Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for services to treat ARFID (Avoidant Restrictive Food Intake Disorder), to include: a psychiatrist (once a month), a therapist (once a week), and a dietician (once a week).American Psychiatric Association (APA) guidelines for the treatment of eating disorders indicate that when treating adults with eating disorders, the psychiatrist may assume the leadership role within a program or team that includes other physicians, psychologists, registered dietitians, and social workers or may work collaboratively on a team led by others. The APA guidelines state that for the management of acute and ongoing medical and dental complications, it is important that psychiatrists consult other physician specialists and dentists. When a patient is managed by an interdisciplinary team in an outpatient setting, communication among the professionals is essential to monitoring the patients progress, making necessary adjustments to the treatment plan, and delineating the specific roles and tasks of each team member. The APA guidelines explain that services available for treating eating disorders can range from intensive inpatient programs (in which general medical care is readily available) to residential and partial hospitalization programs to varying levels of outpatient care (in which the patient receives general medical treatment,  nutritional counseling, and/or individual, group, and family psychotherapy).The diagnosis of avoidant restrictive food intake disorder (ARFID) in adults has been considered by several studies examining the treatment of adults with the disorder. These studies indicate a multimodal approach for these patients, including cognitive behavioral therapy, nutritional assistance, and psychiatric care. Harer and colleagues state that data demonstrate the need to appropriately screen patients for ARFID and point to the need utilize a multidisciplinary treatment approach that takes into account GI, psychological, and nutritional needs. While there are no treatment guidelines at this time for ARFID in adults, there are treatment guidelines for children and adolescents with ARFID that indicate multimodal treatment should be maximized with a combination of psychiatric, psychological, nutritional, and medical care depending on the severity of the illness. Brigham and colleagues state that treatment can range from an outpatient multidisciplinary team treatment to inpatient medical hospitalization.In this case, the patient has been evaluated and received a diagnosis of ARFID by specialists in psychiatry and clinical psychology. While there are no treatment guidelines at this time for ARFID in adults, there are treatment guidelines for children and adolescents with ARFID that indicate multimodal treatment should be maximized with a combination of psychiatric, psychological, nutritional, and medical care depending on the severity of the illness. Therefore, the requested services to treat ARFID (Avoidant Restrictive Food Intake Disorder), to include a psychiatrist (once a month), a therapist (once a week), and a dietician (once a week), are consistent with APA guidelines relating to general approaches to eating disorders as well as treatment guidelines for children and adolescents with ARFID that indicate multimodal treatment should be maximized. Accordingly, it is medically necessary for the patient to receive services to treat ARFID (Avoidant Restrictive Food Intake Disorder). Furthermore it is medically necessary for the patient to see a psychiatrist once a month to treat her ARFID, to see a therapist once a week to treat her ARFID, and to see a dietitian once a week to treat her ARFID.