National Eating Disorders Association

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.
    • c) Lack of motivation in treatment
      • i. Discuss external influences on the patient’s motivation (i.e. stress within family) and emphasize the need for ongoing support during this difficult time. Also emphasize the triggering effects of these external influences and the likelihood of relapse if patient is stepped down too soon.
      • ii. Highlight anything patient has said or done which would indicate patient wants recovery
      • iii. Change something (medications, structure, schedule, therapeutic approach, anything that could spark a change)
    • d) Inconsistent attendance
      • i. If absences were planned or for legitimate reasons, the explanation should be enough. However, it always helps to discuss the reasons in clinical terms related to the patient’s recovery. (Ex: The patient’s schedule was modified to allow her to work a few shifts per week. This was discussed with the treatment team and will alleviate some of the financial burdens that have distracted her from focusing 100% on recovery. She has worked with her dietary team to plan meals and structure outside of treatment).
      • ii. If absences were not planned or were not for legitimate reasons, discuss the next steps the treatment team plans to take in order to encourage attendance. It is important to convey that the treatment team takes absences very seriously. It is also important to emphasize the patient’s need for extra support during this time. It does not hurt to speculate about the costs of terminating treatment while the patient is struggling.
      • iii. Frame it as “struggling with the ED” and discuss interventions moving forward
  4. Absence of Behaviors (i.e., patient is doing too well in treatment and may be appropriate for a step-down)
    • a) Continued weight restoration is imperative for a successful recovery. Stepping down now would slow or stop restoration altogether. (This argument is especially effective with patients who have previously failed at restoring weight on an outpatient or IOP basis.)
    • b) The patient has been using the program very effectively and is learning healthy coping skills. The patient is challenging herself with new skills and will benefit from additional time to practice these skills in a structured environment.
    • c) The patient will have several meals off within the next week. The patient must complete several successful meals off before we can determine that a step-down would be appropriate. If the patient struggles with the meals off, he or she will benefit from the continued structure of program in order to identify and address the issues that arise.
    • d) Emphasize the emotional/MH issues that contribute directly to the ED and the patient’s need for continued structure and support while beginning to address these issues.
  5. No medical complications
    • a) Emphasize the medical issues that the patient will likely develop if the behaviors continue. Serious, internal, long-term damage is not always apparent right away.
    • b) Dig for more information from the patient and/or medical providers. Patients often minimize or deny medical issues out of embarrassment and may be more forthcoming once they understand the benefits of disclosing the information.
    • c) Check the medical necessity criteria. Sometimes this is cited as a reason for denial even if it is not a criterion. In that case you have a pretty simple rebuttal.