Eating Disorder Tool Kit

Common Reasons for Insurance Denials and How You Can Respond

While individual cases differ, there are several common reasons for insurance denials of coverage for eating disorder treatment. Below are listed frequent reasons for denials of coverage and relevant arguments and supporting materials for responding to these denials. Use this information in communicating with the patient’s insurance company about specific denials.

1. Denial because treatment is not "medical"

   Insurers frequently attempt to characterize eating disorder treatment as purely mental health (psychiatric psychological or not biologically based) disorders in order to avoid coverage through a person’s medical benefits. The patient may receive a denial stating, "mental health benefits not covered" OR "patient has exhausted mental health benefits." In contrast to mental health benefits, medical benefits are often more comprehensive or less restrictive. Thus, it is often in the patient’s best interest to use medical benefits, if appropriate, instead of or before using mental health benefits.

   Your Response:

   • Eating disorders are medical diagnoses.
   
   
   

2. Denial because patient does not meet specific coverage criteria

   Although several practice guidelines define generally consistent criteria for hospital treatment of eating disorders, insurers sometimes attempt to avoid coverage of hospitalization on the grounds that hospitalization is not "medically necessary."

   Your Response:

   • Published practice guidelines require a comprehensive medical, psychological and nutritional assessment to determine the appropriate level of care for patients with eating disorder. [References ].
   • Consistent indications for hospitalization have been defined in published practice guidelines. [References ].
   • Eating disorders are dangerous and potentially lethal if they are not effectively treated. [References]
   • Established treatment programs with specialized expertise, adequate experience, and a good reputation lead to better patient outcomes. [References].
   • Effective eating disorder treatment is cost-effective in the long run. [References].
   • Untreated eating disorders can have lifelong (and expensive) medical consequences. [References].
   
   
   1. If the plan is governed by state law, check to see if there is a state regulation controlling the medical necessity definition in the insurance plan. [Link to Table 4 of the samsha.gov publication ]
   2. Offer as many details, including references/information from the physician, and the medical literature provided here as to why the requested treatment fits within the medically necessity definition.
   3. If the plan is governed by ERISA, read the plan’s definition of medically necessary to determine whether the plan administrator is following the proper procedure and criteria for making a medical determination. See below for ERISA-specific strategies.




3. Denial because a young patient does not meet specific coverage criteria:

   Because the criteria for eating disorders (including weight thresholds) were not developed inclusive of younger patients, insurers may deny care to younger patients based on criteria developed for older patients.

   Your Response:

   • Younger patients with eating disorders often to not meet criteria that were developed for adult patients. However, they are at particular risk because of their developmental stage and therefore require earlier and more aggressive treatment. [References].




4. Denial because the requested facility or specialist is out of network

   Many insurers refuse to cover out-of-network coverage for a specialist or treatment program, even when there is no appropriate specialist or treatment center in-network.

   Your Response:

   • An established treatment program with specialized expertise, adequate experience, and a good reputation can lead to better patient outcomes. [References]
   
   
   1. Read the terms of coverage - although many insurance policies state that they do not cover out of network treatment, there is often an exception for medically necessary services not available from participating providers. This means that the insurer should make a referral to a nonparticipating provider.
   2. Establish that no "in-network" provider will offer adequate care.
   3. Identify the out-of-network provider and explain the precise nature of the medically necessary treatment it will provide.




5. Denial of comprehensive care because it is "not covered"

   Insurers frequently deny multidisciplinary care, especially care by a dietician.

   Your Response:

   • Published practice guidelines require a comprehensive medical, psychological and nutritional assessment to determine the appropriate level of care for patients with eating disorder. [References]
   • Effective eating disorder treatment is cost-effective in the long run. [References]




6. Denial of your request for day treatment or residential care:

   The insurer may deny coverage because the requested treatment (particularly residential treatment facilities or day treatment facilities) is not licensed as a "hospital" as defined by the insurance plan.

   Your Response:

   • An established treatment program with specialized expertise, adequate experience, and a good reputation can lead to better patient outcomes. [References ]
   • Published practice guidelines require a comprehensive medical, psychological and nutritional assessment to determine the appropriate level of care for patients with eating disorder. [References]




7. Denial because patient has met coverage limits or because medical or mental health benefits have been exhausted

   Your Response:

   • Effective eating disorder treatment is cost-effective in the long run. [References].
   • Eating disorders are dangerous and potentially lethal if they are not effectively treated. [References].




8. Denial of continuing care:

   Insurers may use a relapse as a reason to terminate coverage for treatment on the grounds that the treatment is ineffective.

   Your Response:

   • Treatment for eating disorders is typically protracted and is often characterized by a waxing and waning course with one or more periods of relapse. [References]