Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health. 
Treatment: Mental Health Residential. 
The insurer denied Mental Health Residential Treatment. 
The health plan's determination is overturned in whole.

The patient is a female with history of eating disorder best characterized as severe bulimia nervosa, restricting and purging type and comorbidity with major depressive disorder and elements of persisting parent-child relational problems, as well as a history of poly-substance use. The patient presented with worsening symptoms of her eating disorder together with symptoms of anxiety and depression in the context of the eating disorder that included body image disturbance with disordered eating and restricted caloric intake, purging and misuse of laxatives.

The patient was referred to residential level services by her outpatient clinicians due to persistent and worsening eating behaviors and depression with chronic suicidal ideation with at least two prior suicide attempts with overdoses. There was no mention of abuse of diuretics, but the patient had used stimulants (amphetamines and cocaine), as well as past use of hallucinogens (mushrooms and lysergic acid diethylamide [LSD]) and alcohol with intermittent use with a binge pattern. She was tobacco dependent. Her worsening clinical features were precipitated by multiple stressors with functional impairments and somatic symptoms of generalized weakness, fatigue, constipation, dyspepsia, and muscle aches. Chronic conditions included only allergy treated with Zyrtec.

The health plan's determination is overturned in whole.

The patient's eating disorder and co-morbid psychiatric condition and severity of symptoms, and co-occurring substance use disorders prompted the need for residential level services, as proposed. The patient had failed to respond to treatment at a lower level of care compounded by the COVID-19 Pandemic. Moreover, safety concerns, the need for the structure of a residential program, and the intensity of services provided in the program including meal monitoring and bathroom monitoring could not have been and could not be effectively provided at a lower level of care for the duration of the treatment interval under review.

The patient could not be effectively treated at a lower level of care. The patient had failed to respond to clinically appropriate, intensive treatment in the community and had worsening symptoms of the mood and eating disorder; thus, the treatment plan with respect to residential level care addressing disordered eating and purging behavior, meal portioning/monitoring, anxiety and emotional regulation problems (triggers), and, other interventions were reasonable in this case scenario.

The co-occurring substance use disorders and co-morbid psychiatric condition (major depressive disorder) complicate this case and pose a risk for suicidal behavior, requiring the continued intensity of services and monitoring of a residential setting, as well as the structure of a residential level program with comprehensive eating disorder services. The patient was at high risk for relapse and needed to continue her residential level treatment and services as requested in order to receive safe and effective treatment, as proposed.

Thus, medical necessity is met. This answer is consistent with the guidelines, American Society of Addiction Medicine (ASAM) Criteria and the scientific literature, referenced below, as well as prevailing standards of medical practice.