Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia Nervosa

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This adolescent was admitted to inpatient hospital treatment due to worsened eating disorder symptoms including weight loss of 4 pounds (lbs.) in one week and 5 percent (%) weight loss in 39 days, a Body Mass Index (BMI) of 15.2 which is considered severe, moderate malnutrition, hypotension, electrolyte abnormalities including low potassium of 2.1 and low magnesium of 1.2. She reportedly had severe anxiety during meals, was aggressive when her parents forced her to eat, and she had body image distortion. They stated that the admission weight of 39.1 kilograms (kg) was only in the second percentile for her age. She reportedly had a diagnosis of Anorexia Nervosa-severe restricting. She reportedly was in multimodal outpatient treatment and had the above symptoms reported. She had 1:1 observation including bathroom use, daily labs, nutritional supplements, supervised meals and was on a strict eating regimen. She continued to have significant anxiety surrounding meals. She had medication changes including increasing Lexapro and adding Ativan prior to meals to target anxiety when eating. She reportedly gained enough weight and was discharged. 
   
The medical records provided enough specific evidence to support that the patient required this inpatient level of care. According to the InterQual 2022 Behavioral Health Child and Adolescent Psychiatry guidelines, it states that inpatient care is recommended for eating disorders when the patient is below the 10th percentile for BMI. Also, the Milliman Care Guidelines (MCG) guidelines for eating disorder child/adolescent reports that suboptimal BMI or low expected weight for height, age, and sex or current rapid rate loss, electrolyte abnormalities, the need for strict staff supervised meals or bathroom use, or the need to improve motivation to recover meets criteria for inpatient hospital treatment. In this case this patient reportedly had suboptimal BMI and low expected weight for age, height, and sex as she was in the second percentile which is very low. She reportedly had moderate malnutrition. She also reportedly had electrolyte abnormalities including a potassium of 2.6 and also a magnesium of 1.2. She also reportedly was hypotensive. She also required strict staff supervised meals and bathroom use and needed to improve motivation and coping skills to decrease her maladaptive eating behaviors which resulted in the above medical consequences putting her more at risk medically. She also had severe anxiety and past aggression during meals. It was reported that her Lexapro was increased to try to better target anxiety and also Ativan was added during her hospital stay prior to meals to help decrease anxiety. 

The medical records did provide enough specific evidence to support that she required 24-hour hospital treatment.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for full hospital admission is substantiated.