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11th Cir. – Eating Disorder, Partial Hospitalization Medical Necessity

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  • 11th Cir. – Eating Disorder, Partial Hospitalization Medical Necessity

    Here’s a new case from the Eleventh Circuit, unpublished, entitled Alexandra H. v. Oxford Health Insurance, Inc. This case deals with the medical necessity of a partial hospitalization and the insurer’s contention that a step-down to a lower level of treatment was appropriate. The plaintiff disagrees and believes that the partial hospitalization was medically necessary. The court finds in favor of the defendant.

    Both considerations—stability of improvement and risk of setback—animated Oxford’s decision. For the medical director and the reviewers who upheld her decision, the benefits denial turned on two factors: the marked improvement in Alexandra’s precipitating symptoms and the absence of dangerous symptoms. See R. 130-5 at 36 (noting weight gain, meal completion, and treatment compliance, and concluding that “ongoing personality-related issues . . . can continue to be addressed in [intensive outpatient care]”); id. at 36–37 (noting “improvements in the initial precipitating symptoms,” that “there no longer appear to be such significant impairments,” and that “treatment could continue in a less restrictive setting”); id. at 37 (noting “no serious risk of harm to self” or “psychosis” and “the patient could safely be treated at a lower level of care”); see also R. 130-3 at 32 (noting “psychiatric disturbances had improved and [she] did not exhibit severe symptoms,” and concluding her “condition could be safely and effectively managed at a lower level-of-care”). Because this evidence shows that Alexandra could safely transition to less intensive care, it was fair to conclude that partial hospitalization was no longer “most appropriate.”
    Further, the court finds:

    When Oxford denied benefits, Alexandra had no symptoms indicating “a significant likelihood of deterioration . . . if transitioned to a less intensive level of care.” Id. at 46–47. She instead had improved on each front. Neither was there any indication that she could not “effectively” and “safely” continue to recover following a treatment step-down. Id. at 47. She was eating consistently and improving emotionally even while looking after herself every evening and weekend. Under the plan’s definition of “medically necessary,” Oxford could deny benefits for continued partial hospitalization and recommend a transition to intensive outpatient care and the fewer hours of therapy per day that came with it.
    The opinion is attached below.
    Attached Files