NEDA TOOLKIT for Parents
How to manage an appeals process
Continue treatment during the appeals
process. Appeals can take weeks or months to complete, and
health professionals and facilities that treat eating
disorders advise that it’s very important for the
patient’s well-being to stay in treatment if at all
possible to maintain progress in recovery.
Clarify with the insurer the reasons for the
denial of coverage.
Most insurers send the denial in writing. Claims
advocates at treatment centers advise patients and
families to make sure they understand the reasons for
the denial and ask the insurance company for the
reason in writing if a written response has not been
received. Send copies of the letter of denial to all
concerned parties with documentation of the
patient’s need.
Claims advocates at treatment centers state that
sending documentation of an appeals request to the
medical director, the human resources director of the
company where the patient works (or has insurance
under), if applicable can help bring attention to the
situation. Presenting a professional-looking and
organized appeal with appropriate documentation,
including an evidence-based care plan makes the
strongest case possible. Initial denials are often
overturned at higher appeal levels, because higher-
level appeals are often reviewed by a doctor who may
have a better understanding than the initial claims
reviewer of the clinical information provided,
especially well-organized, evidence-based
documentation. Ask the insurer what evidence-based
outcome measures it uses to assess patient
health and eligibility for benefits.
Some insurance companies may use body mass index
(BMI) as a criterion for inpatient admission or
discharge from treatment for bulimia nervosa, for
example, which may not be a valid outcome measure.
This is because patients with bulimia nervosa can have
close-to-ideal BMIs, when in fact, they may be very
sick. Thus, BMI does not correlate well with good
health in a patient with bulimia nervosa. For example,
if a patient with bulimia nervosa was previously
overweight or obese and lost significant weight in a
short timeframe, the patient’s weight might approach
the norm for BMI. Yet, a sudden and large weight loss
in such a person could adversely affect his or her
blood chemistry and indicate a need for intensive
treatment or even hospitalization.
Ask that medical benefits, rather than mental
health benefits, be used to cover
hospitalization costs for bulimia nervosa-
related medical problems.
Claims advocates advise that sometimes claims for
physical problems such as those arising from excessive
fasting or purging, for example, are filed under the
wrong arm of the insurance benefit plan—they are
filed under mental health instead of medical benefits.
They say it’s worth checking with the insurance
company to ensure this hasn’t happened. That way,
mental health benefits can be reserved for the
patient’s nonmedical treatment needs like
psychotherapy. Various diagnostic laboratory tests can
identify the medical conditions that need to be treated
in a patient with eating disorders. Also, if a patient has
a diagnosis of two mental disorders (also called a dual
diagnosis), and if that diagnosis is considered by the
insurance company to be more “severe” than an eating
disorder, the patient may be eligible for more days of
treatment. Page | 83