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

A 20-year-old female enrollee has requested acute inpatient services, residential treatment services, and partial hospitalization services for treatment of her eating disorder. Findings:  The physician reviewer found that the submitted medical documentation indicates that the severity of the patients eating disorder and restrictive behavior was well documented on admission to the acute inpatient treatment facility. Physical exam noted dehydration and lanugo. She presented with severe distortion of body image, an intense desire for thinness and preoccupation with thoughts of being overweight. However, after approximately three weeks, the patient had experienced some improvement, as her weight was 99% of ideal body weight. Additionally, her vital signs were stable, an NG tube was not required, suicidal ideation was not present, and there was no documentation of severe mood disturbance. Thus, medical necessity for acute inpatient treatment approximately after the third week to her discharge date is not established. While the patient still required intensive treatment, including 24-hour monitoring, she was appropriate for transfer to a residential level of care after approximately the third week. By this point, she was medically stable and no longer met American Psychiatric Association (APA) treatment guidelines for acute inpatient level of care. All told, the submitted documentation supports the medical necessity of a portion of the patients acute inpatient stay. Based on the documentation provided, residential treatment was medically necessary from the admission date to the discharge date. The patient was on a treatment plan to monitor and supervise all meals and she continued to struggle significantly with body image, urges to restrict and functional impairment. During the course of treatment, co-morbid issues were present which included an anxiety disorder with obsessive compulsive disorder components and a depressive disorder.  These were additional factors to consider regarding the level of care provided and impact on relapse potential. There were also issues related to her recovery environment. Although the patients weight was above the 85th percentile, APA practice guidelines for eating disorders clearly state that highly structured inpatient programs may be medically and psychiatrically necessary even for patients above the weight level of 85%. APA guidelines for residential level of care include patients who are preoccupied with intrusive and repetitive thoughts around their eating disorders for four to six hours per day. The guidelines also include patients who are cooperative because they are in a highly structured treatment environment and patients who are able to ask for and utilize support and participate in the intense cognitive and behavioral interventions offered. This patient met these requirements. She required a supportive, structured treatment environment to maintain weight gain and to avoid relapse. Therefore, residential treatment was medically necessary during the time period at issue. Partial hospitalization as a step-down service from residential treatment was medically necessary from the admission date to the discharge date. The patient was cooperative with treatment but continued to have intrusive thoughts related to her eating disorder. In addition, she continued to require staff structure and therapeutic support to maintain weight and was still experiencing significant body distortion. As noted in the APA practice guidelines, anorexia nervosa is a complex life threatening illness. While the patient had experienced some improvement by the date of admission, she continued to require a level of care that was intensive enough to prevent relapse. Thus, the level of care provided was medically appropriate and consistent with APA treatment guidelines. In sum, partial hospitalization services on the dates of service at issue were medically necessary.