Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eating Disorder
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission.
The denial is modified.

Patient is a teen female with a past medical history notable for depression, anxiety, complex regional pain syndrome, rumination syndrome, chronic constipation and recent bulimia that was referred to the Emergency Department for evaluation and treatment of purging with all meals, excessive exercise, and purposeful calorie restriction for concerns of refeeding syndrome. The patients' symptoms included intermittent dizziness and lightheadedness. Of note, the patient had been receiving virtual therapy with an outpatient feeding program that was ineffective. The patient's admitting weight was 51 kilograms, and her height was 157.5 centimeters corresponding to a body mass index (BMI) 52nd percentile for age. Admitting laboratories were notable for sodium 136, potassium 3.6, chloride 103, bicarbonate 27, blood urea nitrogen (BUN) 13, creatinine 0.68, glucose 94, magnesium 2.2, calcium 9.2, phosphorus 3.3, white blood cell 7.9, hemoglobin 12.5, platelets 251 and a normal hepatic profile. An electrocardiogram (EKG) was unremarkable. Her physical exam was unremarkable. She was admitted for refeeding and 1:1 observation with all meals. 

The insurer is denying the entire admission for lack of medical necessity because the patient's weight was not low, her body temperature was normal, her blood pressure was normal, and her clinical chemistries were non-critical citing Milliman Care Guidelines for Failure to Thrive (ORG:P-187). The hospital is appealing since the patient had failed intensive outpatient intervention, was at risk of refeeding syndrome and required 1:1 observation with meals citing InterQual Guidelines 2022 Adult and Geriatric Psychiatry and Milliman Care Guidelines 26th Ed. Eating Disorders, Inpatient Behavioral Health Level of Care, Children and Adolescents. 

This patient's prior treatment could hardly be called intensive (~ 1 week of 3 virtual encounters per week) but regardless she did meet criteria for at least the initial part of her hospitalization. The decision to discharge her appears to have been an arbitrary decision to discharge toward the end of the week without justification for the total days needed to change her purging behavior. 

The main manifestation noted in this particular patient was transient electrolyte abnormalities requiring correction. The markedly abnormal electrolytes noted in the appeal were spurious results that on repeat were unremarkable. The electrolytes had been unremarkable x 2 days. Another cardiac concern was transient bradycardia [heart rate (HR) in the 50's]. This unexpected cardiac sequela (normally tachycardia is of concern) was never of hemodynamic consequence and actually was never evaluated by repeat EKG or treated. 

In summary, this patient did have indications for the inpatient setting with stabilization. The additional days were without complication and certainly did not cure her psychiatric/behavioral issues that will require long-term intervention.

The inpatient admission is considered partially medically necessary for this patient.                                              

The health plan acted reasonably in part with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is modified. Medical necessity is substantiated for initial days. Medical necessity is not substantiated for continued stay.