Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

A 22-year-old female enrollee has requested behavioral health services for treatment of her eating disorder.  Findings:  The physician reviewer found that a series of treatment interventions in the outpatient setting for the patient, who was 21 years of age at the time, and diagnosed with unspecified anxiety disorder and unspecified eating disorder. The patient had been treated previously in the outpatient setting for depression, anxiety and eating disordered behavior. In addition to therapy and counseling, she was previously prescribed sertraline. There was no mention in the submitted documentation of any prior treatments in a setting other than the outpatient venue. The patient temporarily relocated to another state for an academic internship. During that period, the patient consulted several providers for outpatient treatment services related to her anxiety and eating disorder.  Initial treatment interventions focused largely on interpersonal and supportive therapy. There were no crisis interventions or imminent safety concerns evident in the documentation provided. The patient was noted as insightful in her therapeutic processing and was in no acute distress. While the services were helpful they were not provided to address a psychiatric emergency medical condition and were not necessary to prevent a serious deterioration in the patients health. The patient had been previously seen by a licensed clinical social worker, at which time it was noted she was not in crisis and had no thoughts of harming herself or others. All told, these behavioral health treatment interventions did not meet criteria for emergent/urgently needed services.Concurrently, the patient presented with a poorly controlled eating disorder. Nutrition evaluation is a core component of a patient-centric treatment plan for patients with eating disorder. In this circumstance, the patient was at risk for serious deterioration of her health without periodic nutritional evaluation and counseling. Since it had been recommended during the patients previous in-person evaluation with a nutritionist that she be seen in follow-up in one month, it was medically prudent for her to seek nutritional evaluation while out of the service area. Thus, this behavioral health treatment intervention met criteria for emergent/urgently needed services. Subsequent nutritional counseling telephone services were not provided for the treatment of an emergent medical condition. Thepatient met with a nutritionist and there is no indication that additional nutritional counseling telephone treatments were required on an emergent or urgently needed basis to prevent serious deterioration of the patients health. The nutritionist documentation did not reveal an acute syndrome that necessitated emergent or urgently needed care. As such, nutritional counseling telephone treatment did not meet criteria for emergent/urgently needed services.   Considering the patients symptom burden and psychosocial factors, careful monitoring by a physician was necessary on an emergent/urgent basis. The patients initial presentation to a physician was for purposes of clinical assessment and active treatment of a potentially life threatening condition. Additionally, these services were warranted due to the possibility of deterioration in the patients condition while she was away from her support system at home. Therefore, this initial treatment intervention met criteria for emergent/urgently needed services. No medical records were submitted for subsequent physician services and in the absence of medical documentation, it cannot be established that these services met the criteria for emergent/urgently needed services.