Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe eating disorder symptoms.

Treatment: Inpatient mental health child services request of 3 days/units. 

The insurer denied coverage for the inpatient mental health child services request of 3 days/units. 

The denial is overturned. 

This patient is a female child who was admitted to inpatient hospital treatment due to severe eating disorder symptoms. She reportedly was restricting food intake, purging as it was reported that her mother found bags of chewed food hidden as she was chewing and spitting out food into bags and hiding them, excessive exercise, sad mood, increased anxiety, and loss of 13% of her body weight 1 month prior to admission. Her admission body weight reportedly was 47.9 kilograms (kg) with a height of 61 inches. She reportedly had a history of self-injurious behavior. She reportedly had past bradycardia due to her eating disorder symptoms. She reportedly had 2 past hospitalizations due to eating disorder symptoms and returned to maladaptive eating behaviors upon discharge from the hospital. She reportedly had weight restoration and nutritional stabilization. She reportedly took Prozac, was working on a safety plan for discharge, still lacked insight into her illness, and required hospital treatment until discharge after a discharge meeting with her mother who agreed to better supervise the patient and help make every effort to help the patient maintain her weight.

The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Eating Disorders reports that the least restrictive level of treatment for safe and effective treatment is appropriate. 

In this case it was reported that the patient required the entire hospital stay. It was reported that during the denial period she still had poor insight into her eating disorder illness and was still attempting to hide food while in this 24 hour unit, was limited into her difficulties that she may have when returning home without this intense supervision and structure. It also was reported that she quickly returned to her maladaptive eating behaviors after 2 hospital discharges, so she required more time in the hospital this time to work on a safety plan for discharge and to improve insight into the triggers to her eating disorder symptoms so as not to return to them when not as supervised. She also needed the safety plan and strong focus on ability to maintain gains while in the community with outpatient providers. It was reported that during the denial period the health care team remained concerned about the patient's status and ability to maintain behavioral changes if outside of the hospital setting with significantly less supervision and level of support. After the discharge meeting with her mother, it was reported that her mother stated that she would make every effort to help maintain the patient's weight and provide more supervision regarding meals and to observe for maladaptive eating behaviors. Discharging this patient prematurely would likely have increased her chances of returning to maladaptive eating behaviors upon discharge as evidenced by her doing this upon her past 2 hospitalization discharges for eating disorder symptoms. She also had past medical issues related to her eating disorder including bradycardia and had significant weight loss prior to this hospitalization so she was at risk medically if discharged prematurely.  

Continued inpatient hospital treatment was medically necessary as the medical records provided enough specific evidence to support that the patient required continued hospital treatment until discharge. It did not appear that the health care plan acted in the best interests of the patient.  

The insurer's denial of coverage for the inpatient mental health child services request of 3 days/units is overturned. Medical necessity is substantiated.