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

The patient is a 24-year-old female with long-standing bulimia nervosa, polysubstance abuse, and major depression, previously treated in a number of eating disorder programs. She was admitted to residential treatment on 1/11/05 due to binging and purging cycles lasting all day within the past two years. This was interspersed with excessive sleeping, drinking alcohol 2-3 nights a week to the point of intoxication, promiscuity and use of methamphetamine as well as cocaine almost daily. Apparently, the patient found the drug use useful in partially helping her stop the binging. She had been unable to hold a job due to lateness, fatigue, and sense of illness due to the vomiting.Review of her chart notes indicates the patient did become variably involved in her residential treatment program, consisting of various group therapies, inclusive of family therapy, and pharmacotherapy. She was eventually thought relatively stabilized on a regimen of Wellbutrin 150 mg XL, Effexor 225, and Buspar 10 mg bid. Chart notes of relevance include the following:3/8/05 - Patient quiet and appeared in depressed mood. Patient did not talk during dinner and talked very little at snack.3/19/05 - Patient seemed in positive mood.3/20/05 - Patient seemed to be in a positive mood.3/21/05 - Patient seemed in positive mood at snack.3/22/05 - Patient very opinionated about certain affair, though not very intelligently informed. Patient quick to be opinionated without knowing much about the topic. Usual occurrence.3/24/05 - (Psychiatrist) Pervasive depressed feelings but glimmers of positive feelings. No opposition to treatment, no avoidance of responsibility.4/7/05 - (Psychiatrist) Patient feels she is less depressed on this regimen (Wellbutrin, Effexor, Buspar), crying much less but still cries in group and art group, and she feels there is hope but is scared to be on her own as she will binge and purge.Throughout the patients stay, the chart notes point to her being exquisitely self-centered, petulant, insensitive to the desires of others, and extremely focused about her appearance, with a penchant for overspending on material goods with aid of her parents credit cards, to the sum of $14,000. She was also able to convince her parents, for example to pay for breast augmentation with the argument that this would necessarily improve her self-image in a very notable way, expecting to become a trophy wife eventually. Furthermore, the patient found it extremely disturbing to consider that she would have to support herself. By 3/25/05, the patients weight was stable, she was not at all binging and purging. Although the patient had not been binging and purging for a number of months, when discharge was discussed she threatened that were she discharged, she would necessarily relapse. Though the patient did suffer from bulimia nervosa and warranted residential treatment, she also appears to suffer from a narcissistic personality disorder. Evidence of the patients narcissistic personality disorder is supported by the 3/22/05 chart note. Furthermore, to the extent that she actually did improve both in level of depression as well as weight and cessation of binging and purging, there is no evidence demonstrating the patient required residential treatment beyond 3/25/05. In addition, although all evidence points to the patients improvement and need to progress with her recovery by moving to a less intense level of care, she threatened that she would relapse if she were discharged from residential care. At this point, to cede to the patients threats would be countertherapeutic and only promote stasis, not growth. Moreover, no matter how long a patient remains in residential treatment, there is no guarantee that he or she will not relapse at some point once released. The evidence submitted indicates this patient progressed well with her residential treatment and was ready to progress to a less intense level of care as of 3/25/05. There is no evidence demonstrating continued residential treatment is medically necessary for this patient. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition The Health Plans denial should be upheld.