This is a patient with an eating disorder who was referred and re-admitted on to partial hospital program (PHP) level treatment. The patient has a complicated history of an eating disorder characterized by restricting intake and over-exercising. Upon admission she was approximately 102 lbs and had lost 15 pounds while participating in an intensive outpatient program (IOP) which had followed a brief PHP stay at the same treatment facility. The health plan's determination is overturned.
The requested health service/treatment of partial hospitalization mental health treatment - 5 days a week, 6 hours a day is medically necessary for this patient. The patient could not be effectively treated at a lower level of care. The patient has failed to respond to clinically appropriate, intensive treatment in the community at the outpatient (IOP) level of care; thus, the treatment plan with respect to PHP level care addressing disordered eating and related disturbances, meal portioning/monitoring, anxiety and obsessive compulsive related disorders, and other interventions to address the severe psychosocial stressors with safety monitoring are reasonable in this case scenario.