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

A 30-year-old female has requested past and prospective coverage for residential treatment center services for treatment of her anorexia nervosa, post-traumatic stress disorder and major depressive disorder.  Findings:  The physician reviewer found that it is accepted practice within the psychiatrically community to place patients in the least restrictive treatment setting that is likely to be successful. 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. According to the American Psychiatric Association (APA) clinical practice guideline for eating disorders, In determining a patients initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patients overall physical condition, psychology, behaviors, and social circumstances rather than to 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.Further, co-occurring depression and PTSD places individuals at high-risk for a poor prognosis and suicide. Much like the parameters suggested in the treatment of eating disorders, the APA clinical practice guideline for depression accounts for a variety of factors in the determination of the most appropriate level of care, The psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patients condition. The determination of an appropriate setting for treatment should include consideration of the patients symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning.Regarding the case of this patient, after her admission eight months ago, the patient was disconnected and left the eating disorder group. She has since struggled to achieve a healthy weight and maintain her meal plan. She has required appetite stimulating medication adjustments, tube feedings, frequent prompting and support regarding her dietary intake, and in mid-November, she was abusing a laxative. The patient continues to subscribe to significant body distortionism and a self-defeating coping strategy that rewards eating disordered behaviors. In and of itself, such an under-developed sense of self, pathologic organization and poor support system poses an imminent risk that psychosocial stressors will produce significant distress and functional impairment enough to undermine treatment in a lower level of care. In addition, as of four months after admission, the patient continued to demonstrate an impairing level of dissociation, cognitive distortion, depression, anxiety, ruminations and self-loathing, with suicidal ideation. In consideration of the patients history and symptom complex, the psychiatrist and primary therapist both strongly urge continued residential treatment.  While review of the submitted documentation demonstrates the patient has made some progress, she has not yet been successful in instilling meaningful learned behaviors or achieving the durable therapeutic gains necessary to succeed in a less restrictive setting.  Discharge at this time would expose the patient to undue morbidity and risk for acute hospitalization.