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

The patient is a 37-year-old-female who was admitted for inpatient detoxification in November 2005. Her provider indicated she sometimes had suicidal ideation, although there was no plan or specific intent. In November 2005 the progress note indicates the patient was doing well by self report. No symptoms of withdrawal were documented; she was felt to be stable and her vital signs were normal.  The patient transferred to residential care in November 2005 and her diagnoses were documented as alcohol and cocaine dependence.In December 2005 there was a revised Medical Physicians Order Sheet noting diagnoses of bulimia nervosa, ADHD, depression, alcohol dependence and cocaine dependence. The patients medications were changed from Celexa to Prozac and Topamax, weights were ordered three times per week and there were instructions to encourage five meals per day.  There was a relapse noted in late November 2005.  The remainder of the clinical documentation indicates the patient was generally doing well, was motivated, and was purging only one to two times per day.  It was stated in the record the patients treatment plan included 22 hours per week of group therapy and two hours per week of individual therapy. The patients request for reimbursement for the residential treatment services provided from November 2005 through February 2006 was denied by the Health Plan citing a lack of medical necessity. Residential detoxification and psychiatric services were not medically necessary and the patient could have been appropriately treated in an intensive outpatient program (IOP).   She never manifested any signs or symptoms of withdrawal. The record indicates she was stable during this period and there was no evidence of frequent monitoring for withdrawal symptoms. The need for medical management of detoxification is not apparent.  The patients suicidal ideation was intermittent and only documented at the time of admission. Her detoxification orders did not include any arrangements for suicide precautions. The patient was described as motivated to receive treatment, demonstrating insight into the need for treatment, engaged in the program, and having a support system available to her.  These factors all point toward the likelihood of a successful IOP.  Additionally, there is an apparent lack of the treatment intensity and the frequency of therapeutic interventions generally expected within the residential treatment setting or anticipated to support the severity of illness that is appropriately treated at this level of care.  Some specific concerns are as follows:According to LOCUS the residential level of care requires psychiatric care available either on site or by remote communication 24 hours daily and psychiatric contacts at least weekly, but may occur as often as daily. On site nursing care should be available about 40 hours per week if medications are being administered on a frequent basis. On site treatment should be available seven days per week including individual, group and family therapy. Despite the expressed concern for the patients constant suicidal ideation she was allowed to go on passes on three separate occasions.There is no evidence of interventions specific to the diagnosis of bulimia nervosa either in the chart notes or the therapists letters.  Instead the patients eating disorder program was primarily comprised of three self-help groups per week which is contrary to the American Association of Psychiatry guidelines which specifically recommend against this as the sole initial treatment approach for bulimia nervosa. Cognitive-behavioral therapy combined with pharmacotherapy has emerged as the most efficacious treatment for bulimia nervosa.  There is no evidence that during this residential stay these modalities were coordinated or aimed at addressing the patients symptoms.Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.