center testified that, at the request of Mr. Shaw,

she also reviewed R.H.Ós admission in terms of the New

Directions eating disorder residential criteria. Dr. Center

noted that R.H. was not at a dangerous body weight (122 pounds,

with a BMI of 22.2) at the time of her admission on September 9.

There was no indicati on of medical instability or of out - of -

control eating disorders requiring 24 - hour care. Dr. Center

testified that DBT is rou tinely taught on an outpatient basis

and that she recommended outpatient treatment for the stay

beginning on September 9. She opined that R.H. did not meet

numbers 3 through 7 of the New Directions eating disorder

residential criteria.

38. As to the McLe an Hospital admission beginning on

October 15, 2015, Dr. Center recommended intensive outpatient

treatment. Dr. Center knew that R.H. had been transitioned from

McLean Hospital to the Cambridge Center to address the eating

disorder as her primary symptom. Dr. Center felt that

continuing R.H. in an intensive outpatient setting would help

her stabilize and maintain the progress she had made at the

Cambridge Center.

39. Dr. Center stated that a basic tenet of medical care,

and especially psychiatric care, i s that the patient be treated

in the least restrictive setting possible under the

circumstances. She stated that it is always best to treat

people in the environment they live ineatment in the 24 -

hour residential setting removes the patient from the stressors

she will have to deal with when she goes home.

40. Upon her readmission to the McLean Hospital from

Cambridge Center, R.H. denied suicidal ideation and homicidal

ideation, and the record disclosed nothing to indicate suicidal

thoughts. R.H. den ied auditory or visual hallucinations and her

mood was described as Ðeuthymic,Ñ i.e., essentially normal.

41. Dr. Center acknowledged that the medical record showed

that R.H. had been in intensive outpatient treatment for her

eating disorder at the Renf rew Center in Florida from July 23

through August 21, 2015, with limited success. Dr. Center

stated that the issue for R.H. had recently changed from her

eating disorder to her self - harming behavior and believed that

an intensive outpatient program focusi ng on skills to deal with

self - injurious behaviors would be the appropriate placement

under the circumstances.

42. Dr. Center also acknowledged that her review did not

include the records of R.H.Ós treating psychiatrist and

therapist during her stay at R enfrew, and that their notes

indicated that R.H.Ós condition had regressed while in intensive

outpatient care. Dr. Center testified that these records might

have persuaded her to recommend a higher level of care, such as

a partial hospital program, but th at she still would not have

recommended residential placement.

43. After Dr. Center rendered her opinion that R.H.Ós

residential stays at McLean Hospital were not medically

necessary, the claim was reviewed by Dr. Frank Santamaria,

Florida BlueÓs care man agement medical director. In rendering

his opinion, Dr. Santamaria reviewed the medical records sent by

Petitioner and McLean Hospital, the log of contact notes kept by

New Directions, and Dr. CenterÓs report. 7/ He testified that the

available records we re adequate to allow him to render an

opinion as to medical necessity.

44. Dr. Santamaria concluded that, as to the New

Directions criteria for psychiatric residential admissions, R.H.

failed t o meet criteria 3, 4, and 5. He opined generally that

when as sessing the need f or a residential stay, he is looking

for someone who is at risk of self - harm or harming others or who

has an acute severe psychiatric condition such as a psychotic

disorder that requires confinement. Dr. Santamaria noted that

R.H.Ós eati ng disorder was not the primary concern at the time

of her admissions to McLean Hospital; however, because the

eating disorder was occurring at the same time as the

psychiatric problem, he was also looking for medical

manifestations of the eating disorder, such as severe weight

loss affecting blood chemistry.

45. Criterion 4 requires documented symptoms and/or

behaviors that are a significant deterioration from baseline

functioning and create a significant functional impairment in at

least three of five li sted areas. Under area 4a, Ðprimary

support,Ñ Dr. Santamaria noted that R.H. had good support from

her mother and grandmother. He did not believe that primary

support was a problem. 8/

46. As to area 4b, Ðsocial/interpersonal,Ñ the notes

indicated that R .H. recently had an altercation with a friend.

Dr. Santamaria did not find such an altercation out of the

ordinary for a 15 - year - old and thus found no functional

impairment under 4b.

47. Area 4c, Ðoccupational/educational,Ñ appeared to pose

no problem be cause the records indicated that R.H. was an A - B

student, despite her rocky first week of high school.

48. As to area 4d, Ð health/medical compliance,Ñ

Dr. Santamaria noted that R.H. had been compliant with medical

instructions and her family had been go od about seeking care for

her.

49. As to area 4e, Ðability to maintain safety for either

self or others,Ñ Dr. Santamaria acknowledged that R.H. had hit

her hand with a hammer and acted in other self - injurious ways,

chiefly superficial cutting. He testifi ed that such behaviors

are not uncommon in younger populations and do not necessarily

make the person a candidate for residential care. Self - injury

alone does not satisfy the criterion, unless there is a concern

for suicide or homicide. The hammer incide nt occurred in

August, at least one week before R.H.Ós admission to McLean

Hospital. The McLean Hospital admission note of September 9,

2015 , indicates no reported his tory of suicidal thinking.

Dr. Santamaria found no documentation to indicate R.H. was

a ggressive against herself or others. She had no acute

conditions such as psychotic disorders.

50. Dr. Santamaria noted that even if area 4e were deemed

to have been met, criterion 4 requires significant functional

impairment and degradation from baseli ne functioning in at least

three of the listed areas, and that R.H. at most satisfied one

area of the criterion.

51. Criterion 5 of the New Directions psychiatric

residential criteria requires that one of three conditions

relating to the patientÓs support system or treatment history be

met. Dr. Santamaria concluded that none of the three conditions

were met. Condition 5c requires a recent history of multiple

brief acute inpatient stays without a successful transition to a

lower level of care. Dr. Santam aria conceded that the record he

examined disclosed little information about prior therapies that

had been tried with R.H., but he concluded that the record was

sufficient to confirm that R.H. did not have multiple brief

inpatient stays. He was reasonably confident that McLean

Hospital would have documented such stays had they occurred

because they would be a very significant part of her history.

Dr. Santamaria also noted that R.H. had been able to transition

to an intensive outpatient program from her in patient admission

to the Renfrew Center in May 2015.

52. Condition 5a requires that family members or the

patientÓs support system demonstrate behaviors that are likely

to undermine the goals of treatment, such that treatment at a

lower level of care is unlikely to be successful. The record

disclosed that R.H.Ós mother, who was her custodial guardian,

had a history of substance abuse but had gone through a

rehabilitation program, attended Narcotics Anonymous regularly,

and had been sober for one yea r at the time of R.H.Ós

October 15, 2015 , admission to McLean Hospital. Dr. Santamaria

testified that if R.H.Ós mother were currently using drugs and

R.H. had nowhere else to go, then condition 5a might be met.

However, the actual situation presented by the m edical record

did not establish that R.H. was living in an unsafe environment

that could undermine her treatment.

53. As to condition 5b, a documented history of an

inability to be managed at an intensive lower level of c are,

Dr. Santamaria concluded that R.H. had responded to various

therapies in the past.

54. As noted above, criterion 3 of the New Directions

psychiatric residential criteria is exclusionary, i.e., if the

placement appears not to be medically necessary, then one begins

to seek another mot ivation, such as the desire for a change of

pace or a respite for the family. Dr. Santamaria noted that DBT

does not require placement at the residential level. It can be

done at an intensive outpatient or partial hospitalization

level, both of which are lower levels of care than residential. 9/

This fact made Dr. Santamaria suspect that the prime motive for

R.H.Ós placement may have been custodial.

55. Dr. Santamaria testified that he also analyzed R.H.Ós

admission under the New Directions eating disord er residential

criteria. He stated that he could not be certain from the

record whether McLean Hospital was treating R.H.Ós eating

disorder , as well as providing DBT, but he knew that McLean

Hospital was mindful of the eating disorder. He also knew that

R.H.Ós transfer to the Cambridge Center was partly because her

eating disorder was becoming worse. Dr. Santamaria concluded

that R.H. did not satisfy criteria 3 through 7 for an eating

disorder residential admission.

56. Dr. Santamaria testified that R.H . did not meet eating

disorder residential criteria 3 through 5 for the same reasons

she did not meet the identical criteria 3 through 5 of the

psychiatric residential criteria.

57. Criterion 6 concerns biomedical complications of an

eating disorder. Dr. Santamaria reviewed the medical records

and concluded that R.H. presented none of the complications that

would require 24 - hour care at the time of her admission on

September 9, 2015.

58. Dr. Santamaria likewise found that R.H. satisfied

neither factor 7a nor 7b of Criterion 7. As to 7a, R.H. did not

present with a low body weight and there was no documentation

that she had lost 10 percent of her body weight in the last

30 days. As to 7b, there was no evidence that R.H.Ós

Ðcompensatory behaviors,Ñ i.e., binging and purging, had caused

Ðsignificant physiological complicationsÑ or that such behaviors

occurred multiple times daily and did not respond to treatment

Ðat an intensive lower level of care.Ñ

59. Dr. Santamaria testified that his analysis as to the

October 15, 2015 , admission was identical to that for the

September 9, 2015 , admission. As to both admissions, he

believed that intensive outpatient was the appropriate level of

care. Dr. Santamaria defined Ðintensive outpatientÑ as three

hours of inten sive therapy for at least three days per week. He

believed that this level of care could address all of R.H.Ós

issues, including her self - injurious behavior.

60. Dr. Santamaria concluded that if R.H. tried the

intensive outpatient level of care and fai led, then a higher

level could be considered. Like Dr. Center, he stated that he

might have recommended a partial hospitalization setting had he

known that intensive outpatient had been tried and failed, but

he still would not have recommended a 24 - hour r esidential

admission.

61. PetitionerÓs presentation implied that Florida Blue

and/or Prest & Associates base their coverage decisions on

financial considerations rather than strictly on the merits of

the claims. Dr. Center and Dr. Santamaria both testifi ed that

they had no incentive, financial or otherwise, to deny a claim

for reimbursement. Their testimony on this point is credible.

Petitioner offered no direct evidence that Florida Blue or Prest

& Associates directly pressure their physician employees to

reject meritorious claims, an d there is no evidence that

Dr. Santamaria or Dr. Center based their recommendations on

anything other than their assessment of R.H.Ós medical records

in light of the relevant medical necessity criteria.

62. Petitioner rai sed questions about the completeness of

the records examined by Dr. Santamaria and Dr. Center and

sounded a skeptical note as to the diligence of the physiciansÓ

efforts to obtain additional documentation. As found above,

both Dr. Santamaria and Dr. Cente r testified that they had

adequate documentation to render an opinion as to medical

necessity in this case. Both physicians stated that in other

cases they have taken additional steps to obtain missing

information, including making peer - to - peer calls to t he treating

physicians or reaching out to the case managers, but that no

such steps were necessary in this case.

63. Both physicians conceded that not all of the medical

records were available to them at the time of their reviews.

They did not have recor ds from R.H.Ós stays at the Renfrew

Center and the Cambridge Center or the notes of R.H.Ós treating

physicians in Florida. Both Dr. Center and Dr. Santamaria

credibly testified that nothing in these additional records

would have changed their opinion as t o the medical necessity of

residential treatment for R.H.

64. Section 12 of the Plan, which sets forth the appeal

process for a denied claim, expressly states: ÐYour appeal may

include any additional documentation, information, evidence or

testimony that you would like reviewed and considered during the

appeal process.Ñ This language is included in the explanations

for both the Level I and Level II appeals. Nothing prevents the

member from providing any documentation whatsoever during the

appeal process . Dr. Center and Dr. Santamaria are physician

reviewers, not medical investigators. If something Petitioner

asserted to be relevant to the decision was missing from the

files, it was not the fault of the reviewing physicians. It is

ultimately the member Ós responsibility to provide appropriate

documentation for review.

65. By letter dated April 5, 2016, Florida Blue notified

Petitioner that it Ðremains unable to approve additional

coverage and/or payment for the Residential Treatment.Ñ The

letter set forth the following rationale for the denial:

Per the State EmployeesÓ PPO Plan Booklet

and Benefits Document page 5 - 5: ÐServices

or supplies that are not Medically

Necessary, as determined by Florida Blue

and/or CVS Caremark clinical staff and

Division o f State Group Insurance, are non -

covered.Ñ Specifically, coverage for the

Mental Health (Eating Disorder) Residential

stays is denied as it does not meet the

definition of medical necessity. This is

for hospital stay on and after 09/09/2015

and 10/15/201 5. The final decision to

proceed with the requested services is

between the provider and the member.

Records show that the member was not deemed

to be a present risk to self or to others.

Though the member had a preoccupation with

weight sand [sic] eati ng, there was no

evidence of inability to adequately care for

self with functioning in multiple sphere

areas, including stabilization of the eating

disorder issues. There was no report of

medical instability or psychosis. The

member was in a body weight range. The

member was described as having her eating

disorder symptoms under control. From the

clinical evidence, this member could have

been safely treated at each occasion at a

lesser level of care such as in an eating

disorder intensive outpatient set ting. This

review was done using New Directions

Clinical Care criteria and is based on the

opinion of a board certified psychiatrist.

Services that are not medically necessary

are not covered under your health benefit

plan.

66. The denial letter provid ed Petitioner with information

regarding the Level II appeal process to DSGI, including a

reference to the pertinent section of the Plan. The denial

letter reiterated that Petitioner could submit any information

or documentation that Petitioner believed c ould assist in DSGIÓs

review of the appeal.

67. Petitioner submitted a request for a Level II appeal

to DSGI on May 23, 2016. The Level II appeal was reviewed by

DSGIÓs legal nurse coordinator, Kathy Flippo. Ms. Flippo

reviewed all of the documents revi ewed by Dr. Center and

Dr. Santamaria , plus additional records submitted by Petitioner

with the Level II appeal request.

68. Ms. Flippo determined that the stays at issue were

non - emergency admissions that required pre - certification and

that the pre - certi fication requirements of the Plan were not

met.

69. Ms. Flippo reached the same conclusions as Dr. Center

and Dr. Santamaria regarding the New Directions psychiatric

residential criteria. Ms. Flippo concluded that R.H. did not

meet criteria 3, 4, or 5.

70. Ms. Flippo testified that she did not review the case

pursuant to the New Directions eating disorder residential

criteria because PetitionerÓs Level II appeal addressed only the

psychiatric issues and because R.H.Ós eating disorder stay at

the Cambrid ge Center was covered by Florida Blue.

71. By letter dated July 29, 2016, signed by Tami Fillyaw,

director of DSGI, Petitioner was informed that the Level II

appeal had been denied. The letter informed Petitioner of his

rights under the Plan to file a pe tition for a formal or an

informal hearing contesting the denial of the appeal and/or to

request a binding external review from an Independent Review

Organization (ÐIROÑ). 10/ Petitioner requested both an

administrative hearing and an external review. 11/

72. The external review was conducted under the auspices

of the Medical Review Institute of America, Inc. (ÐMRIoAÑ), a

URAC - accredited external review network. The MRIoA assigned a

physician whom it stated is board - certified by the American

Board of Psy chiatry and Neurology in the specialties of General

Psychiatry and Child & Adolescent Psychiatry. 12/ The external

review upheld the adverse determinations regarding coverage for

the McLean Hospital stays.

73. In its decision letter dated November 11, 2 016, the

MRIoA provided the following relevant clinical summary and

findings:

At the time in question, the patient was a

15 year old female with a variety of

difficulties related to depression, anxiety,

eating disorder symptoms, and symptoms of

obsessive c ompulsive disorder (OCD) with

self - harming behaviors. This review has to

do with a question of whether residential

treatment center (RTC) level of care (LOC)

for two episodes of service 9/9/15 - 9/22/15

and 10/15/15 - 12/11/15 met the plan criteria

for medica l necessity. It is noted that the

patient was treated in a special eating

disorders program on the dates between these

two episodes.

* * *

The patientÓs presentation did not meet the

plan criteria for medical necessity for the

dates in question. Specif ically, the

patient did not meet criteria #5 of the

Admission Criteria. The patient is noted to

have a caring and effective support system

that would have supported a less intensive

level of care. There was no recent history

of inability to be effectivel y treated at an

intensive level of service below residential

treatment center (RTC) level of care (LOC),

and there was no recent history of inability

to transition from inpatient treatment into

a less intensive level of care.

At the time of admission to r esidential

treatment, it is clear that the patient

struggled with mood dysregulation along with

episodes of food restriction and self -

harming behaviors. She was not responding

to attempts at outpatient treatment. The

residential program in question was s ought

out specifically due to its approach to the

utilization of DBT (dialectical behavior

therapy). However, there is no indication

that the patient could not have responded to

attempts to escalate her treatment in the

outpatient setting through the use of either

intensive outpatient or partial

hospitalization services. In particular,

the patient could have been involved in a

formal DBT program without utilization of

residential treatment. Her symptom severity

for the dates in question was not of a

seve rity to require the use of round the

clock observation and treatment. As a

result, there was no medical necessity for

residential treatment center (RTC) level of

care (LOC).

* * *

The appeal letters from the patientÓs

family, outpatient providers, and

r esidential facility discuss the need for

residential treatment due to the patientÓs

symptoms severity, particularly the

patientÓs episodes of self - harming behavior

and the need for her to participate in the

immersive DBT program utilized at the

residential program in question. The

patientÓs need for more intensive treatment

is acknowledged. However, the patientÓs

recent treatment history was one of

outpatient treatment with a previous history

of residential treatment for eating disorder

symptoms. For the DOS in question, the

patient could have obtained appropriate and

effective DBT in a less restrictive setting,

such as either a partial hospitalization

program (PHP) or an intensive outpatient

program (IOP).

Based on the above, the previous

determination has been upheld.

74. At the hearing, Petitioner complained that, prior to

receiving the letter denying the Level II appeal, he had no

inkling that medical necessity determinations were based on

criteria produced by New Directions. The PlanÓs definition of

Ðmedically necessaryÑ does not reference the fact that Florida

Blue relies on the New Directions criteria for medical necessity

determinations in psychiatric and eating disorder admissions.

Petitioner basically argues that not having the precise langu age

of the New Directions medical necessity criteria deprived him

and the medical providers of the ability to frame the coverage

requests in such a way as to satisfy the criteria.

75. The record evidence shows Florida Blue does not make

the New Directions medical necessity criteria directly available

to its members. In fact, New Directions is nowhere mentioned in

the Plan. Witnesses for DSGI correctly stated that anyone can

download the criteria from the New Directions website, but

Petitioner pointed out that one must be aware the criteria exist

before one can download them. If this case is typical, it

appears that a Florida Blue member must be denied coverage and

go through the appeal process before Florida Blue makes him

aware of precisely how the dete rmination of medical necessity is

made.

76. Dr. Santamaria testified that Florida Blue does not

expect its members to have any knowledge of the New Directions

criteria or to Ðunderstand all the medical jargon.Ñ The member

is expected to present Florida B lue with the best and most

accurate medical information available (preferably before the

services are rendered) and rely on Florida Blue to make the

decision.

77. Dr. Santamaria stated, ÐYour role is not to do the

utilization management. ThatÓs my role. Your role is, if you

disagree with a coverage determination, to appeal it and to even

have your doctor speak on your behalf or write a letter or do

whatever. ItÓs not your role to access the documents and to use

them on your own. That -- thatÓs not what t hey were created for.Ñ

78. Dr. Santamaria emphasized that the memberÓs ÐroleÑ is

not to Ðmeet criteriaÑ but to provide Florida Blue with

information sufficient to allow its experts to apply the

criteria. While his phrasing may be condes cending,

Dr. Santa mariaÓs statement is basically accurate: the medical

records determine whether the criteria have been met.

PetitionerÓs awareness of the particulars of the criteria would

not change the substance of the medical record.

79. The undersigned tends to agr ee with Petitioner that

Florida BlueÓs process could be more transparent. However,

Petitioner failed to show how the outcome would have been

different if the New Directions medical necessity criteria had

been available to him or McLean Hospital. Every ex pert who

examined the medical records agreed that R.H. did not meet the

criteria for medical necessity. Their opinions are credited.

80. Ms. Flippo emphasized that Florida Blue did not deny

coverage merely because McLean HospitalÓs 3 East DBT program was

self - pay. If the member had been able to obtain pre -

certification for hospitalization and a proper bill had been

presented to Florida Blue, it would have been covered at the

allowable non - network coverage amount.

81. Ms. Flippo also stated that even i f pre - certification

had been obtained, Florida Blue would certainly not have covered

the 70 days that R.H. spent in McLean Hospital. Ms. Flippo had

never seen more than 15 days at a time approved, even for

members who were floridly psychotic and admitted under the Baker

Act. With modern treatments and medications, it is seldom

necessary to keep patients at a residential level of care for

months at a time. All of the experts agreed that DBT is more

commonly provided on an outpatient basis.

82. Additional ly, Mr. Shaw pointed out that the ability of

the insurer to pay the non - contracted, non - network rate to the

hospital is contingent on the hospitalÓs willingness to accept

insurance payments. McLean HospitalÓs 3 East DBT program did

not accept insurance. Mr. Shaw succinctly stated, ÐWeÓre not

obligated to pay you back because you made the choice to go to a

facility that takes your money but not ours.Ñ

CONCLUSIONS OF LAW

83. The Division of Administrative Hearings has

jurisdiction of the subject matt er of and the parties to this

proceeding. §§ 120.569 and 120.57(1), Fla. Stat.

84. Respondent is the agency charged by the L egislature

with the duty to oversee the administration of the State Group

Insurance Program, including the group disability insura nce

program.

85. Section 110.123, titled ÐState Group Insurance Plan,Ñ

describes the powers and duties conferred on Respondent as

follows, in relevant part:

(5) DEPARTMENT POWERS AND DUTIES. Ï The

department is responsible for the

administration of the state group insurance

program. The department shall initiate and

supervise the program as established by this

section and shall adopt such rules as are

necessary to perform its responsibilities.

To implement this program, the department

shall, with prior approval by the

Legislature:

(a) Determine the benefits to be provided

and the contributions to be required for the

state group insurance program. Such

determ inations, whether for a contracted

plan or a self - insurance plan pursuant to

paragraph (c), do not constitute rules

within the meaning of s. 120.52 or final

orders within the meaning of s. 120.52. Any

physicianÓs fee schedule used in the health

and accide nt plan shall not be available for

inspection or copying by medical providers

or other persons not involved in the

administration of the program. However, in

the determination of the design of the

program, the department shall consider

existing and comple mentary benefits provided

by the Florida Retirement System and the

Social Security System.

* * *

Final decisions concerning enrollment, the

existence of coverage, or covered benefits

under the state group insurance program

shall not be delegated or deeme d to have

been delegated by the department.

86. The general rule is that the burden of proof, apart

from a statutory directive, is on the party asserting the

affirmative of an issue before an administrative tribunal.

Young v. Dep't of Cmty. Aff. , 625 So . 2d 831, 833 - 834 (F l a.

1993); Dep't of Transp. v. J.W.C. Co., Inc. , 396 So. 2d 778, 788

(Fla. 1st DCA 1981); Balino v. Dep't of HRS , 348 So. 2d 349, 350

(Fla. 1st DCA 1977). Petitioner, as the party asserting the

right to payment of his claim under the S tate EmployeesÓ PPO

Plan, has the initial burden of demonstrating by a preponderance

of the evidence that his claim qualified for coverage. If

Petitioner meets this requirement, the burden shifts to

Respondent to prove that the claim was not covered due t o the

application of a policy exclusion. Herrera v. C.A. Seguros

Catatumbo , 844 So. 2d 664, 668 (Fla. 3d DCA 2003); State Comp .

Health AssÓn v. Carmichael , 706 So. 2d 319, 320 (Fla. 4th DCA

1997).

87. Insurance contracts are to be construed in accordanc e

with the plain language of the policy, with any ambiguity

construed against the insurer, and in favor of coverage. U.S.

Fire Ins. Co. v. J.S.U.B., Inc. , 979 So. 2d 871, 877 (Fla.

2007); Kohl v. Blue Cross & Blue Shield of Fla., Inc. , 988 So.

2d 654, 658 (Fla. 4th DCA 2008). Exclusionary clauses are to be

construed even more strictly than coverage clauses. Purelli v.

State Farm Fire & Cas. , 698 So. 2d 618, 620 (Fla. 2d DCA 1997).

88. Based on the Findings of Fact set forth above,

Petitioner has not met his initial burden of demonstrating

entitlement to reimbursement for R.H.Ós stays at McLean

HospitalÓs 3 East DBT program.

89. The Plan provides coverage for mental health treatment

at the residential level of care only if the residential

treatment is me dically necessary.

90. The Plan requires non - emergency hospital stays to be

pre - certified. Pre - certification requires a review of the claim

for medical necessity prior to the provision of the service.

91. Petitioner provided no evidence to demonstrate that

either of R.H.Ós admissions to McLean Hospital was an emergency.

DSGIÓs expert witnesses all agree that the admission was not an

emergency.

92. Petitioner provided no evidence that he sought pre -

certification. At best, the evidence indicates that Petitioner,

or some person on his behalf, made inquiries regarding coverage

for the McLean Hospital stay shortly before R.H.Ós first

admission. The evidence established that New Directions

attempted to address the issue but was rebuffed by McLean

Hospital , which steadfastly refused to cooperate with the

insurer, in keeping with its self - pay only policy. Petitioner

clearly understood McLean HospitalÓs policy. The evidence was

uncontroverted that McLean Hospital is a non - network provider.

93. His failur e to obtain pre - certification

notwithstanding, Petitioner was afforded the opportunity to have

Florida Blue review the claim for medical necessity on a post -

service basis.

94. Dr. Center, Dr. Santamaria, Ms. Flippo, and the MRIoA

all completed independent reviews of the medical records for

medical necessity and all concluded that the criteria were not

met for either stay at McLean Hospital. The experts were

unanimous in concluding that the residential level of care was

not the most clinically appropriate level of care for R.H. at

the time of either admission. Petitioner disagreed with the

expertsÓ conclusions but presented no countervailing evidence.

95. The Plan clearly states that the determination of

medical necessity is made by Florida Blue and DSGI, not by the

patientÓs treating physician. In this context, Ðmedical

necessityÑ is a definition used to establish coverage under the

Plan. ÐMedical necessityÑ does not limit the treating

physicianÓs diagnostic and prescriptive options or prevent the

Plan member from following the advice of the treating physician.

However, the member must understand that the Plan is not

required to cover the costs associated with a service outside

the bounds of Ðmedical necessity.Ñ

96. Petitioner failed to meet his burden of demonstrating

that the pre - certification requirement was met or that the

services provided to R.H. were medically necessary for purposes

of coverage under the Plan.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is

R ECOMMENDED that the Department of Management Services,

Division of State Group Insurance , issue a final order denying

PetitionerÓs claim for coverage under the State EmployeesÓ PPO

Plan for R.H.Ós residential treatment at McLean Hospital from

September 9, 2015 , to September 30, 2015 , and October 15, 2015 ,

to December 11, 2015.

DONE AND ENTERED this 17th day of May , 2017 , in

Tallahassee, Leon County, Florida.

S

LAWRENCE P. STEVENSON

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 17th day of May , 2017 .

ENDNOTE S

1/ The 2015 edition of the New Directions Medical Necessity

Criteria is applicable to this case. Tara Adams, New

DirectionsÓ regional clinical director, testified that the

criteria are reviewed annually by the companyÓs chief medical

officer t o ensure that the processes and standards of care are

up to date.

2/ R.H.Ós stay at the Renfrew Center occurred before she was

added to her fatherÓs policy on September 1, 2015.

3/ The terms Ðpre - certificationÑ and Ðpre - authorizationÑ are

used intercha ngeably in practice.

4/ The PPO Plan defines PHS Providers as those Ðnot in the

Preferred Patient Care Network but who have a Hospital services

agreement with Florida Blue to provide services, as Florida Blue

PHS Providers, at a negotiated fee.Ñ

5/ In deed, the first McLean Hospital employee with whom Mr. Shaw

spoke declined even to confirm that R.H. was a patient there.

The hospital was entirely uncooperative regarding insurance

billing.

6/ The Utilization Review Accreditation Commission is a

nonpro fit health care review and accreditation organization. In

1996, it officially changed its name to the acronym ÐURAC.Ñ

7/ At the hearing, Dr. Santamaria testified prior to Dr. Center.

His testimony was lengthier and more detailed than Dr. CenterÓs,

larg ely because Dr. Center was present for Dr. SantamariaÓs

testimony, agreed with nearly all of his analysis, and saw no

need to repeat it. This is by way of explaining why the

findings as to Dr. SantamariaÓs testimony are more detailed than

those regarding Dr. CenterÓs.

8/ Petitioner adamantly contested the family support issue.

R.H. lived with her mother, a recovering addict who had been

sober for a year and regularly attended Narcotics Anonymous.

A.H. lived an hour away, and Ms. Harrison lived 300 mile s away.

Every testifying expert examined R.H.Ós current family situation

and found nothing about it that tended to undermine her

treatment. Mr. Shaw pointed out that the family was able to pay

$96,000 out - of - pocket for R.H.Ós treatment and wished aloud t hat

he had such support. While R.H.Ós family situation may not have

been ideal, it did not rise to the level of meeting criteria for

24 - hour residential treatment.

9/ Mr. Shaw of New Directions testified that in his experience,

99 percent of people who choose DBT treatment obtain it on an

outpatient basis.

10/ More specifically, an IRO decision reversing the denial of

coverage would be binding on DSGI and allay the need for an

administrative hearing; an IRO decision upholding the denial

would not affec t the memberÓs right to pursue the administrative

hearing.

11/ DSGI reasonably delayed referring PetitionerÓs

administrative hearing request to DOAH until after the external

review was completed.

12/ Oddly, the physicianÓs full name is not given in the MRIoAÓs

denial letter.

COPIES FURNISHED:

Pearl Harrison

3783 Hunt Club Road

Jacksonville, Florida 32224

Anita J. Patel, Esquire

Department of Management Services

Suite 160

4050 Esplanade Way

Tallahassee, Florida 32399

(eServed)

J. Andrew Atkinson, General Counsel

Office of the General Counsel

Department of Management Services

4050 Esplanade Way, Suite 160

Tallahassee, Florida 32399 - 0950

(eServed)

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions

to this Recommended Order should be filed with the agency that

will issue the Final Order in this case.

4 4