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

The parent of a 15-year-old female has requested coverage for past eating disorder residential treatment center (RTC) services provided for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, placement in more restrictive settings is often clinically appropriate. Accordingly, we entrust physicians and therapists working directly with the patient population to interpret and apply clinical guidelines and patient placement criteria in consideration of clinical presentation and treatment needs.  This current concept of care is captured in the American Psychiatric Association (APA) Clinical Practice Guideline, which states that [i]n determining a patient's initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patient's overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight.Patients need to both gain healthy body weight and learn to maintain that weight prior to discharge; patients who reach a healthy body weight but are discharged before this learning occurs are likely to immediately decrease their caloric intake to excessively low levels that are often insufficient to sustain their healthy body weight.Le Grange and colleagues also indicated that [m]edium (a few weeks) and longer-term (a month or more) admissions to a psychiatric facility that specializes in the treatment of eating disorders should be considered for severely underweight patients, particularly those who have been unresponsive to outpatient efforts at weight restoration, as well as those patients who present with serious comorbid psychiatric conditions that warrant more intensive supervision and treatment.Further the American Association of Child and Adolescent Psychiatry (AACAP) Practice Parameters for depression endorse that the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care (e.g., hospitalization). The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology, and family environment.In this patients case, she is struggling with unique family dynamics and her negotiation of identity formation, both of which jeopardizes a healthy and successful second individuation. This patient had continued urges to excessively exercise per the therapist note from a date at issue.  That same day, there was a reassuring psychiatry note but a minor medication change was made.  Accordingly, discharge on that day would have been premature and inconsistent with good clinical practice in the United States.  The following day, the patient had a visit from the medical provider in which a three pound weight gain was noted as was an unremarkable physical examination.  The impression was making progress with weight.  The therapist note from that day did not mention any exercise concerns and the remainder of the progress notes did not describe a symptom burden in need of 24 hour care in a supervised setting. The patient had progressed, yet she had not yet integrated the sustained learned behaviors or consolidated the treatment gains necessary to succeed in the outpatient setting. Thus, continued care remained indicated. However, based on the documentation provided, partial hospitalization would have been a safe and appropriate placement starting the next day. Thus, a portion of the services at issue were medically necessary for treatment of the patients medical condition.