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The Insurance Appeal Pack

 
In addition to a letter and many forms required by the insurance company, include the following:
  1. American Psychiatric Association (APA) Guidelines for Treatment of Eating Disorders
Important medical findings reviewed in the APA guidelines
 
  • Physical consequences of eating disorders include all serious sequelae of malnutrition, especially cardiovascular compromise.
  • Prepubertal patients may have arrested sexual maturity and growth failure
  • Even those who “look and feel deceptively well,” with normal EKGs may have cardiac irregularities, variations with pulse and blood pressure, and are at risk for sudden death
  • Prolonged Amenorrhea (less than six months) may result in irreversible Osteopenia and a high rate for fractures.
  • Abnormal CT scans of the brain are found in less than 50 percent of patients with anorexia nervosa
  •  Bulimic Behaviors may result in electrolyte, fluid, and mineral imbalance, may be presenting cardiac risk, gastric irritation and bleeds, large bowl abnormalities, dental enamel erosion, peripheral muscle weakness, cardiomyopathy, and hypo metabolism. These consequences may be present despite normal weight.
  • Bulimic patients of normal weight may also be severely malnourished and have serious nutritional deficiencies. 
II.                Court cases to site as precedent for medical coverage of eating disorders
 
·         Simmons vs. Blue Cross and Blue Shield of Greater New York, 1989
Starvation from Anorexia Nervosa is a physical state which should be covered by medical benefits
·         State of Minnesota vs. Blue Cross and Blue Shield of Minnesota, 2001 (for the wrongful death of Anna Westin)
·         Blue Cross/Blue Shield agreed to allow an independent panel of three experts to review denial of coverage. The majority decision is binding upon the insurance company if the policy holder is part of a state-regulated managed care system. (Unfortunately, these covered by a self-insured plan in Minnesota are not subject to state laws and therefore, for them, the panel’s decision is only advisory.)
·         After receiving a claim, Blue Cross will make an immediate decision as to payment within twenty-four hours for urgent care and within two business days for non-urgent care. Blue Cross/Blue Shield agreed to increase access to psychiatrists and other therapists and significantly increase coverage for intensive treatment of eating disorders, which until them, it had rarely covered.
·         Blue Cross had to reimburse families who paid for care out-of-pocket. The company also had agreed to consider claims by families who did not participate in the lawsuit, but who believed they were inappropriately denied coverage.
·         Manhattan vs. Travelers Insurance Company (United States District Court): Until the patient is at least 85 percent of target weight, treatment is medical and should be covered by medical benefits, even if treatment takes place in a psychiatric hospital
III.             Important Studies/Research to Date
·         Individuals who were 90% of there body mass index (BMI) or less at the time of transfer from residential treatment to a day hospital program were more than ten times likely as someone who was above 90 percent of their ideal BMI to fail day hospital treatment and require either readmission to an inpatient unit or discharge against medical advice.
·         For individuals less than 90 percent of their BMI, there is a strong economic advantage for continued inpatient treatment, because it avoids the immediate relapse and readmission for more than one third of those individuals.
·         Over the past fifteen years the treatment of eating disorders has gone from longer hospitalizations for disease management to short hospitalizations for acute stabilization (average length of stay in 1984 was 149.5 days and in 1998 was 23.7). This shift to short hospitalizations has been accompanied by a significant rise in hospital readmissions. (O percent readmissions in 1984 and 27 percent in 1988). This can significantly increase the cost and duration of treatment.
·         Patients of anorexia who are discharged and are still underweight had a 50 percent chance of readmission versus a ten percent chance for readmission for those who were discharged after full weight recovery.
·         Assuming treatment consisting of inpatient weight restoration with a gradual step-down to partial hospitalization program and them outpatient treatment, the treatment is cost effective when looking at cost per year of life saved, as compared to any other medical interventions.
·         10-15 percent of people with anorexia will die form their eating disorder. This is the highest mortality of any psychiatric illness.
·         The risk for death for people with eating disorders is increased with the longer duration of the illness.
·         1-3 percent of people with bulimia will die.
·         The longer someone has bulimia, the worse the outcome.
·         If children and young adolescents with anorexia do not receive intensive intervention, severe and permanent stunting of growth will occur.
·         People under the age of fifteen with strong eating-disordered attitudes and a low rate of weight recovery during admission, need a longer hospitalization and a period of weight management before discharge. Upon discharge, they require a step down to intensive therapy in a day program.
·         If girls with eating disorders do have stunted growth, catch-up growth is possible. However, to achieve this, they need long-standing weight gain. The sooner this is achieved the better, because the capacity for growth will eventually decline.
 

EDRC


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