State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1400 Virginia Street -----

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1 Joe Manchin, III Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1400 Virginia Street Martha Yeager Walker Secretary August 13, 2009 Dear : Attached is a copy of the findings of fact and conclusions of law on your hearing held August 6, Your hearing request was based on the Department of Health and Human Resources decision to deny prior authorization of a MRI of the cervical, thoracic and lumbar spine; MRI of the bilateral hips and a CT of the brain. In arriving at a decision, the State Hearings 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 the Medicaid program is based on current policy and regulations. These regulations provide that effective 10/01/05, prior authorization will be required on all outpatient radiological services that include Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI). Failure to obtain prior authorization will result in denial of the service (Hospital Manual ). The information submitted at your hearing was insufficient to support the medical necessity of the MRIs and CT. It is the decision of the State Hearings Officer to Uphold the action of the Department to deny prior authorization of a MRI of the cervical, thoracic and lumbar spine; MRI of the bilateral hips and a CT of the brain. Sincerely, Kristi Logan State Hearings Officer Member, State Board of Review cc: Erika Young, Chairman, Board of Review Bureau of Medical Services

2 WEST VIRGINIA DEPARTMENT OF HEALTH & HUMAN RESOURCES BOARD OF REVIEW, Claimant, v. Action Number: 09-BOR-1354 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 concluded on August 6, 2009 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 on August 6, 2009 on a timely appeal, filed June 16, II. PROGRAM PURPOSE: The Program entitled Medicaid is administered by the West Virginia Department of Health & Human Resources. 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 Stacy Holstein, Bureau of Medical Services (testified by phone) Julie Mobayed, West Virginia Medical Institute (testified by phone) - 1 -

3 Presiding at the Hearing was Kristi Logan, State Hearing Officer and a member of the Board of Review. IV. QUESTIONS TO BE DECIDED: The question to be decided is whether or not the Department s decision to deny prior authorization of a MRI of the cervical, thoracic and lumbar spine; MRI of the bilateral hips and a CT of the brain for Claimant was correct. V. APPLICABLE POLICY: Hospital Manual VI. LISTING OF DOCUMENTARY EVIDENCE ADMITTED: Department s Exhibits: D-1 Hospital Manual D-2 Prior Authorization Request Forms dated May 28, 2009 D-3 InterQual SmartSheets for MRI of the Cervical Spine D-4 InterQual SmartSheets for MRI of the Thoracic Spine D-5 InterQual SmartSheets for MRI of the Lumbar Spine D-6 InterQual SmartSheets for MRI of the Knee D-7 InterQual SmartSheets for CT of the Brain D-8 Denial Notification Letters dated May 28, 2009 to Claimant, Dr. Jafary Hassan and Beckley ARH Hospital Claimants Exhibits: None VII. FINDINGS OF FACT: 1) A request for prior authorization for a MRI of the cervical, thoracic and lumbar spine, a MRI of bilateral hips and a CT of the brain was submitted to the West Virginia Medical Institute (WVMI) on May 28, 2009 for Claimant by Dr. Jafary Hassan for approval. Pertinent parts of the request forms for the MRIs of the spine and hips read (D-2): Diagnosis Related to Study: Back pain, leg pain and neck pain Clinical Reasons for Study: Patient complaining of back pain, leg pain and neck pain - 2 -

4 Previous Related Diagnostic Studies: None Related Medications, Treatments, and Therapies (include duration): Opana 30 mg The request form for the CT of the brain read in pertinent parts (D-2): Diagnosis Related to Study: Menieres Disease Clinical Reasons for Study: Patient has uncontrolled hypertension, dizziness Previous Related Diagnostic Studies: None Related Medications, Treatments, and Therapies (include duration): Bystolic 5 mg and Maxzide 25 mg 2) A denial notification letter dated May 28, 2009 was issued which read in pertinent parts (D-8): A request for prior authorization was submitted for imaging services. Based on the medical information provided, the request has been denied. MRI Cervical, Thoracic, Lumbar Spine Criteria 100, 142, there is no documentation of cervical, thoracic or lumbar radiculopathy and no documentation that symptoms have continued after conservative treatment with NSAID s for more than 3 weeks and Activity Modification such as physical therapy for more than 6 weeks. MRI Bilateral Hips There is not enough clinical information to determine medical necessity. There is no documentation of symptoms, physical exam findings or medications, treatments and therapies related to hips. CT Brain Criteria 100, 300, 500, there is no documentation of symptoms related to an acute onset of persistent neurologic symptoms/findings as in a suspected stroke/cva and no documentation of symptoms related to new transient neurologic symptoms/findings as in a suspected TIA. There is also no documentation of acute or chronic headaches. 3) Julie Mobayed, nurse reviewer with WVMI, testified to the reasons for the denial of the MRIs and CT. The indication used on the InterQual SmartSheets for the MRIs of the spine was 100, suspected cervical radiculopathy. Following the chart under 100, Ms. Mobayed selected 140, mild to moderate pain. She could go no farther with the InterQual criteria as there was no mention in the request forms of failed conservative treatments such as medication or activity modification (D-2 and D-3). Ms. Mobayed stated the InterQual criterion is the same for a MRI of the cervical, thoracic and lumbar spine. All three (3) MRIs of the spine were denied for the same - 3 -

5 lack of information regarding failed conservative treatments. The request forms did not mention any prior studies of the spine or the duration of Claimant s medication (D-2, D-3, D-4 and D-5). 4) Ms. Mobayed testified that the request for the MRI of the bilateral hips went directly to a physician reviewer as there was not enough information provided that met any of the InterQual criteria. The MRI of the hips was denied for lack of information regarding prior studies of the hips and failed conservative treatments (D-2 and D-6). 5) Ms. Mobayed used indicators 100, acute onset of persistent neurologic symptoms; 300, new transient neurologic symptoms and 500, headache for CT of the brain. There was no record of prior diagnostic studies or the history and duration of Claimant s medications. The only symptom related to the brain on the request form was dizziness. More information was needed to follow through with the InterQual criteria (D-2 and D-7). 6) Claimant testified that he was diagnosed with Menieres disease in 1998 by Dr. Wallace. That was the last time he had a MRI. He was unable to obtain those medical records since he had not been seen by Dr. Wallace in over ten (10) years. Claimant expressed concern as to how he was to provide the information needed when he could not get approved for the tests. 7) Hospital Manual states: Effective 10/01/05, prior authorization will be required on all outpatient radiological services that include Computerized Tomography (CT), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography Scans (PET), and Magnetic Resonance Cholangiopancreatography (MRCP). Prior authorization requirements governing the provisions of all West Virginia Medicaid services will apply pursuant to Chapter 300 General Provider Participation Requirements, provider manual. Diagnostic services required during an emergency room episode will not require prior authorization. It is the responsibility of the ordering provider to obtain the prior authorization. Failure to obtain prior authorization will result in denial of the service; the Medicaid member cannot be billed for failure to receive authorization for these services. Prior authorization must be obtained from West Virginia Medical Institute (WVMI) prior to the provision of the service. Failure to obtain prior authorization will result in denial of the service; the Medicaid member cannot be billed for failure to receive authorization for these services

6 VIII. CONCLUSIONS OF LAW: 1) The authorization form completed by Dr. Jafary was insufficient for WVMI to make a determination of the medical necessity of MRIs of the cervical, thoracic and lumbar spine; MRI of the bilateral hips and a CT of the brain as shown on the InterQual SmartSheets. 2) The Department correctly denied prior authorization of the MRIs and CT for Claimant for lack of medical documentation supporting the medical necessity of these procedures. IX. DECISION: It is the decision of the State Hearing Officer to uphold the decision of the Department to deny prior authorization of a MRI of the cervical, thoracic and lumbar spine; MRI of the bilateral hips and a CT of the brain. X. RIGHT OF APPEAL: See Attachment XI. ATTACHMENTS: The Claimant s Recourse to Hearing Decision Form IG-BR-29 ENTERED this 13 th day of August Kristi Logan State Hearing Officer - 5 -