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

The patient is a 27-year-old female with long-standing anorexia nervosa who was admitted to residential treatment on 6/26/04 due to persistently decreased intake to a low of 400-500 calories. The patient stopped eating entirely some days prior to entry. This resulted in seven syncopal episodes, including one episode in which the patient fell on a stairway and was found to be dehydrated. The patient subsequently received a liter of intravenous fluids at the emergency room. The patient described her mood as anxious, acknowledging passive suicidal ideation though nothing active, and feeling increasingly helpless. She also described persistent difficulty with sleep and fatigue during the daytime. Chart notes reveal the following: on 10/18/04 the patient was noted to have been doing an experiment getting rid of some of her food to see if she can maintain her weight on fewer calories. On 10/25/04, the patient was noted to have had difficulty eating her meal after much encouragement, she did manage to drink 1 Ensure Plus and 1 Ensure. It took her some time to drink the Ensures and therefore did not make it to art therapy. On 10/21/04, the patients psychiatrist noted the patient to be present with continuing report of a.m. light headedness. Patient reports variable mood with episodic suicidal ideation. She acknowledges lack of independent motivation to sustain weight and nutritional eating patterns. Staff reports that she was found to be hiding and throwing away food. At that point, the patients psychiatrist increased her Lexapro to 40mg every morning. Notes from 10/23/04 indicate the patient was having problems during meals or snack. Patient was forced to eat at least 80%. Patient also restricted water. On 11/1/04, the patient was noted to have had a hard time with meals, took patient some time to get started and on 11/4/04, it was noted the patient restricted water and food. Notes from the nutritional therapist on 11/8/04 indicate the patient had a variable intake and opted for supplement (Ensure Plus) in place of several meals, often eating less than 75%. Hid Ensure Plus under the table once this past week. On 11/11/04, her psychiatrist noted the patient continues to display abnormal orthostatic vitals each a.m., has subjective symptoms of dizziness, weakness, and unsteadiness preventing participation in program in first two hours. Another note from that date indicates patient came late to group because it took her 1.5 hours to eat her lunch. By 11/18/04, the patient was noted by her psychiatrist to have made a successful eating contract with her mother, with weight gain to 117 3/4 pounds. By 12/2/04, now involved in the partial program, the patient was evaluated by her psychiatrist as having increased anxiety, increased insomnia, tendencies to restrict food. Weight stable for two weeks. Her Geodon was then increased to 80mg. Notes from the patients psychiatrist on 12/7/04 indicate the patient had improved activity and alertness. Generally she has sustained nutrition with support of in-home staff and peer support. Mood stable, attitude more hopeful. The Health Plan authorized residential treatment services through 9/20/04 and later authorized two weeks of partial hospitalization from 11/9/04 through 11/24/04. A request has been made for reimbursement for past residential treatment services as well as for coverage for continued residential treatment. By all accounts, this patient is rather compromised with respect to her eating disorder and based upon the submitted treatment notes her condition did not substantially improve until the end of November 2004. The aforementioned notes point to the patients inordinate struggle to eat and maintain her weight. However, it does appear that the patients struggle was not as arduous by 12/1/04 as she showed signs of improvement at that time. As such, residential treatment services were medically necessary through 12/1/04. As an obvious extension of that care, partial hospitalization thereafter was medically appropriate and indicated for the following month, taken in the context of the longevity of the patients illness and need for continuity of care. Based upon the information set forth above, I have determined that residential treatment services were medically necessary until 12/1/04. As such, the Health Plans denial should be partially overturned.