Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for (1) residential treatment center (RTC) services provided by Paradigm Treatment Center (Malibu), and (2) any days of RTC services provided by Paradigm Treatment Center (Malibu) beyond the authorized initial 14 days. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment.With regard to risk of harm, the records support a score of 2. The patient had some risk of harm due to a history of suicidal ideation without suicide attempts, and symptoms of anxiety and depression.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious symptoms of obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), and restrictive eating. The patient was spending up to eight hours daily with rituals and while his time spent in rituals appeared to have decreased to approximately three hours daily, this still significantly impeded his social and academic functioning. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity due to the presence of debilitating OCD, BDD, anxiety, eating disorder, and daily cannabis use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to academic pressures but reported getting along with his parents and sisters. With regard to level of support of the recovery environment, the records support a score of 2 due to the support of his parents.In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as he had some response at lower levels of care but continued to be compromised and anxious with significant rituals and preoccupations. With regard to treatment acceptance and engagement, the records support a score of 3. The patient participated in group sessions but continued to present as anxious and to give in to his compulsions and preoccupations and ruminations of needing to look attractive. Thus, the patient has a total score of 21. The records support a 4 in terms of functional status and comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and comorbidity noted, the patient meets CALOCUS 5b extended stay criteria. This is consistent with the level of care that the patient received and is receiving at the RTC. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, RTC services provided by Paradigm Treatment Center (Malibu) were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.