Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old female with long-standing anorexia nervosa who was admitted to residential treatment on 11/11/04 due to notable obsessive concern about being fat, with concurrent caloric restriction. Admission weight was 103 pounds. She was treated with a number of therapies as well as medications. The patient was eventually stabilized on a regimen of Klonopin, Seroquel, Risperdal, and Zoloft. A very significant concurrent problem concerned obsessive rumination about possibly being sexually inappropriate with her young son. The noted medication regimen helped quite a bit in this regard.Notes from 12/29/04 indicate the patient stated, Im on a new medication and I feel that I have more control of the thoughts and can counteract them. I have less rumination and Im following my meal plan. Her therapist noted she focused on her abdomen being distended and feeling fat and was trying to get staff to comment on her abdomen.On 1/3/05, it was noted the patients weight had increased and she had progressed but remained fragile, and easily tearful because of irrational thoughts and beliefs that she has.On 1/12/05, it was noted the patient was pleasant, cooperative, and her affect was bright and she socialized with peers and staff most of the night. The patient stated she is now comfortable with what she eats. It was noted she ate 100% of her snack and tolerated it well without any distress.On 1/14/05, the patient stated, Im looking forward to going home, and Ive learned to deal with my OCD thoughts and my rough times, the rough times are what helped me get through. The patient was also noted as stating, I am getting better, I cant wait to be with my baby on discharge. Her therapist noted her affect was brighter and her weight was 110 pounds. It was further reported the patient was still having obsessive-compulsive thoughts, but was handling them in a positive way.On 1/16/05, the patient discussed going to the outpatient program and stated, I think Im finally able to do it. It was noted her affect was somewhat depressed but more realistic.On 1/17/05, the patient was interacting well with peers, participated in groups, was helpful with others, and eating 95% of her meals. The patient stated, I am doing so much better. It was noted she was compliant with the eating disorder program.On 1/18/05, the patient stated, Im looking forward to going into the partial program. I think it will be a good transition for me. Her therapist noted the patient was quiet, calm and compliant and affect/mood was appropriate. The patient was making discharge plans, experiencing less obsessive-compulsive thoughts, and eating 100% of meals.On 1/19/05, the patient stated, I am doing good. I like the program Im working on. Her therapist noted the patient looked alert and cheerful, and was sitting in the kitchen eating apple pie with a cup of hot cocoa. Her affect was appropriate.The patient has requested reimbursement for residential treatment services received from 1/18/05 through 1/22/05. The Health Plan has denied the request on the basis the services at issue were not medically necessary.Though this patient suffered from a number of problems including anorexia nervosa, obsessive-compulsive disorder, and depression, she clearly improved quite a bit by 1/18/05. The clinical notes provided do not include any evidence of a significant level of morbidity by 1/18/05. In fact, notes from 1/19/05 indicate the patient looked alert and cheerful, and was eating apple pie with a cup of hot cocoa. Hence, the submitted evidence demonstrates the patient could have been managed at a lower level of care as of 1/18/05. As such, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.