National Eating Disorders Association

The most common (and frustrating) reason for a denial is “the patient does not meet the criteria for medical necessity.” The specific criteria will vary from insurance company to insurance company, but some of the most common criteria include:

  1. Weight—usually not low enough
  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
    • b) Patient’s condition is chronic and past treatments at the requested level of care have been ineffective
  3. Lack of Progress in Treatment
    • a) Patient is not restoring weight
    • b) No reduction in behaviors
    • c) Lack of motivation in treatment
    • d) Inconsistent attendance
  4. Absence of Behaviors (i.e. someone is doing too well in treatment and may be appropriate for a stepdown)
  5. No medical complications