Bulimia Nervosa denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings:The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (CALOCUS Level 5). The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) services and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.1 criteria for PHP services and prospective RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient has no signs or symptoms of withdrawal. Thus, she can safely be managed in in a Level 3.1 setting.

Where the denial was upheld

An enrollee who was admitted for partial hospitalization program level of care. In an individual session, she reported cutting on herself one month prior to admission. She is noted to have used alcohol and cannabis. Her body mass index was noted to be. She denied a history of medical problems. The patient had a history of binging and purging as well as food restriction, body checking, and fear of certain foods. A review of the records indicates that the patient was feeling uncomfortable in her own skin. The patient expressed urges to purge or restrict. On, she reported stress regarding meals. On, the patient reported minimal anxiety with transitioning to intensive outpatient program (IOP). Per the records, her diagnoses included major depressive disorder, bulimia nervosa, and anxiety.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided from. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee’s bulimia nervosa. At issue in this case is whether the residential treatment center services at issue, provided, were medically necessary for treatment of the enrollee’s behavioral health condition.The patient was admitted to the residential treatment center after a suicide attempt via overdose. She indicated she took an overdose of antidepressant pills after she was weighed and was unhappy with her weight. On admission she denied any active suicidal or homicidal ideation and did not express any active suicidal ideation during her stay. She did not engage in any self-harm behaviors.

A diagnosis does not by itself establish treatment intensity. See the separate record for residential, PHP, IOP, inpatient, and withdrawal-management denials: behavioral-health level-of-care evidence guide.

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 bulimia nervosa, then check the rights and deadlines that apply to your plan.