Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia Nervosa-binge eating/purging.

Treatment: Six units of extended outpatient (OP) mental health (MH) visits, code 90837 Psychotherapy, 60 minutes with patient and/or family member.

The insurer denied coverage for six units of extended outpatient (OP) mental health (MH) visits, code 90837 Psychotherapy, 60 minutes with patient and/or family member.

The denial is overturned.

This patient was in outpatient mental health treatment. The patient had worsened eating disorder symptoms including food restriction and also relapse with recent purging again. She had increased depressive symptoms including depressed mood, hopelessness, poor appetite, and decreased self-esteem. She also had worsened anxiety and obsessive-compulsive symptoms as she worked in a hospital during this pandemic and feared exposure which resulted in more compulsive behavior, anxiety, and obsessing. She reportedly had diagnoses of Anorexia Nervosa-binge eating/purging type. It was reported that she had increased severity and frequency of eating disorder, depressive, anxiety, and obsessive-compulsive symptoms.
  
Extended sessions of 60 minutes with code 90837 for outpatient mental health treatment psychotherapy for 6 sessions was medically necessary as she required more time every other week in sessions because her schedule had time restraints for weekly 45 minute sessions and she had reports of worsened eating disorder symptoms including food restriction and also relapse with recent purging again, increased depressive symptoms including depressed mood, hopelessness, poor appetite, and decreased self-esteem, worsened anxiety and obsessive compulsive symptoms as she worked in a hospital during this pandemic and feared exposure which resulted in more compulsive behavior, anxiety, and obsessing. 

It was reported that the therapist was utilizing cognitive behavioral therapy techniques to target increased severity and frequency of eating disorder behaviors including food restriction and purging as well as decrease obsessive compulsive symptoms, anxiety, and depression. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders reports that the least restrictive setting for safe and effective treatment is appropriate and that longer durations of treatment are often necessary as this is a difficult disorder to treat. This was the case with this patient. In this case this patient required longer durations of sessions at a code of 90837 as the patient had worsened eating disorder symptoms, obsessive compulsive symptoms, anxiety symptoms, and depressive symptoms. She was unable to be seen weekly for 45 minutes due to time restraints so 60-minute appointments every other week was considered medically necessary treatment. She had obsessive compulsive symptoms and hopelessness in addition to eating disorder symptoms so she required extra time to work each session every other week to try to work on several different problematic eating disorder and mental health issues as she could not be seen due to time restraints every other week for 45 minutes. She was considered at risk for requiring more intensive treatment than outpatient treatment if her eating disorder, depressive, anxiety, or obsessive-compulsive symptoms worsened even more. It did not appear that the insurer acted in the best interests of the patient. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for six units of extended outpatient (OP) mental health (MH) visits, code 90837 Psychotherapy, 60 minutes with patient and/or family member is overturned. Medical Necessity is substantiated.