Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Eating Disorder
Treatment: Continued Inpatient Hospital Admission
The insurer denied the Continued Inpatient Hospital Admission
The denial is overturned, in part.

The case involves a female with a history of eating disorder best characterized as anorexia nervosa, restricting type and psychiatric comorbidity that includes unspecified anxiety disorder, and obsessive-compulsive disorder (OCD). The patient had onset of the obsessive compulsive disorder (OCD) and eating disorder during adolescence with worsening symptoms and restricted intake and weight loss well below her ideal body weight of 51 kilograms (KG) and a target body mass index (BMI) of at least 18.8. The obsessive compulsive disorder compounded the eating disorder including compulsive cleaning and rituals with high anxiety. She presented with body image disturbance with disordered eating and restricted intake. The patient had evidence for malnutrition and general medical complications including Wolfram syndrome with type I diabetes mellitus, orthostatic hypotension with dizziness, abnormal electrocardiogram (EKG) with bradycardia, amenorrhea, low muscle tone with parathesis, strabismus, eczema and chronic constipation.  

The patient was admitted to inpatient level treatment for medical screening and monitoring, and stabilization of her general medical symptoms. There was no use of diet pills, laxatives or diuretics, or other substances of abuse. She had eating disorder and mental health treatment at varying levels of care with worsening clinical features perpetuated by multiple stressors with functional impairments. She had repeatedly declined residential treatment, and was prone to opposition and defiant behaviors in the context of the obsessive compulsive disorder and eating disorder.

The patient was admitted to inpatient services with the structure, intensity of services and monitoring consistent with inpatient 24-hour programming that included seven days per week treatment. The patient remained medically unstable with laboratory assessments and electrocardiogram (EKG) monitoring. For the dates in question, the patient received refeeding per protocol and was not consistently compliant with use of a nasogastric tube per protocol, and she was struggling to achieve intuitive eating. The family was significantly involved in the treatment, but the patient was deemed capable of refusing treatment. The treatment team prescribed psychotropic medications that included Zoloft and as needed (PRN) use of hydroxyzine, as well as vitamin therapy with supplements and comfort medications for dyspepsia and constipation. She continued to receive monitoring with insulin to maintain glucose metabolism. Case management was working to identify appropriate placements for continued care.

The patient continued to struggle with the refeeding protocol sometimes refusing breakfast invoking the use of a NG (nasogastric) tube per protocol. She continued to take Zoloft at 300 milligrams (mg) daily to address anxiety and symptoms of obsessive compulsive disorder. Her weight had dipped to a low of 37.1 kilograms down 2.4 kilograms in the previous two months. Cardiorespiratory, hemodynamic, and laboratory assessments of pertinent parameters were continued, as well as the refeeding protocol. 

The patient was noted to have gained weight approaching stabilization with regard to the general medical complications. The patient repeatedly refused referrals for continued inpatient or residential care; despite having a guardian assigned, she was deemed capable of refusing the referrals. Thus, she was discharged to home in stable condition with clinically appropriate aftercare and a guarded prognosis. The progress notes indicate that there were significant issues with regard to control and decision-making (individuation). 

Denial of continued coverage was on the basis of Milliman Care Guidelines (MCG) indicating that inpatient level care was only considered medically necessary when severe problems existed.

The appeal was on the basis of Milliman Care Guidelines pertinent to inpatient level behavioral health care indicating that the patient was not optimally safe and was under suicide precautions with medical monitoring and efforts to secure an appropriate placement as well as guardianship that was assigned. 

Yes, in part, the proposed treatment was medically necessary for this patient; however, no in part, for the remaining days in question, the proposed treatment was not medically necessary for this patient.
Continued eating disorder and mental health services at the inpatient level of care are medically necessary in this case scenario for the first part of the dates in question. Prevailing standards of medical practice are met in this case, in view of the severity of symptoms and general medical complications of the eating disorder, impairment of functioning, stressors related to psychosocial factors, and influence of co-morbid psychiatric conditions. The patient was not amenable to treatment at a lower level of care, as the patient remained at high risk for relapse and hemodynamic, cardiac and metabolic complications, and symptomatic with regard to body image disturbance, and the need for continued meal monitoring and refeeding in order to achieve healthier eating and meal portioning (intuitive eating) while working with the family and treatment team to develop a solid plan for a safe discharge and disposition. The case was complicated by the patient's lack of insight and refusal for referrals. The monitoring and structure of inpatient care was warranted until the patient was stable enough to be discharged. Thus, the requested treatment should be covered under the plan as medically necessary for these dates of service. However, the continued inpatient level services could have been effectively provided with lower level of care in a less restrictive treatment setting and should be excluded from coverage as the health plan asserts in the denial determination.

Yes, in part, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient for certain dates in question; however, no, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient for the dates of service in question
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For the dates of service in question, prevailing standards of medical practice are met in this case, in view of the severity of symptoms and general medical complications of the eating disorder, impairment of functioning, stressors related to psychosocial factors, and influence of co-morbid psychiatric conditions. The patient was not amenable to treatment at a lower level of care, when she had reached a level of stability such that treatment could be continued with lower level care.

These answers are consistent with the scientific literature and published guidelines, referenced below, as well as prevailing standards of care and New York State instruction for this binding medical necessity review.