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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. Page  | 50