Bulimia: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential treatment center (RTC) services (ASAM Level 3.5) provided from 6/16/21 forward at Olympia House.At issue is whether RTC services (ASAM Level 3.5) provided from 6/16/21 forward at Olympia House were and/or are medically necessary for treatment of the patient’s mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A).Per the American Society of Addiction Medicine (ASAM) criteria, this patient met and meets Level 3.5 criteria for RTC services provided from 6/16/21 forward.

The patient is a 28-year-old female with a history of anorexia nervosa and bulimia as well as major depression versus bipolar disorder. She was admitted to inpatient treatment on 6/20/04 and discharged on 8/2/04. This was preceded by the patient having restricted her intake to such an extent that she entered the hospital at 89 pounds with osteopenia, which led to a stress fracture of her left foot. The patient was treated with a range of therapies along with medications. She was eventually stabilized on a regimen of Abilify, Topamax, Prozac, Strattera, and Neurontin. As of 7/27/04, the patient’s psychiatrist noted she was struggling to limit ritualistic eating and systemic choosing. Her nutritionist noted her affect was brighter yet she was still depressed and anxious as well as fragile. A nursing note of the same date indicates the patient was still taking extended time to eat.

Where the denial was upheld

he patient was diagnosed with bulimia and major depressive disorder. The patient was admitted to a partial hospitalization program (PHP). The patient had previously been treated in a residential treatment program (RTC). The patient reported a history of cutting her arms and legs. The patient denied any symptoms of psychosis. The patient endorsed food restriction, binge-eating, self-induced emesis, and a history of excessive exercise. Patient reported a history of eating disorder symptoms for several years. The patient was living with parents at the time of the PHP admission, and reported a close relationship with parents. Patient denied active suicidal thoughts and denied current self-harm thoughts. The patient was noted to have an improved mood with significantly diminished thoughts of self-harm.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ketamine for treatment of the enrollee’s behavioral health conditions. Findings: Three physician reviewers found that ketamine is not approved by the United States Food and Drug Administration (FDA) for treatment of mood disorders, bulimia or anxiety. However, ketamine has shown promise for dramatic improvement for patients with depression. Unfortunately, the duration of action is rather brief, while the poor bioavailability of oral ketamine has prompted the use of intramuscular, intravenous and intranasal delivery systems. In addition to the difficulty delivering the medication, there is also potential concern regarding the safety, addictiveness and long-term effects of ketamine therapy.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for bulimia was denied, the published record says the denial is worth fighting.