Boston Children's Hospital Case Study

A review of the records reveals the member to be an adolescent male with a birth date of 04/18/2005. The member has diagnoses including suspected learning disability, global cognitive impairment and dual sensory loss. The member’s treating provider, Susan Ray-Lamond, MD recommended the member be seen at Boston Children’s Hospital a (non-plan provider) for neuropsychiatric evaluation.

The carrier has denied coverage of neuropsychiatric evaluation at Boston Children’s Hospital a (non-plan provider) as not medically necessary. There is a letter from the carrier to the member’s parents dated 05/31/2016 which states in part:

“…The service is not a covered benefit. 1 Under the terms of your Baystate Health Silver HMO plan, non-emergency services
However, the member’s family specifically wants the testing to be performed at Boston Children’s Hospital where the member is receiving other services. The problem is that Boston Children’s is considered an out-of-network provider. The member’s Health Plan does have in-network providers who are capable of performing the evaluation, including a physician named Dr. Mitchell who is a member of Neuropsychology Associates of Western MA.

The specific question in this case is whether or not an out-of-network provider for neuropsychological testing is medically necessary.

The health plan has already determined that neuropsychological testing would be appropriate for this individual given his complicated medical history. However, there is no specific reason provided, aside from the member’s family preference, why the neuropsychologist at Boston Children’s Hospital would be more qualified to do the testing than the neuropsychologists who are in-network with the plan.

Therefore, the carrier’s decision in denying coverage for a neuropsychiatric evaluation at Boston Children’s Hospital, a non-plan provider, was