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Expert Q&A

I have a question surrounding CPS cases for newborns. Has anyone found any documentation to support continued stay due to CPS hold on an infant with MCOs?

October 9, 2025 · Anna McGraw

Every state is different. You can check with her state’s Child Protective Services (CPS) for more specific information. Here are some thoughts with references that may help in an appeal. I hope this helps.

If the infant is currently under Child Protective Services (CPS) hold, continued hospitalization is appropriate due to complex medical, social, and legal factors. Children in CPS custody require comprehensive evaluation and coordination of care to address physical, developmental, and psychosocial needs, as well as to ensure safe discharge planning.

The American Academy of Pediatrics (AAP) states that managed care arrangements must recognize the unique needs of children in foster care or those enduring adverse conditions, support flexible eligibility and treatment policies, and facilitate access to coordinated, multidisciplinary care teams. Hospitalization is medically necessary to ensure that all recommended specialty evaluations, social work assessments, and care coordination are completed prior to discharge, as these children are at increased risk for adverse health outcomes and require ongoing follow-up.

Discharge planning for infants in CPS custody must consider the availability and reliability of safe placement, skilled nursing coverage, and the ability of caregivers to meet medical needs. Social or resource issues in the home environment may justify continued institutional care when safe alternatives are not available. The hospital team must verify that the placement can provide adequate medical supervision and that all legal and consent requirements are met, as outlined by AAP guidelines for children in child welfare protective custody.

Additionally, managed care organizations are required to provide timely authorization for necessary inpatient and specialty services and should not impose barriers to care for federally mandated services or urgent needs. The ongoing hospital stay is essential to ensure compliance with these standards and to protect the health and safety of the infant during this period of legal and social transition. Hospitals providing care to children should review their contracts with payers regarding payment for ongoing care for a child in CPS custody.

I would argue that continued hospitalization is medically necessary for this infant under CPS hold to complete multidisciplinary evaluation, ensure safe discharge planning, and comply with legal and managed care requirements for children in protective custody.

Here are some references that may help support an appeal.

Ongoing Pediatric Health Care for the Child Who Has Been Maltreated.

Flaherty E, Legano L, Idzerda S. Pediatrics. 2019;143(4):e20190284. doi:10.1542/peds.2019-0284.https://publications.aap.org/pediatrics/article/143/4/e20190284/37179/Ongoing-Pediatric-Health-Care-for-the-Child-Who?autologincheck=redirected

What Happens After the Hospital? An Analysis of Longitudinal Care Needs in Children Treated for Child Physical Abuse.

Johnson BL, Gerzina EA, Naik-Mathuria B, et al. Journal of Pediatric Surgery. 2021;56(10):1696-1700. doi:10.1016/j.jpedsurg.2021.05.019.https://www.sciencedirect.com/science/article/abs/pii/S0022346821004280

Hospitalizations Among Children Involved in the Child Protection System: A Long-Term Birth Cohort Study From Infancy to Adulthood Using Administrative Data.

Gnanamanickam ES, Nguyen H, Armfield JM, et al. Child Abuse & Neglect. 2020;107:104518. doi:10.1016/j.chiabu.2020.104518.https://www.sciencedirect.com/science/article/abs/pii/S0145213420301733

Guiding Principles for Managed Care Arrangements for the Health of Newborns, Infants, Children, Adolescents and Young Adults.

Carlson KM, Berman SK, Price J. Pediatrics. 2022;150(2):e2022058396. doi:10.1542/peds.2022-058396.https://publications.aap.org/pediatrics/article/150/2/e2022058396/188583/Guiding-Principles-for-Managed-Care-Arrangements

Considerations in the Determination of Medical Necessity in Children: Application to Contractual Language.

Giardino AP, Hudak ML, Sood BG, Pearlman SA. Pediatrics. 2022;150(3):e2022058882. doi:10.1542/peds.2022-058882.https://publications.aap.org/pediatrics/article/150/3/e2022058882/188901/Considerations-in-the-Determination-of-Medical

Special Requirements of Electronic Health Record Systems in Pediatrics: Clinical Report.

Dufendach KR, Lehmann CU, Spooner SA. Pediatrics. 2024;154(4):e2024068509. doi:10.1542/peds.2024-068509.https://publications.aap.org/pediatrics/article/154/4/e2024068509/199440/Special-Requirements-of-Electronic-Health-Record

Related

We are seeing an increased number of payor appeals which state “The HBV review performed is a payment integrity review, not a level of care or a medical necessity review, focused on the payment of services documented in the medical record. Facility documentation submitted and reviewed by HBV has identified outpatient services were delivered, and not acute care inpatient services. HBV is not denying the services provided, rather the review is focused on the payment of services documented in the medical record. In accordance with the application of MCG guidelines, HBV has determined that the services delivered are consistent with an outpatient or observation payment.” We have tried outlining the services performed, resources required, how IP level of care were met by the MCG / IQ criteria they outline. They are still being upheld. What else can we do to argue these denials?
Expert Q&A

We are seeing an increased number of payor appeals which state “The HBV review performed is a payment integrity review, not a level of care or a medical necessity review, focused on the payment of services documented in the medical record. Facility documentation submitted and reviewed by HBV has identified outpatient services were delivered, and not acute care inpatient services. HBV is not denying the services provided, rather the review is focused on the payment of services documented in the medical record. In accordance with the application of MCG guidelines, HBV has determined that the services delivered are consistent with an outpatient or observation payment.” We have tried outlining the services performed, resources required, how IP level of care were met by the MCG / IQ criteria they outline. They are still being upheld. What else can we do to argue these denials?

Mar 27, 2025