Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Eating Disorders. 
Treatment:  Residential Mental Health Treatment. 

The insurer denied residential mental health treatment.  The denial was upheld.

The patient is a female.  The patient was admitted due to anorexia and food restriction.  The patient had difficulty concentrating, deterioration in activities of daily living (ADL), difficulty with academics, over exercising and obsessive thoughts about food.  The patient had lost 20 pounds (lbs) prior to admission.  The patient had a body mass index (BMI) of 18.1 and was 86% of her ideal body weight.  The patient was diagnosed with Other specified eating disorder, Generalized anxiety disorder (GAD) and Mixed obsessional thoughts and acts.  The patient's parents brought her into treatment.  The patient stated that "parents found out about my eating disorder."

As of the day prior to the first date in question, the patient was compliant with her meal plan.  The patient was now 97.46 % of her ideal body weight and had a BMI of 20.4.  The patient was on a meal plan of 2700 kilocalories (kcal) a day.  The patient was not engaging in food restriction, purging or food refusals.  Family was supportive and involved in her treatment.  The request at the time was for an additional week prior to step down to a Partial Hospitalization Program (PHP).  The patient was not on medications.  The patient was attending individual, group, and family therapy.  Her blood pressure (BP) was 113/78.  Her pulse did change with position from 91 to 117 from sitting to standing.

Lab abnormalities included a carbon dioxide (CO2) at 30, blood urea nitrogen (BUN) was high at 30, Albumin/Globulin ratio was high at 2.4.  There were comments from the patient that she wanted to go home in order to restrict and purge.  There was concern for risk of relapse given the holiday.  Glucose was 56, CO2 remained at 30 which is borderline high, BUN was 26.7 and Albumin/Globulin ratio was 2.5.

The patient remained meal plan compliant with no need for supplementation, no refusals, binging or purging.  The patient did have urges.  The patient was participating in groups and individual therapy.  The patient's internal motivation continued to be an issue.  There was no suicidal ideation, homicidal ideation, or psychosis.  No self-injurious behaviors, mania, or threatening behaviors.  The patient continued to gain weight as expected and engaged in food exposures.

At issue is the medical necessity of residential mental health treatment.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of residential mental health treatment was not medically necessary for this patient.

The patient had steadily been gaining weight since admission.  The patient was not at a dangerously low body weight.  The patient was not engaging in restriction, purging, or binging behaviors.  The patient was 100% compliant with meal plan.  There was no indication the patient needed direct supervision at all meals or bathroom supervision for a time period after each meal.  The patient did not have significant biomedical instability that required around the clock monitoring.  Her family was supportive.  There was no clinical documentation to support the patient was unable to control obsessive thoughts or reduce negative behaviors in a less restrictive environment.

Therefore, continued residential mental health level of care was not medically necessary.