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

The patient is a 28-year-old female with a history of anorexia nervosa and bulimia as well as major depression versus bipolar disorder. She was admitted to inpatient treatment on 6/20/04 and discharged on 8/2/04. This was preceded by the patient having restricted her intake to such an extent that she entered the hospital at 89 pounds with osteopenia, which led to a stress fracture of her left foot. The patient was treated with a range of therapies along with medications. She was eventually stabilized on a regimen of Abilify, Topamax, Prozac, Strattera, and Neurontin. As of 7/27/04, the patients psychiatrist noted she was struggling to limit ritualistic eating and systemic choosing. Her nutritionist noted her affect was brighter yet she was still depressed and anxious as well as fragile. A nursing note of the same date indicates the patient was still taking extended time to eat. The patients psychiatrists notes on 7/29/04 indicate the patient was so uncomfortable that she still had strong urges to purge. On 7/30/04, the patients Abilify was increased in view of affective instability. By 8/2/04, the patient was deemed ready for discharge from inpatient treatment to the partial hospitalization program. She is stated to be feeling better with increased Abilify. By the point of discharge, she had gained 17 pounds, but was still struggling to maintain the gain, approximately 86% of ideal body weight.Following her inpatient stay the patient was transferred to a partial hospitalization program. The Health Plan indicates the submitted documentation does not demonstrate continued partial hospitalization services were medically necessary after 9/7/04. A request has been made for coverage for continued partial hospitalization services. Review of the clinical evidence reveals the patient has a very significant illness, namely anorexia nervosa attendant with major depression. She was notably underweight throughout her inpatient hospitalization. Though the patient had some successful passes towards the end of her stay, she was still struggling to keep up with the required caloric intake and was seen as affectively unstable up until 8/2/04, as noted in the hospital notes cited above. Particularly in the context of the longevity of her illness and her underweight status upon admission, her entire inpatient stay was medically warranted. Furthermore, given the history of the patients illness and severe caloric restriction, finding her as improving per se or having attainted 86% of ideal body weight is not sufficient justification to immediately deem her ready for intensive outpatient therapy (IOP). A patients weight alone is not determinative of whether transition to IOP is appropriate. Given the patients previous level of treatment and the degree of oversight that was required to allow her to attain the relatively meager weight goal, it is apparent that she required continued partial hospitalization services as of 9/7/04 and was not appropriate for transfer to IOP at that time. Thus, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.