NEDA TOOLKIT for Parents
Strategies for Providers for Fighting Insurance Denial
Although this next section may be most useful for clinicians and treatment facilities to use directly, knowing
common strategies can help you formulate appeals for your loved one.
1. Weight — not low enough
a) Patients with severe EDs are often within
the normal weight range, especially with
Bulimia Nervosa and EDNOS
b) If the patient has dropped a significant
amount of weight or has fluctuated a lot
within the past few months or one year,
a higher level of care can be justified in
order to stabilize the behaviors. Basically
if you can show that the patient is on a
steep downward trajectory, the insurance
companies will often let you “catch” the
patient before he or she hits rock bottom.
c) The brain does not function at an optimal
level below about 90% IBW, so if a patient
meets the criteria in every other way but
his or her weight is “not low enough,” you
can make the argument that the patient
will actually be able to use program more
effectively than if he or she were at a lower
weight because the brain is nourished.
They will be in a better position to learn
and to implement the skills taught in
program. 2. Treatment History (mainly applies to
precertification requests)
a) Patient has not tried a lower level of care
prior to requesting a higher level of care
i. Emphasize the severity of behaviors
and risks of continuing behaviors (i.e.
“This is so severe that we have to
stop it now. Patient is likely to fail at
a lower level of care. This failure will
waste valuable resources such as time,
money, and patient’s hope/motivation
for recovery.”)
ii. Outpatient providers who have been
working with patient for X length of
time are recommending this level of
care (if applicable)
iii. Availability of programs (some areas
have scarce resources for treating
eating disorders, may not have many
treatment options available)
b) Patient’s condition is chronic and past
treatments at the requested level of care
have been ineffective
i. Emphasize any changes and give
concrete reasons why this treatment
will be different
1) Patient’s motivation, development
of insight (ex: Last time patient
was forced into treatment by
family/spouse. This time patient
requested treatment and wants to
change for himself/herself)
2) Changes in support system
3) Changes on Axis IV
4) Different treatment approach
5) Different goals for treatment
ii. Financial benefits – If left untreated,
patient will end up in a higher, more
expensive, level of care
3. Lack of Progress in Treatment
a) Patient is not restoring weight
i. Weight restoration may not be the
focus of treatment (bulimia, BED, ED
NOS) ii. Identify the reasons (usually behaviors)
and the planned intervention
strategies. This is usually enough to get
a few extra days to see if patient can
start to restore.
b) No reduction in behaviors
i. Highlight progress in other areas and
explain how this progress will lead to a
reduction in behaviors.
ii. Have a plan ready for interventions
moving forward to reduce behaviors.
For example, we discovered that a
patient had been exercising in her
room at night, so we created a protocol
for staff to check on the patient every
X minutes and required her to keep
her door slightly open. The reviewer
understood that the protocol would
likely disrupt the patient’s behaviors so
she authorized additional days.
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