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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services. With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to continued struggles with restricting behaviors, even in the protected, structured, and highly supportive setting of the RTC. The records noted that the patient had gained weight during a prior RTC admission, and then lost weight during a month in a virtual PHP program before they were readmitted to the RTC. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient progressed while in the structured setting of the RTC but reported ongoing difficulties in family communication and expressing emotions.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to continued orthostasis as measured by heart rate, presumably related to restricting food and fluids, and required significant monitoring throughout their stay at the RTC. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to the spending an extended time in residential treatment. With regard to level of support of the recovery environment, the records support a score of 2 due to their parents active involvement in the patients care and stability of the home environment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment due to continued struggles with disordered eating and body image despite inpatient hospitalization and two separate courses of residential treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient was incompletely engaged, due to their ongoing struggles to adhere to the dietary plan at the RTC. Thus, the patient has a total score of 20. While the recommended level of care for this score is typically medically monitored community-based services, consistent with PHP level of care, in this case, the patients recent clinical history indicated that they had not been able to maintain their weight when they transitioned from residential treatment to virtual PHP.  In this clinical setting, continuing at a RTC level of care until the availability of an in-person PHP program with eating disorders was medically indicated. Literature shows the use of higher levels of care for adolescents with eating disorders, Residential treatment is typically indicated when a patient is medically and psychiatrically stable but still requiring more support than is possible at a lower level of care. This may be due to difficult-to-manage urges to binge, purge, or exercise, or to chronic challenges regarding appropriate nutrition intake. Most eating disorder providers strongly prefer to keep young patients at home with their families, if possible, given that it is disruptive and potentially traumatic to remove a young person from the comfort and safety of his or her home. However, adequate eating disorder treatment resources may not be locally available in all areas, and some patients require more support due to extreme disease severity, or because their family is struggling to implement treatment recommendations or does not agree with the philosophy of FBT (family-based therapy).  Therefore, RTC services provided at were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.