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

The patient is a 14-year-old female with an approximate three-year history of severe anorexia nervosa, restrictive type.  She was admitted to residential treatment at the current facility in November 2005 after having failed three prior hospital stays and two prior residential treatment stays.  Her previous residential treatment admissions did not last longer than three months and the patient continued to severely restrict her intake and maintained a weight of approximately 87 pounds. The highest recorded weight for the patient was 104 pounds at the age of 10 years. It was suggested that social factors at that age such as her parents marital discord and separation were etiologic in the development of her eating disorder. During that difficult time, her parents may also have yielded to the patients food-restrictive behaviors. Due to the failure of all prior treatment attempts, the patient was referred to this residential treatment facility for more longitudinal care. By this point her comorbid medical conditions included amenorrhea, osteoporosis, and osteopenia. The admission physical examination report described her as presenting a fragmented history and very thin, vague and sometimes ambiguous.  According to her psychiatrist she was subdued, cachectic, depressed mood, (and) some anxiety.  There appeared to be a delay in answering questions and the patient was very guarded and careful in her answers.  The patient was diagnosed with anorexia nervosa, major depression, and paranoid traits along with malnutrition.The patient began treatment with Prozac just prior to her admission and she was continued on the medication along with a variety of other therapies. Throughout her stay she was noted to be very defensive, prone to laughing off her food refusal, and eating overly slowly despite the fact that these behaviors were actively pointed out to her by the dietician. The patient eventually gained weight to 106.8 pounds by February 2006 through very strict enforcement of eating guidelines. Nonetheless, she still viewed what her peers considered normal body habitus as fat and disgusting, according to a note of February 2006. Additional psychiatric notes of relevance include the following: December 2005 - Patient is eating and restoring herself slowly but has a very long way to go. The issue is denial of the severity of her illness. She has no ability to remain free of restriction outside of this level of supervision.February 2006 - Showing insight and willing to discuss and understand family dynamics and impact of divorce etc., but drifts off in group, not listening to the group discussion. Had to prompt her to answer my question.February 2006 - Patient gains weight and yet very little insight. Patient has strong thoughts of restricting, fear of being fat.February 2006 - No self-oriented program of recovery. She will look for any avenue to relapse/restrict. She just tunes out  is this ADD possibly or denial?February 2006 - The more I talk with her, the more I am aware of ADD-like presentation as well as denial of severity of illness and dissociative behavior  she just spaces out.March 2006 - Does not own her recovery but will eventually when she must stop being the princess and actually takes responsibility for herself. But too young, immature, dissociative, and vacuous.Considering the number of treatment attempts and the medical comorbidities of amenorrhea and osteoporosis at such a young age, this patient clearly suffers from a severe degree of Anorexia Nervosa.  She has consistently failed to gain weight or to budge from her notion of being overweight.  Based on the record provided, she had not made notable gains on an emotional level by March 2006 and it appears that due to her denial, she will need a considerably longer residential treatment stay.  She requires a strictly supervised environment to counter her persistent desires to restrict; hence returning home is not yet an option.  Prior residential treatment attempts of limited duration (three months) have not been successful.  The patients treating psychiatrist believes that the severity of her illness warrants residential care on the order of nine months duration.  This is a reasonable assessment considering all of the before mentioned factors.  All told, I have determined the requested services are medically necessary for treatment of the patients medical condition. An additional five months of residential treatment should be anticipated and authorized by the Health Plan.  The Health Plans denial should be overturned.