Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services provided by Paradigm Treatment Center.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 4. The patient had a serious risk of harm, due to a history of suicidal ideation, substance use, and risky behavior including alcohol use. In terms of functional status, the records support a score of 4. The documentation noted serious impairments in judgement due to drinking, risky behavior, and defiant and reactive behaviors.  With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to the presence of substance abuse and depression. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to a strained relationship with her parents, who shared custody, due to the patients drinking. With regard to level of support of the recovery environment, the records support a score of 3 due to significant conflicts with her parents and a loss of trust. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment due to continued symptoms of depression, substance use, and elopement despite a history of therapy. With regard to treatment acceptance and engagement, the records support a score of 2 as the patient appeared responsive to treatment.Thus, the patient has a total score of 22. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care was medically monitored residence-based services. This is consistent with the level of care that the patient received at the RTC. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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 were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.