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

The parent of a 16-year-old female has requested past and future coverage for residential treatment services for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  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. It is impossible for even the most comprehensive of standard placement algorithms to account for the myriad of variables unique to complex cases.  Accordingly, we entrust physicians and therapists working directly with the patient population to interpret and apply clinical guidelines and patient placement criteria in consideration of clinical presentation and treatment needs.  This current concept of care is accurately captured in the APA Clinical Practice Guideline, which states that [i]n determining a patient's initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patient's overall physical condition, psychology, behaviors, and social circumstances rather than 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. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for depression also indicates the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care (e.g., hospitalization). The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology, and family environment.Additionally, Le Grange and colleagues indicated that [m]edium (a few weeks) and longer-term (a month or more) admissions to a psychiatric facility that specializes in the treatment of eating disorders should be considered for severely underweight patients, particularly those who have been unresponsive to outpatient efforts at weight restoration, as well as those patients who present with serious co-morbid psychiatric conditions that warrant more intensive supervision and treatment.In this patients case, she is struggling in her negotiation of identity formation which jeopardizes a healthy and successful second individuation.  This patient has neither integrated the sustained learned behaviors nor consolidated the treatment gains necessary to succeed in the outpatient setting. Further, her persistent symptomatologies, negative schemas, self-defeating behaviors and pathological distortionism would more than likely undermine efforts at a lower level of care at this time, which would place her at risk for readmission.  Accordingly, the eating disorder residential treatment center services provided were and are medically necessary for treatment of the patients medical condition.