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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided from. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bulimia nervosa. At issue in this case is whether the residential treatment center services at issue, provided, were medically necessary for treatment of the enrollees behavioral health condition.The patient was admitted to the residential treatment center after a suicide attempt via overdose. She indicated she took an overdose of antidepressant pills after she was weighed and was unhappy with her weight.  On admission she denied any active suicidal or homicidal ideation and did not express any active suicidal ideation during her stay. She did not engage in any self-harm behaviors. The records indicate that the patient had not been in any intensive treatment for her eating disorder in a significant amount of time.  It appears that her last treatment on an outpatient basis was several months prior to her admission.  She indicated that she had success and remission or resolution of her eating disorder symptoms with past treatment. The records do not indicate that the patient has any physical health concerns at this time. She does not have any substance use issues. There is no indication that she is using medications to purge or using laxatives for weight loss. Her weight on admission was within normal range. There is no indication of any cardiac problems and it does not appear that the patient is currently underweight. The patient had no significant history of substance use or abuse. The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy (CBT) can be effective for treatment of eating disorders as referenced in the following: After inpatient weight restoration, Pike et al. showed that CBT significantly reduced relapse risk and increased the likelihood of good outcomes compared with nutritional counseling, based on nutritional education and food exchanges. The literature indicates that therapy on a consistent basis along with medication treatment is the most successful method for eating disorder treatment. The patients LOCUS score for the stay as of is as follows:1) Risk of harm--- moderate (3), this is due to a lack of current suicidal ideation but history of a recent suicide attempt.2) Functional status--- mild (2), this is due to developing problems in school with some difficulty meeting obligations but overall ability to maintain meaningful relationships.3) Medical, Addictive and Psychiatric Co-Morbidity---none (1), this is due to no evidence of medical illness or substance use.4A) Recovery environment, level of stress, ---mild (2), this is due to some performance pressure in school. 4B) Recovery environment, level of support moderate (3) this is due to positive relationship with but also substance use in the home.5) Treatment and Recovery historysignificant (2), this is due to successful past treatment episodes.6) Engagement and Recovery Status---positive (2), this is due to good cooperation in treatment and insight into need for treatment. This gives the patients stay a composite score of. A score correlates with a treatment intensity level of two. Level two is described as Low Intensity Community Based Services. According to the patients score on the LOCUS, residential treatment was not medically necessary. The patient could have been treated in a less restrictive setting and therefore, the services at issue were not medically necessary.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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.