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 all or any of the residential treatment center (RTC) services provided at Paradigm Treatment.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 3. The patient had a significant risk of harm, due to a history of suicidal ideation and attempts, including previous inpatient hospitalization for suicidal ideation.In terms of functional status, the records support a score of 4. The documentation noted significant functional impairment due to dysphoria, anxiety, panic attacks, poor self-esteem including poor body image, posttraumatic stress disorder and depressive symptoms. The patient had a history of self-harm and suicidal ideation and presented with fragile mental health, including blunted affect and nervous and guarded demeanor. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to the presence of major depressive disorder, posttraumatic stress disorder, and gender dysphoria.In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a very stressful environment due to severe conflicts with parents.With regard to level of support of the recovery environment, the records support a score of 3 due to the patients continued severe conflicts with parents and perception that the parents are not supportive.In terms of resiliency and treatment history, the records support a score of 4. The patient has poor resiliency and/or response to treatment as the patient has not been able to attain adequate mood and behavioral stability or regulation despite previous hospitalization, outpatient services, and a trial of IOP. With regard to treatment acceptance and engagement, the records support a score of 3. The patient appears to be participatory and working on treatment goals, however still presents as guarded and reluctant to discuss or acknowledge past trauma.  Thus, the patient has a total score of 24. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received and is receiving at the RTC. With the functional impairment and elevated risk of harm noted, the patient meets CALOCUS 5b extended stay criteria.  Therefore, all of the RTC services provided at Paradigm Treatment 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.