Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia Nervosa, Restricting Type
Treatment: Inpatient Mental Health Services
The health plan denied the requested mental health services. The health plan's determination is overturned.

This case involves a young adult female, admitted for inpatient psychiatric eating disorder treatment. The patient was brought to the emergency department by her parents for urgent psychiatric care after she had become increasingly thin and malnourished in the context of anorexia nervosa with a restricted intake of 1000 calories per day. She had a history of mood disorder best characterized as severe major depressive disorder and the co-morbid eating disorder with anorexia nervosa, restricting type. She presented with a decline in functioning and inability to care for self; she indicated that she could not gain weight. She had been hospitalized in the past for treatment of depression and had received residential level eating disorder treatments twice in the past with clinically appropriate aftercare. Despite access to treatment in the community, she had continued to worsen with the eating disorder. She denied abuse of substances and excessive exercise.
The mental status examination revealed depressed mood with sad affect that was flat and anhedonia and low self-worth. She was anxious, cooperative and thin. There was no evidence for mania or psychosis, and she denied suicidal ideation or aggressive impulses. Sleep, appetite, energy levels and volition were disturbed. Insight was limited and judgment fair. She had body image disturbance and the disordered eating without binge eating, purging or other symptoms of an eating disorder.

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

The patient's eating disorder and co-morbid psychiatric condition and severity of symptoms warranted the continued inpatient level services, as proposed. The patient had failed to respond to treatment at a lower level of care despite receiving intensive treatment and services in the context of a recrudescence of symptoms and deterioration in functioning. Moreover, safety concerns, the need for the structure of an inpatient setting, and the intensity of services provided by the acute inpatient program including assistance with meals and basic activities of daily living with active treatment could not have been and could not be effectively provided at a lower level of care during the time interval under review.
The patient had failed to respond or sustain a response to clinically appropriate, intensive treatment in the community with medication management and therapy; thus, the treatment plan with respect to acute inpatient level care was necessary to address the disordered eating with restricted intake and to manage the mood disturbance, and, to continue to provide evidence-based interventions and monitoring that were reasonable in this case scenario going forward.
The co-morbid psychiatric condition and the risk for general medical problems complicate this case, requiring the intensity of services and monitoring of an inpatient setting, as well as providing support for patient functioning that had deteriorated. The patient was at high risk for relapse and needed the continued inpatient level treatment and services as requested in order to continue active treatment and to develop a safe and clinically appropriate discharge plan and disposition with step down to PHP level services.