Tuesday, August 11, 2009

The appeal process

And the appeal process begins. My insurance broker has all of the necessary medical paperwork and my therapist sent him this letter to go along with the appeal today. I am thoroughly enjoying how passionate therapist has been about this appeal process. It has been very entertaining. It has also been very honoring and humbling. She has spent a lot of time over the last few days working for me to get me the coverage she says I deserve. I know I survived before I met therapist, but some day I really wonder how. Below is the letter she wrote my insurance company. Any identifying factors have been removed for confidentiality purposes, but I wanted to share her awesome words and all of her hard work on our behalf. :D The words in green are the ones I changed for confidentiality reasons.

Therapist Name, M.S.S.W., L.C.S.W.
Licensed Clinical Social Worker

Insurance Broker's name
Insurance Services, LLC
City, State, Zip

Dear Insurance Broker,

I am writing per the request of my client, Bravehearts, to comment on the reasons given by Health Insurance Company #1 for denying her application for health insurance. One reason given referenced a positive toxicology report for benzodiazepine poisoning. A second reason referenced an eating disorder diagnosis. And a third reason referenced the opinion that individuals who have a mental health diagnosis and have received mental health treatment are likely to have a higher utilization of general medical services and thus incur higher healthcare costs.

1. The toxicology report (enclosed) dated 12/10/2007 very plainly indicates that the results were NEGATIVE for all substances listed, including benzodiazepines.
2. Bravehearts was admitted specifically to the Trauma Disorders Program at Hospital Name in February 2008, not the Eating Disorders Program. The discharge summary dated 03/20/08 included four Axis I diagnoses, the last of which was Eating Disorder NOS. The detailed summary explicitly states:
“… the patient stated that severe PTSD symptoms, attributed to a particular self-state, prevented her from eating during daylight hours. … Notably, the patient exhibited eating disordered behavior (refusal to eat anything before 6pm each day), but this was attributable to her efforts to avoid increased PTSD symptoms which were triggered by eating. Therefore, her eating disorder was also a focus of treatment in the context of managing her PTSD.”
The “eating disordered behavior” had to do with the time of day she ate, which as mentioned above was directly attributable to the PTSD symptoms. It did not involve any restrictions regarding quantity or nutritional quality of intake, or any type of purging behaviors – all of which are principal elements of a primary Eating Disorder diagnosis.
3. While some research indicates that individuals with mental health conditions often have a high utilization of other healthcare services, other research (see quote and additional references provided) indicates that individuals who show progress as a result of receiving mental health treatment have a lower utilization of other healthcare services.
“Cost offsets may be achieved in several ways. Specialty mental health treatment may prevent unnecessary medical care use, reduce future demands on medical resources, or simply substitute for mental health care delivered by primary care providers in instances when it is ineffective. Some mental disorders masquerade as general medical illnesses and lead to unnecessary use of medical care services. If accurate diagnosis leads to an appropriate refocusing of treatment on the underlying mental condition, it may reduce use of such unnecessary, and potentially harmful, medical services. Early and effective treatment of disorders such as alcohol and drug abuse may reduce medical complications and future medical costs. In still other cases, appropriate mental health care may reduce unnecessary medical spending by improving self-care and adherence to prescribed medical regimens (Olfsen, Sing & Schlesinger, 1999).”

The results of a metaanalysis conducted by Gabbard in 1999 revealed that “... eight (80%) of the 10 clinical trials with random treatment assignment and all eight (100%) of the studies in which treatment was not randomly assigned sugget that psychotherapy reduces a variety of costs. Combinig the studies, we can conclude that 88.9% of the relevant studies suggest a beneficial economic impact of psychotherapy (152).“
According to another metanalysis study (Hunley, 2003) “... psychological interventions also appear to have the potential to reduce health care costs, as successfully treated patients frequently reduce their utilization of other health care services. In some instances, the reduced cost to the health care system may actually be greater than the cost of the psychological service, thus resulting in a total cost offset to the system (14).“

Crane, D.R., & Christenson, J.D. (2008). The Medical offset effect: Patterns in outpatient services reduction for high utilizers of health care. Contemporary Family Therapy, 30, (127-138). Retrieved August 10, 2009, from http://www.eftacim.org/doc_pdf/crane-christenson.pdf.
Gabbard, G. O., Lazar, S. G., Hornberger, J., & Spiegel, D. (1997). The Economic impact of psychotherapy: A review. American Journal of Psychiatry, 154(2), 147-155.Retrieved August 10, 2009, from http://ajp.psychiatryonline.org/cgi/reprint/154/2/147.pdf.
Holder, H. (1998). Cost benefits of substance abuse treatment: an overview of results from alcohol and drug abuse. Journal of Mental Health Policy and Economics, 1 (1), 23-29. Retrieved August 10, 2009, from http://www.icmpe.org/test1/journal/issues/v1i1/v1i1text04.pdf.
Hudson, C.G. (2008). The impact of managed care on the psychiatric offset effect. International Journal of Mental Health, 37 (1), 32-60. Retrieved August 11, 2009, from
http://mesharpe. metapress.com/media/7hxdajxwun7kq9jmet8l/contributions/y/0/7/0/y0704g1661216503.pdf.
Hunley, J. (2003). Cost-effectiveness and medical cost-offset considerations in psychological service provision. Canadian Psychology, 44 (1), 61-73. Retrieved August 11, 2009, from
http://pharmacy.auburn.edu/pcs/mtms/LitSearch/Cost-Effectiveness%20and%20Medical%20 Cost-Offset%20Considerations%20in%20Psychological%20Service%20Provision.pdf.
Law, D.D., Crane, D.R., & Berge, J.M. (2003). The influence of individual, marital and family therapy on high utilizers of health care. Journal of Marital and Family Therapy, 29, (3), 353-363. Retrieved August 11, 2009, from
http://russcrane.com/papers/MFT_and_Health _Care/2003_MFT_and_High_Utilizers.pdf.
Law, D. D. & Crane, D.R. (2000). Influence of Marriage and Family Therapy on Healthcare Utilization. Journal of Marriage and Family Therapy, 26 (3), 281-291. Retrieved August 11, 2009, from
http://russcrane.com/papers/MFT_and_Health_Care/2008_Patterns_of_ Outpatient_Services.pdf.
Olfson, M., Sing, M., & Schlesinger, H.J. (1999). Mental health/medical care cost offsets: Opportunities for managed care. Health Affairs, 19 (2), 79-90. Retrieved August 10, 2009, from http://content.healthaffairs.org/cgi/reprint/18/2/79.

Bravehearts is in good physical health and has not excessively utilized medical healthcare services in general or to address any mental-health related issues. I expect that to continue, especially given that she has been and continues to be actively and consistently engaged in the treatment process, is compliant with all treatment recommendations and has a strong prognosis for long-term positive outcomes.

I respectfully request that you re-evaluate Bravehearts' application for insurance coverage giving consideration to the clarifications provided above regarding her toxicology report, the context in which the eating disorder diagnosis was applied and the research which supports my professional assessment that Bravehearts' mental health issues do not create a risk of higher than usual utilization of medical healthcare services.


Therapist Name, MSSW, LCSW
Licensed Clinical Social Worker

1 comment:

  1. How wonderful that you have her on your side.