BlueCross . .- BlueShield Minnesota PO. Box 64560 St. Paul, MN 55164-0560 September 7, 2018 Corrected Letter SOPHIA UHLENKAMP Member UHLENKAMP Date draining .. .. M.-. . . MemberiD: Group ID: Provider Namea Reference Number. Dear UHLENKAMP: A p5 chiatrist has completed a review of the information provided to us requesting coverage for t. services below. . . '7 Service Start Date ?End Date - TotaiDEhied RTF (is-0542013 09-07-2018 n?M- These services or supplies are not approved because they do not meet the criteria for medical necessity based on: Does not Medical Necessity Criteria Per McKesson lnterqual, 2017 Child and Adolescent Subset inpatient. Speci?call she ve Eatin Dis rn or treatment co . .lications due to medical issues. She has been able to adequately restore weight. s. needs .can be met with outpatient treatment? As stated in your plan document, your coverage provides benefits for only those covered services, drugs, and supplies that are medically-necessary and appropriate for the diagnosis or treatment ofa Speci?c illness, injury, or condition. Medical necessity is de?ned as a need for particular services or so plies'that a provider exercising prudent clinical judgment, would provide to a patient or the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its and that are: . in accordance with generally accepted standards of medical practice; . clinically apprOpriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient?s illness, injury or disease; and Blue Cross' and Blue Shield' of Minnesota and Blue Plus? are nonprofit Independent licensees of the Blue. Cross and Blue Shield Association. not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to prodUce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patients illness, injury or disease. No benefits will be provided unless it is determined that the service or supply is medically necessary and appropriate. For additional information, please see the following section of your plan document: Child Adolescent Behavioral Health You may request any or all of the following documentation free of charge by calling the number on the back of your member ID card or by faxing a request to (651) 662?2810. 0 A copy of any policy, criteria, guideline, document, record or other information referenced in making this determination. . The credentials or relevant infermation of the reviewing provider in-connection with the determination. A copy of the diagnosis and/or procedure code including description. . This determination has been made for coverage purposes. in all situations the provider must use his/her professional judgment to provide care he[she believes to be In the best interest of the patient. As always, the provider and member are responsible for treatment decisions. Although your health plan will not cover this service, you can cheese to receive the treatment at your own expense or have other sources pay for it. if you receive services after we have denied coverage, your providerzcan bill you for the cost 'of such services. You may/"also be reSponsible?fo?r payment of services'from out~of~hetwork providers. Please contact your provider to learn how much you might be charged for this service. If your provider would like to discuss this case with a reviewer prior to initiating the formal appeal process, please call 1-855-315-4039. This would not be considered an appeal and will not reverse the denial. This is a tool used to understand why the denial was issued. if you wish to request an appeal of this decision, please follow the steps outlined in the appeal rights descriptions attached to this letter. Our Case Managers are available to help you coordinate your care. We can also work with your ph sician or other health care providers. if you would like to speak with a Case Manager, please cal us at 1-866-489-6947 (TTY 711). Our office hours are Monday through Friday from have questions about this letter, please call Member Services at the number on the back 0 your identification card. Sincerely, Medical Management Attachments: MN Appeal Rights cc: ALLISON STOLZ BiueCross :BIueShieid Minnesota PO. Box 64550 St. Paul, MN 55164-0560 December 14,2017 SOPHIA UHLENKAMP u" RE: member Name: SOPHIA UHLENKAMP Date of irth: Member ID: Group ID: Provider Name:- Reference Number. Dear SOPHIA UHLENKAMP: A has completed a review of the information provided to us requesting coverage for the services below. A . Service Start Date? . End Date Total Denied inpatient- RTF 12-14-2017 12?27-2201 7 14 Days These services or supplies are not approved because they do not rneet the criteria for medical necessity-based on: - . McKesson . Adolescent Eating Disorde The clinical information submitted by your provider does notshow that you need 24 hour supervision. You do not appear to need supervision for safety or for health risks. Your should be able to be managed with Intensive Outpatient treatment . .As stated inyour plandocument, your coverage provides bene?ts for only those covered services, drugs, and supplies that are medically necessary and appropriate for the diagnosis or treatment of a specific illness, injury, or condition. - - 5 - - Medical necessity?is de?ned as a need for particular services or supplies that a provider exercising prudent clinical judgment, would provide to a patient for the purpose of- preventing, evaluating, diagnosing or treating an illness, injury, disease or and that are: . in accordance with generally accepted standards of medical practice; g. clinically appropriate, in terms of. type, frequency", extent, site and duration, an considered effective for the patient?s illness, injury or disease; and . .Biuetrossi' and Blue Shieid' of Minnesota and Blue Pius' are nonprofit independent licensees. of the Biue Cross and Blue Shieid Association. not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to proddce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patients illness, injury or disease. No benefits will be provided unless it is determined that the service or supply is medically necessary and appropriate. For additional information, please see the following section of your plan document: Child 81 Adolescent Behavioral Health You may request any or all of the following documentation free of charge by calling the number on the back of your member ID card or by faxing a request to (651) 662?2810. 0 A copy of any policy, criteria, guideline, document, record or other information referenced in making this determination. The credentials or relevant inferrnation of the reviewing provider in-connection with the determination. A copy of the diagnosis and/or procedure code including description. This determination has been made for coverage purposes. in all situations the provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient. As always, the provider and member are responsible for treatment decisions. Although your health plan will not cover this service, you can choose to receive the treatment at your own expense or have other sources pay for it. if you receive services after we have denied coverage, your providercan billyou for the cost 'of such services. You may'aiso be reSponsib?le'for payment of serVice's'from out?of?network providers. Please contact your provider to learn how much you might be charged for this service. If your provider would like to discuss this case with a reviewer prior to initiating the formal appeal process, please call 143558154039. This would not be considered an appeal and will not reverse the denial. This is a tool used to understand why the denial was issued. if you wish to request an appeal of this decision, please follow the steps outlined in the appeal rights descriptions attached to this letter. Our Case Managers are available to help you coordinate your care. We can also work- with your physician or other health care providers. if you would like to Speak with a Case Manager, please cal us at 1-866-489-6947 (TTY 711). Our office hours are Monday through Friday from have questions about this letter, please call Member Services at the number on the back 0 your identi?cation card. Sincerely, Medical Management Attachments: MN Appeal Rights cc: ALLISON STOLZ