Binge Eating Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for RTC services. For dimension 1, the patient was at moderate risk of harm (score 3).

Where the denial was upheld

The patient is a 42-year-old female with previously diagnosed depression, morbid obesity, and binge eating disorder, though not bulimia per se. The patient was admitted to partial hospitalization on 2/16/04 where she was treated with a number of psychotherapies as well as Lexapro. Pertinent social stressors have included her mother’s alcohol dependence, an emotionally abusive husband’s past infidelity, and her teenage son’s involvement with drugs and alcohol and poor performance in school. Her tendency has been to overeat when distressed. During her stay in the partial hospitalization program, the patient’s weight decreased from 334 pounds to 319 pounds by 5/12/04. The chart notes point to the patient’s growing insight about her aforementioned stressors and her emotional reaction by way of overeating.

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment services for treatment of his binge eating disorder. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Although the patient has a significant eating disorder with psychiatric comorbidity and concerning medical sequelae, the clinical documentation provided simply does not support the medical necessity of residential treatment services. This patient’s pathological eating habits and subsequent obesity have been dominating his routine and impacting his sense of self and physical health. However, he has reasonable insight and concern for his health. The records indicate that the patient has good family support. He successfully lost significant weight in the past when he was adherent to a meal plan.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving binge eating disorder, then check the rights and deadlines that apply to your plan.