Clinical UM Guideline


Subject:Feeding and Eating Disorder Treatment
Guideline #:  CG-BEH-05Current Effective Date:  10/14/2014
Status:RevisedLast Review Date:  08/14/2014

Description

This document addresses the medical necessity criteria for levels of care relating to feeding and eating disorder treatment. The criteria outlined in this document includes three categories; Severity of Illness, Intensity of Service and Continued Stay. Severity of Illness criteria includes descriptions of the member's condition and circumstances. Intensity of Service criteria describes the services being provided and these criteria must be met for admission and continued stay. For continued authorization of the requested service, Continued Stay criteria must be met along with Severity of Illness criteria.

Obesity is not included as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) because of the wide range of genetic, physiological, behavioral, and environmental factors that contribute to the development of obesity (excess body fat) in any given individual.

This document addresses eating disorder treatment for:

Note: Please see the following related documents for additional information:

Clinical Indications

Acute Inpatient

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) Eating Disorder Diagnosis for eating disorder acute inpatient treatment that is consistent with symptoms.

Severity of Illness (SI)
For Anorexia Nervosa, the member must have one or more of the following to qualify:

  1. Medical complications attributable to the eating disorder. This may be based on one or more of the following:
    1. For adults: heart rate less than 40 beats per minute (BPM) or blood pressure less than 90/60mm Hg or temperature less than 97.0 F.
      For children and adolescents: heart rate near 40 BPM or orthostatic pulse or blood pressure changes (greater than 20 BPM increase in heart rate or 10-20mm Hg drop in blood pressure) or blood pressure less than 80/50mm Hg; or
    2. For adults: glucose less than 60 mg/dl; potassium 3 mEq/L; electrolyte imbalance.
      For children and adolescents: potassium, magnesium or phosphorous below normal for age; or
    3. Dehydration; or
    4. Hepatic, renal or cardiovascular organ compromise requiring acute treatment; or
    5. Poorly controlled diabetes; OR
  2. Suicidality: Specific plan with high lethality or intent; suicidal ideation or a recent suicide attempt or aborted attempt with other high level risk factors for suicide; OR
  3. Adult weight as a percentage of healthy body weight: less than 85% or body mass index (BMI) less than 15.
    Children and adolescents, weight as a percentage of healthy body weight less than 85% or BMI percentile less than 5%; OR
    Acute weight decline with food refusal even if not less than 85% of healthy body weight or BMI percentile less than 5%; OR
  4. Motivation to recover, including cooperativeness, insight and ability to control obsessive thoughts: very poor to poor motivation; member preoccupied with intrusive repetitive thoughts; member uncooperative with treatment or cooperative only in highly structured environment; OR
  5. Co-occurring disorders: any existing psychiatric and/or substance abuse disorder that would require hospitalization; OR
  6. Structured need for eating/gaining weight: needs supervision during and after all meals or nasogastric/special feeding modality; OR
  7. Purging behavior (laxatives and diuretics): needs supervision during and after all meals and in bathrooms; unable to control multiple daily episodes of purging that are severe, persistent and disabling, despite appropriate trials of outpatient care, even if routine lab test results reveal no obvious metabolic abnormalities; OR
  8. Environmental stress: severe family conflict or problems or absence of family so member is unable to receive structured treatment in home; member lives alone without adequate support.

For Bulimia Nervosa, must have one of the following:

  1. Serious medical complications such as the following:
    1. Hematemesis; or
    2. Metabolic abnormalities; or
    3. Abnormal vital signs; or
    4. Uncontrollable vomiting; or
    5. Uncontrolled Type I Diabetes; or
  2. Severe psychiatric symptoms that would require hospitalization; or
  3. Severe comorbid alcohol or drug dependence or abuse; or
  4. Serious disabling symptoms despite adequate trials of outpatient treatment.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. Multidisciplinary assessment with a treatment plan which addresses nutritional, psychological, social, medical, and substance abuse needs; AND
  2. Relevant medical tests including lab tests (electrolytes, chemistry, complete blood count [CBC], thyroid) and electrocardiogram (ECG) done on admission and follow up tests done if any abnormality requiring intervention; AND
  3. Documentation of treatment by a qualified physician seven days a week, including management of psychiatric medication if indicated, or documentation as to why not used if indicated; AND
  4. Individual therapy by a licensed provider at least once per week, family therapy by a licensed provider at least once per week for adults and twice per week for children/adolescents (unless contraindicated, with documentation for the reason); AND
  5. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the member's primary care physician (PCP), providing treatment to the member, and where indicated, clinicians providing treatment to other family members, is documented; AND
  6. Nutritional plan with target weight range and refeeding plan to achieve gain of one to two pounds per week (if low body weight reason for admission); AND
  7. 24-hour skilled nursing (by either a registered nurse [RN] or licensed vocational nurse/licensed practical nurse [LVN/LPN]); AND
  8. Discharge plan with recommended aftercare including coordination with outpatient treatment team or development of an outpatient treatment plan if not already present.

Continued Stay Criteria (CS)
Must have one or more of the following to qualify:

  1. Adult weight as a percentage of healthy body weight: less than 85% or BMI less than 15.
    Children and adolescents, weight as a percentage of healthy body weight less than 85% or BMI percentile less than 5%; OR
    Acute weight decline with food refusal even if not less than 85% of healthy body weight or BMI percentile less than 5% and family or other environmental supports are weak and motivation is poor; OR
  2. Weight as a percentage of healthy body weight is greater than 85% or BMI greater than 15, for children and adolescents BMI percentile is greater than 5% and member has one or more of the following:
    1. Not able to eat or feed themselves independently; or
    2. Low level of participation and motivation; or
    3. No access to partial hospital care if this is needed; OR
  3. The member who refuses to eat and requires nutritional support is receiving nutritional support using an enteric feeding tube; OR
  4. The member is cooperative and responsive to treatment or treatment team has taken steps to treat involuntarily including petition for medical conservatorship, medication hearing or involuntary hospitalization; OR
  5. For members with chronic, persistent eating disorders where normal weight range or absence or binge/purge or non-purge bulimic symptoms have not been present for over one year, the member is not at a level of control and stability consistent with their usual/baseline condition.

Not Medically Necessary:

Eating disorder acute inpatient treatment is considered not medically necessary when the above criteria are not met.

 

Residential Treatment Center (RTC) with 24-Hour Nursing

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Eating Disorder Diagnosis for residential treatment center (RTC) treatment that is consistent with symptoms.

Severity of Illness (SI)
Must have one of 1, 2, 3, or 4 and also have all of 5 and 6 to qualify:

  1. If the condition is Anorexia Nervosa and weight restoration is the goal, the adult's weight is less than 85% of estimated healthy weight or BMI less than 15. For children and adolescents, 85% of estimated healthy body weight or BMI percentile less than 5%. And there are no signs or symptoms of acute medical instability that would require daily physician evaluation, intravenous fluids or nasogastric feeding or multiple daily lab tests. Structured treatment with 24 hour nursing needed for eating/gaining weight: Needs supervision at all meals or will restrict eating; OR
  2. Co-occurring disorders: another psychiatric or substance use disorder is present that also requires 24 hour structured treatment; OR
  3. Purging behavior (laxatives and diuretics): The member can ask for and use support from others or can use some cognitive or behavioral skills to stop from purging; OR
  4. Environmental stress: Severe family conflict or problems or absence of family so member is unable to receive structured treatment in home; member lives alone without adequate support; AND
  5. Motivation to recover, including cooperativeness, insight and ability to control obsessive thoughts: poor to fair motivation; member preoccupied with intrusive repetitive thoughts four to six hours a day; member cooperative with treatment in a highly structured environment; AND
  6. Comorbid psychiatric disorders are controlled or stable enough for the primary focus of treatment to be the eating disorder. If suicidality is present, the level of risk can be safely managed at this level of care and inpatient care is not necessary.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. Evaluation by a qualified physician or equivalent professional within 72 hours of admission and at least once weekly visits documented; AND
  2. Physical exam and lab tests done within 72 hours if not done prior to admission, and 24 hour on site nursing and medical availability to manage medical problems if risk for medical instability identified as a reason for admission to this level of care; AND
  3. Programming provided will be consistent with the member's language, cognitive, speech and/or hearing abilities; AND
  4. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the member's PCP, providing treatment to the member, and where indicated, clinicians providing treatment to other family members, is documented; AND
  5. Within seven days, an individualized problem focused treatment plan completed, including nutritional, psychological, social, medical and substance abuse needs to be developed based on a complex bio-psychosocial evaluation, and this needs to be reviewed at least once a week for progress; AND
  6. Treatment would include the following at least once per day and each lasting 60-90 minutes: community/milieu group therapy, group psychotherapy and activity group therapy plus at least once weekly individual therapy with a properly licensed provider; AND
  7. Family supports identified and contacted within 72 hours and family/primary support person participation at least weekly for adults, twice weekly for children and adolescents, unless contraindicated; AND
  8. Discharge planning initiated within one week of admission including identification of community/family resources, connection or re-establishment of connection to an outpatient treatment team and coordination with that team; AND
  9. The treatment is individualized and not determined by a programmatic timeframe. It is expected that members will be prepared to receive the majority of their treatment in a community setting; AND
  10. Medication evaluation and documented rationale if no medication is prescribed.

Continued Stay Criteria (CS)
Must continue to meet "SI/IS" Criteria and have all of the following to qualify:

  1. If low body weight is a reason for admission, target weight for safe treatment on an outpatient basis listed and weight gain of one to two pounds per week documented. The target discharge weight should be over 80% of the estimated healthy body weight and may need to be higher depending on whether the member is feeding themselves and participating in treatment, motivated and has access to partial hospital care for a transitional level of care; AND
  2. If a comorbid active substance use disorder was present at the time of admission, the member still meets American Society of Addiction Medicine (ASAM) Criteria Level 3.7 Residential Levels of Care; AND
  3. Progress toward treatment goals is documented; if progress not achieved then the treatment plan has been adjusted in a manner that is likely to achieve progress toward meeting treatment goals or treatment goals have been adjusted.

Not Medically Necessary:

Eating disorder residential treatment center (RTC) treatment is considered not medically necessary when the above criteria are not met.

 

Residential Treatment Center (RTC) without 24-Hour Nursing

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Eating Disorder Diagnosis for residential treatment center (RTC) without 24-hour nursing care treatment that is consistent with symptoms.

Severity of Illness (SI)
Must have one or more of the following to qualify:

  1. If the condition is Anorexia Nervosa and weight restoration is the goal, the adult's weight is less than 85% of estimated healthy body weight range or BMI less than 15. For children and adolescents, 85% of estimated healthy body weight or BMI percentile less than 5%. And there are no signs or symptoms of acute medical instability that would require daily physician evaluation, intravenous fluids or nasogastric feeding or multiple daily lab tests; OR
  2. Comorbid psychiatric disorders are controlled or stable enough for the primary focus of treatment to be the eating disorder. If suicidality is present, the level of risk can be safely managed at this level of care and inpatient care is not necessary; OR
  3. Motivation to recover, including cooperativeness, insight and ability to control obsessive thoughts: poor to fair motivation; member preoccupied with intrusive repetitive thoughts four to six hours a day; member cooperative with treatment in a highly structured environment; OR
  4. Co-occurring disorders: another psychiatric or substance use disorder is present that also requires 24 hour structured treatment; OR
  5. Structure needed for eating/gaining weight: Needs supervision at all meals or will restrict eating; OR
  6. Purging behavior (laxatives and diuretics): The member can ask for and use support from others or can use some cognitive or behavioral skills to stop from purging; OR
  7. Environmental stress: Severe family conflict or problems or absence of family so member is unable to receive structured treatment in home; member lives alone without adequate support.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. Evaluation by a qualified physician or equivalent professional within 72 hours of admission and at least once weekly visits documented; AND
  2. Physical exam and lab tests done within 72 hours if not done prior to admission,  and 24 hour on site nursing and medical availability to manage medical problems if risk for medical instability identified as a reason for admission to this level of care; AND
  3. Programming provided will be consistent with the member's language, cognitive, speech and/or hearing abilities; AND
  4. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the member's PCP, providing treatment to the member, and where indicated, clinicians providing treatment to other family members, is documented; AND
  5. Within seven days, an individualized problem focused treatment plan completed, including nutritional, psychological, social, medical and substance abuse needs to be developed based on a complex bio-psychosocial evaluation, and this needs to be reviewed at least once a week for progress; AND
  6. Treatment would include the following at least once per day and each lasting 60-90 minutes: community/milieu group therapy, group psychotherapy and activity group therapy plus at least once weekly individual therapy with a properly licensed provider; AND
  7. Family supports identified and contacted within 72 hours and family/primary support person participation at least weekly for adults, twice weekly for children and adolescents, unless contraindicated; AND
  8. Discharge planning initiated within one week of admission including identification of community/family resources, connection or re-establishment of connection to an outpatient treatment team and coordination with that team; AND
  9. The treatment is individualized and not determined by a programmatic timeframe. It is expected that members will be prepared to receive the majority of their treatment in a community setting; AND
  10. Medication evaluation and documented rationale if no medication is prescribed.

Continued Stay Criteria (CS)
Must continue to meet "SI/IS" Criteria and have all of the following to qualify:

  1. If low body weight is a reason for admission, target weight for safe treatment on an outpatient basis listed and weight gain of one to two pounds per week documented. The target discharge weight should be over 80% of the estimated healthy body weight and may need to be higher depending on whether the member is feeding themselves and participating in treatment, motivated and has access to partial hospital care for a transitional level of care; AND
  2. If a comorbid active substance use disorder was present at the time of admission, the member still meets ASAM criteria level 3.5 Level of Care; AND
  3. Progress toward treatment goals is documented; if progress not achieved then the treatment plan has been adjusted in a manner that is likely to achieve progress toward meeting treatment goals or treatment goals have been adjusted.

Not Medically Necessary:

Eating disorder residential treatment center (RTC) treatment without 24 hour nursing is considered not medically necessary when the above criteria are not met.

 

Partial Hospitalization Program (PHP)

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Eating Disorder Diagnosis for partial hospitalization program (PHP) treatment that is consistent with symptoms.

Severity of Illness (SI)
Must have all of the following to qualify:

  1. Current DSM or ICD Eating Disorder Diagnosis with mental health signs and symptoms: The member exhibits serious or disabling symptoms related to an acute mental health condition, or exacerbation of a severe and persistent mental disorder, or severe and persistent symptoms and impairments that have not improved or cannot be adequately addressed in a less intensive level of care; AND
  2. Level of Functioning: Marked impairments in multiple areas of his/her daily life are evident. This may include marked impairments that preclude adequate functioning in areas such as self-care, or other more specific role expectations such as bill paying, working, cleaning, problem solving, decision-making, contacting supports, taking care of others, addressing safety issues, medication compliance, or managing time in a meaningful way; AND
  3. Risk/Dangerousness: The member is not imminently dangerous to self or others and is able to exercise adequate control over his/her behavior to function outside of 24 hour per day care. However, the member may exhibit some identifiable risk for harm to self or others yet is able to develop and practice a safety plan with the structured intensive support of PHP treatment; AND
  4. Social Support System: The member is or can be connected with a community-based network, which supports them within their home environment. The member may present with impaired ability to access or use caretaker, family or community support. In some cases a socially isolated person with serious debilitation symptoms may benefit. In other cases, a member from a trouble family may benefit as well. Minimal ability to set goals to work toward the development of social support is often a requirement for participation. In some cases, removal from a given residence or placement in a residential treatment setting may be a precondition for treatment; AND
  5. Readiness For Change: The presence of significant denial or pre-contemplation regarding change may often be anticipated due to the acute circumstances surrounding an admission. The member must however have the capacity for minimum engagement in the identification of goals for treatment, and willingness to try to participate actively in relevant components of the program. Initially, due to mental health and substance use disorder symptoms, the member may only be able to agree to begin treatment, and may require close monitoring, support and encouragement to achieve and sustain active and ongoing participation; AND
  6. Level of Care Rationale: 
    1. The member has relapsed or failed to make significant clinical gains in a less intensive level of care; or
    2. Less intensive levels of care are judged insufficient to provide the treatment necessary; or
    3. The member is ready for discharge from an inpatient setting, but is judged to be in continued need of ongoing intensive therapeutic interventions, daily monitoring, and support that cannot be provided in a less intensive level of care.
      In addition, must have one or more of the following, to qualify:
  7. If the condition is Anorexia Nervosa and weight restoration is the goal, the member's weight is over 80% of estimated healthy body weight range but there are no signs or symptoms of acute medical instability that would require intensive medical monitoring; OR
  8. Comorbid psychiatric disorders are controlled or stable enough for the primary focus of treatment to be the eating disorder. If suicidality is present, the level of risk can be safely managed at this level of care and inpatient care is not necessary; OR
  9. Motivation to recover, including cooperativeness, insight and ability to control obsessive thoughts, partial motivation, member preoccupied with intrusive repetitive thoughts more than three hours a day; OR
  10. Co-occurring disorders: if another psychiatric or substance use disorder is present it can also be appropriately managed at this level of care; OR
  11. Structure for part or most of the day needed to eat/gain weight; OR
  12. Purging behavior (laxatives and diuretics): The member can reduce purging and does not have significant medical complications; OR
  13. Environmental stress: others are able to provide at least limited support and structure.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. Multidisciplinary treatment provided at least  six hours a day, five days a week; AND
  2. All services must consist of active treatment that specifically addresses the presenting problems of the individuals served and realistic goals that can be accomplished within the duration of treatment. Examples of active treatment include: group psychotherapy, psycho-educational (theme-specific) groups, skills training, expressive/activity therapies, medication evaluation/management, individual and family therapy; AND
  3. Involvement of the family, significant others and/or peers (as available and with signed consent) should be addressed in the mission and reflected in the program services offered; AND
  4. Programs operate under the direction of a physician and a program leader. The physician provides supervision of the clinical needs of the individuals enrolled in the program; the program leader is responsible for the overall clinical and administrative operations of the program; AND
  5. Staff members must possess appropriate academic degrees, licensure, or certification as well as experience with the particular populations treated as defined by program function and applicable state regulations. Core clinical staff members may include: psychiatrists, psychologists, social workers, counselors, addiction counselors, medical and nursing personnel. Occupational, recreational and creative arts therapists may also provide services. Paraprofessionals, non-degreed individuals, students and interns may be included; AND
  6. Coordination of care with other clinicians providing treatment to the member, such as the outpatient psychiatrist, therapist, and the member's PCP, and where indicated, clinicians providing treatment to other family members is documented; AND
  7. Physicians should have face to face contact on admission for an evaluation and thereafter as clinically indicated, at least one time a week. Clearly delineated procedures must be present for detoxification, withdrawal and other medical needs. Coordination of car with the member's PCP will take place in any situation where there are medical comorbidities. Physicians need to be available for consultation with other staff and for face to face evaluations with members during program hours or by telephone outside of program hours to be available 24 hours a day, seven days a week; AND
  8. A member of the clinical staff serves in a case management capacity to coordinate the member's treatment within the program, who will work consistently with the individual (and family as indicated) and follow the course of clinical treatment from admission through discharge; AND
  9. A clinical record is to be maintained for each member admitted. This has to include the following elements: initial assessment, physician orders and certification of need for this level of care, psychiatric assessment, treatment plan addressing only the needs which are of such severity that the intensity of PHP is needed with clear goals which are achievable within the timeframe of the program, medication management, progress notes and a discharge summary; AND
  10. Discharge planning begins at the time of admission with the identification of specific discharge criteria.

Continued Stay Criteria (CS)
Must all of the following to qualify:

  1. Successful engagement in the clinical progress; AND
  2. Active attendance and participation; AND
  3. Capacity to respond successfully to therapeutic interventions.

AND
Must also have one or more of the following to qualify:

  1. Symptoms continue to impair multiple areas of daily functioning; OR
  2. Impaired judgment, awareness, and skill deficits place one at a significant risk for further functional deterioration; OR
  3. Member displays an inability to cope with significant crises or stressors and/or otherwise lacks the necessary skills to cope with marked symptoms; OR
  4. There is a continued significant risk for harm to self or others; OR
  5. Poor insight, skills, judgment, and/or awareness inhibits their return to critical baseline functioning.

AND
Must also have one or more to qualify:

  1. Continued need for medication monitoring and intervention; OR
  2. Capacity to make progress in the development of coping skills to meet baseline functional needs; OR
  3. Need for support and guidance in handling a major life crisis; OR
  4. Continued need for managing risk accompanied by capacity to follow a safety plan; OR
  5. A commitment to developing and following through on a recovery oriented discharge plan.

May need to continue in PHP instead of IOP if at least three or more these are present:

  1. Daily medication and overall symptom monitoring is needed;
  2. Immediate behavioral activation and monitoring is needed;
  3. Potential for self-harm is significant and requires daily observation and safety planning;
  4. Coping skill deficits are severe and require daily reinforcement;
  5. A crisis situation is present and requires daily monitoring;
  6. Family situation is volatile and requires daily observation and client instruction and support;
  7. Mood lability is extreme with potential to create destructive relationship or environmental consequences;
  8. Hopelessness or isolation is a dominant feature of clinical presentation with minimal current supports;
  9. Daily substance use monitoring is needed;
  10. Need for rapid improvement to return to necessary role expectations is present.

Not Medically Necessary:

Eating disorder partial hospitalization program (PHP) treatment is considered not medically necessary when the above criteria are not met.

 

Intensive Outpatient Program (IOP)

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Eating Disorder Diagnosis for intensive outpatient program (IOP) treatment that is consistent with symptoms.

Severity of Illness (SI)
Must have all of the following to qualify:

  1. The presence of moderate symptoms of a serious Current DSM or ICD Eating Disorder Diagnosis; AND
  2. Significant impairment in one or more spheres of personal functioning; AND
  3. The clear potential to regress further without specific IOP services; AND
  4. The need for direct monitoring less than daily but more than weekly; AND
  5. Specific deficits that are directly related to services rendered; AND
  6. Significant variability in day to day capacity to cope with life situations.

    Must also have one or more of the following, to qualify:
  7. If the condition is Anorexia Nervosa and weight restoration is the goal, the member's weight is over 80% of estimated healthy body weight range but there are no signs or symptoms of acute medical instability that would require intensive medical monitoring; OR
  8. Comorbid psychiatric disorders are controlled or stable enough for the primary focus of treatment to be the eating disorder. If suicidal ideation is present, the risk is low enough for the member to be safely treated at this level of care; OR
  9. The individual has fair motivation to recover, including cooperativeness, insight and ability to control obsessive thoughts; OR
  10. Co-occurring disorders: if another psychiatric or substance use disorder is present it can also be appropriately managed at this level of care; OR
  11. The member has sufficient structure outside of this program to eat/gain weight; OR
  12. Purging behavior (laxatives and diuretics): The member can reduce purging and does not have significant medical complications; OR
  13. Environmental stress: others are able to provide adequate emotional and practical support and structure.

A PHP may be appropriate in lieu of an IOP if at least three or more of these are present:

  1. Daily medication and overall symptom monitoring is needed;
  2. Immediate behavioral activation and monitoring is needed;
  3. Potential for self-harm is significant and requires daily observation and safety planning;
  4. Coping skill deficits are severe and require daily reinforcement;
  5. A crisis situation is present and requires daily monitoring;
  6. Family situation is volatile and requires daily observation and client instruction and support;
  7. Mood lability is extreme with potential to create destructive relationship or environmental consequences;
  8. Hopelessness or isolation is a dominant feature of clinical presentation with minimal current supports;
  9. Daily substance use monitoring is needed;
  10. Need for rapid improvement to return to necessary role expectations is present.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. Treatment services offered at least three treatment hours per day at least three times per week. With symptom improvement, a gradual decrease in services per week may occur to help plan for successful discharge and greater independent functioning. In some cases an evidence-based, time limited treatment protocol is provided for a given condition which may include a given number of sessions over several weeks; AND
  2. A comprehensive clinical assessment is done on admission that includes cognition/mental status, emotional/psychological function, activities of daily living, historical data (including social, medical and occupational histories), cultural issues, spirituality and medical screening. The treatment plan will be updated and individualized following previous treatment either from a higher or lower level of care; AND
  3. All services must consist of active treatment that specifically addresses the presenting problems of the individuals served and realistic goals that can be accomplished within the duration of treatment. Examples of active treatment include: group psychotherapy, psycho-educational (theme-specific) groups, skills training, expressive/activity therapies, medication evaluation/management, individual and family therapy. For children and adolescents, family therapy should be provided at least one time each week, unless clinically contraindicated; AND
  4. Group therapy is individualized to meet the member's needs, based on specific clinical needs or functional level; AND
  5. Staff members must possess appropriate academic degrees, licensure, or certification as well as experience with the particular populations treated as defined by program function and applicable state regulations; AND
  6. Coordination of care with other clinicians providing treatment to the member, such as the outpatient psychiatrist, therapist, and the member's PCP, and where indicated, clinicians providing treatment to other family members is documented; AND
  7. A clinical record is to be maintained for each member admitted. This has to include the following elements: initial assessment, physician orders and certification of need for this level of care, psychiatric assessment, treatment plan addressing only the needs which are of such severity that the intensity of IOP is needed with clear goals which are achievable within the timeframe of the program, medication management, progress toes and a discharge summary; AND
  8. A psychiatric evaluation by a physician should be done by the third day of attendance (unless stepping down from a higher level of care) and thereafter as needed.

Continued Stay Criteria (CS)
Must have all of the following to qualify:

  1. Symptoms are moderate and continue to impair daily functioning; AND
  2. Restoration of the level of functioning prior to development of the illness may not be possible, but enhancement of skills to cope with and prevent further deterioration is necessary; AND
  3. The member does not have a high likelihood of relapse to severity of symptoms that would require treatment at an inpatient or partial hospital program level of care; AND
  4. Stability cannot be maintained with regular outpatient treatment. If weight gain is a target of treatment, the member's weight is not at or over 85% of their estimated healthy body weight.

Not Medically Necessary:

Eating disorder intensive outpatient program (IOP) treatment is considered not medically necessary when the above criteria are not met.

 

Outpatient Treatment

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Eating Disorder Diagnosis for eating disorder outpatient treatment that is consistent with symptoms.

Severity of Illness (SI)
Must have one or more of the following to qualify:

  1. Specific symptoms or disturbances of mood and/or behavior are present, with functional impairment, which are consistent with the DSM/ICD diagnosis listed, and these disturbances/symptoms are likely to improve with treatment; OR
  2. The member demonstrates motivation for treatment and is capable of benefiting from the treatment approach planned; OR
  3. Medically stable; OR
  4. If weight restoration is the goal, the member's weight is over 85% of estimated healthy body weight range and there are no signs or symptoms of acute medical instability that would require more extensive medical monitoring; OR
  5. Fair to good motivation to recover, including cooperativeness, insight and ability to control obsessive thoughts; OR
  6. If a comorbid psychiatric disorder or substance use disorder is present, it is also appropriate for outpatient treatment; OR
  7. Self- sufficient in eating/gaining weight; OR
  8. Others able to provide adequate emotional and practical support and structure; OR
  9. Lives near treatment setting.

Note: The severity of illness factors important for distinguishing between PHP, IOP and outpatient is the members' level of insight, social support, motivation, and ability to self-control eating disorder symptoms.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. Treatment goals target resolution of specific symptoms or stabilization of mood and/or behavior consistent with the DSM/ICD diagnoses listed and also target specific domains of functional impairment; AND
  2. Medication is being used for conditions where indicated, and if not, documentation of the reason and treatment interventions addressing the omission of this treatment; AND
  3. If substance abuse/dependence is a diagnosis or indicated to be present, a substance use evaluation has been performed when appropriate and treatment is being provided; AND
  4. Community/natural supports and resources are identified and utilized or skills to develop community/natural supports is  a treatment goal, including school/work interventions, self-help or diagnosis specific support groups, spiritual/religious, and community recreational activities; AND
  5. Coordination of care with other clinicians providing care to the member or family members, including psychiatrist/therapist and PCP is documented; AND
  6. Treatment is not duplicative of services being provided by another clinician for the same reasons/diagnoses; AND
  7. Provider must be properly licensed to provide the treatment requested.

Continued Stay Criteria (CS)
Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress with the eating disorder symptoms and behaviors is documented and the member is cooperative with treatment and showing evidence of motivation that is consistent with likely continued benefit; if progress is not occurring, then the treatment plan is being re-evaluated and amended with goals that are still achievable.

Not Medically Necessary:

Eating disorder outpatient treatment is considered not medically necessary when the above criteria are not met.

Coding

Coding edits for medical necessity review are not implemented for this guideline.  Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Discussion/General Information

Eating disorders are characterized by a persistent disturbance of eating or behaviors related to eating. This disturbance results in altered consumption or absorption of food. Signification impairments are seen in physical health and psychosocial functioning. The specific disorder most likely to be life threatening is anorexia nervosa. Individuals with anorexia lose more weight than is healthy for their age and height. The disorder is associated with an intense fear of gaining weight or becoming "fat" even when an individual with anorexia is under weight for height and age. Anorexia is characterized by a disturbance in the way body weight or shape are experienced such that body weight has an excessive influence on self-evaluation or the affected individual fails to adequately recognize the seriousness of being underweight.

Many individuals with anorexia also have bulimia symptoms. Bulimia nervosa is an illness in which an individual binges on food or has regular episodes of overeating and feels a loss of control. The individual then uses different methods such as vomiting or abusing laxatives to prevent weight gain. In the United States it is estimated that approximately 0.5% of adolescent girls have anorexia nervosa and 1%-2% meet diagnostic criteria for bulimia nervosa (Rosen, 2010). Medical conditions associated with eating disorders can include gastrointestinal disorders, endocrine disorders, other psychiatric disorders including substance abuse, and cardiac conditions including blood pressure and pulse changes. Although about 50% of individuals with child and adolescent onset eating disorders will recover and many of the remaining population improve, a troubling minority of individuals will have a chronic illness often associated with malnutrition. Some people with chronic eating disorders will need custodial services. Anorexia nervosa is associated with excess mortality relative to the general population with sudden death and suicide common causes of death.

A reliable determination of expected body weight is critical for diagnosis and management of eating disorders. A commonly agreed upon method for expected body weight calculation such as the BMI percentile method is recommended for children and adolescents (Le Grange, 2012; DSM-5). Weight estimation methods for adults include the BMI and Weight for Stature method. According to Golden and colleagues (2012), the Weight for Stature method and BMI methods are not necessarily equivalent. These workers concluded that it remains to be determined which method better predicts meaningful clinical outcomes. Healthy body weight is a calculation based on height, gender, and age. BMI is a measure of body fat based on height and weight that applies to adult men and women. The American Psychiatric Association (APA) in their 2006 guideline for Treatment of Patients with Eating Disorders uses weight as a percentage of healthy body weight in determining appropriate levels of care for eating disorders. The APA notes that weight level alone should not be used as a sole criterion from discharge from one level of care to another and other factors should be appropriately considered. The DSM-5 (2013) cites BMI in determining appropriate levels of care for eating disorders. At this time, there is no concrete conversion of BMI to percentage of healthy body weight.

Feeding and eating disorder treatment should not be primarily for the avoidance of incarceration of the member or to satisfy a programmatic length of stay (refers to a pre-determine number of days or visits for a program's length instead of an individualized determination of how long a member needs to be in that program). There should be a reasonable expectation that the member's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the member's illness. 

It is noted that there is variation in the availability of services in different geographic and regional areas. If an indicated service is not available within a member's community at the level of service indicated by the criteria, authorization may be given for those services at the next highest available level.

In some geographical areas, state regulations allow non-physicians to treat members at inpatient facilities. In these documents, such non-physicians with prescriptive authority who are operating within the scope of their license may be substituted where the criteria specifies a physician.

Definitions

Acute Inpatient Hospitalization: Acute inpatient psychiatric hospitalization is defined as treatment in a hospital psychiatric unit that includes 24-hour nursing and daily active treatment under the direction of a psychiatrist and certified by The Joint Commission or the National Integrated Accreditation for Healthcare Organizations (NIAHO) as a hospital. Acute psychiatric treatment is appropriate in an inpatient setting when required to stabilize members who are in acute distress and return them to a level of functioning in which a lesser level of intense treatment can be provided. A need for acute inpatient care occurs when the member requires 24-hour nursing care, close observation, assessment, treatment and a structured therapeutic environment that is available only in an acute inpatient setting.

Residential Treatment: Residential treatment is defined as specialized treatment that occurs in a residential treatment center. Residential treatment is 24 hours per day and requires a minimum of one physician visit per week in a facility based setting. Wilderness programs are not considered residential treatment programs.

Partial Hospitalization: Partial hospitalization (sometimes called day treatment) is a structured, short-term treatment modality that offers nursing care and active treatment in a program that is operable at a minimum of six (6) hours per day, five (5) days per week. Members must attend a minimum of 6 hours per day when participating in a partial hospitalization program. Members are not cared for on a 24-hour per day basis, and typically leave the program each evening and/or weekends. Partial hospitalization treatment is provided by a multidisciplinary treatment team, which includes a psychiatrist. Partial hospitalization is an alternative to acute inpatient hospital care and offers intensive, coordinated, multidisciplinary clinical services for members that are able to function in the community at a minimally appropriate level and do not present an imminent potential for harm to themselves or others.

Intensive Outpatient Treatment: Intensive outpatient is a structured, short-term treatment modality that provides a combination of individual, group and family therapy. Intensive outpatient programs meet at least three times per week, providing a minimum of three (3) hours of treatment per session. Intensive outpatient programs must be supervised by a licensed mental health professional. Intensive outpatient treatment is an alternative to inpatient or partial hospital care and offers intensive, coordinated, multidisciplinary services for members with an active psychiatric or substance related illnesses who are able to function in the community at a minimally appropriate level and present no imminent potential for harm to themselves or others.

Outpatient Treatment: Outpatient treatment is a level of care in which a mental health professional licensed to practice independently provides care to individuals in an outpatient setting, whether to the member individually, in family therapy, or in a group modality.

References

Peer Reviewed Publications:

  1. Frances A Docherty JP, Kahn DA. The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry. 1996; 5(Suppl 12A):1-88.
  2. Golden NH, Yang W, Jacobson MS, et al. Expected body weight in adolescents: comparison between weight-for-stature and BMI methods. Pediatrics. 2012; 130(6):e1607-1613.
  3. Gowers SG, Clark A, Roberts C, et al. Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised controlled trial. Br J Psychiatry. 2007; 191:427-435.
  4. Gowers SG, Clark AF, Roberts C, et al. A randomised controlled multicentre trial of treatments for adolescent anorexia nervosa including assessment of cost-effectiveness and patient acceptability - the TOuCAN trial. Health Technol Assess. 2010; 14(15):1-98.
  5. Hartmann A, Weber S, Herpertz S, et al. Psychological treatment for anorexia nervosa: a meta-analysis of standardized mean change. Psychother Psychosom. 2011; 80(4):216-226.
  6. Hebebrand J, Himmelmann GW, Wewetzer C, et al. Body weight in acute anorexia nervosa and at follow-up assessed with percentiles for the body mass index: implications of a low body weight at referral. Int J Eat Disord. 1996; 19(4):347-357.
  7. Le Grange D, Doyle PM, Swanson SA, et al. Calculation of expected body weight in adolescents with eating disorders. Pediatrics. 2012; 129(2):e438-446.
  8. Lemmens HJ, Brodsky JB, Bernstein DP. Estimating ideal body weight--a new formula. Obes Surg. 2005; 15(7):1082-1083.
  9. McEvoy JP, Scheifler PL, Frances A. Treatment of schizophrenia 1999. The expert consensus guideline series. J Clin Psychiatry. 1999; 60 Suppl 11:3-80.
  10. Rosen DS.; American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010; 126(6):1240-1253.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Agency for Healthcare Research and Quality. Management of eating disorders. Evidence Report/Technology Assessment. 2006 April. Publication No. 06-E010. Available at: http://archive.ahrq.gov/downloads/pub/evidence/pdf/eatingdisorders/eatdis.pdf. Accessed on April 25, 2014.
  2. American Psychiatric Association. Clinical Practice Guideline Treatment of Patients with Eating Disorders. 2006. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on April 24, 2014.
  3. American Psychiatric Association. Guideline watch: Practice Guideline for the Treatment of Patients with Eating Disorders. 2012. Available at: http://psychiatryonline.org/pdfaccess.ashx?ResourceID=5391825&PDFSource=6. Accessed on April 28, 2014.
  4. Association for Ambulatory Behavioral Health Care. Standards and Guidelines for Partial Hospitalization Programs. 5th Ed. Portsmouth, VA. 2012.
  5. American Society of Addiction Medicine. Public Policy Statement on Co-occurring Addictive and Psychiatric Disorders. 2000. Available at: http://www.asam.org/docs/publicy-policy-statements/1co-occurring-disorders-12-00.pdf?sfvrsn=0. Accessed on April 24, 2014.
  6. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA. 2013. Available at: http://dsm.psychiatryonline.org/book.aspx?bookid=556. Accessed on April 24, 2014.
  7. Mee-Lee, D. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. American Society of Addiction Medicine. 2013. pp 250 and 266-267.
  8. National Institute for Health and Clinical Excellence (NICE). Clinical Guideline 9. Eating disorders Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. January 2004. Available at: http://www.nice.org.uk/nicemedia/live/10932/29218/29218.pdf. Accessed on April 24, 2014.
  9. Treatment of Major Depression. Volume 2. Treatment of Major Depression Clinical Practice Guideline Number 5. AHCPR Publication No. 93-0551: April 1993.
Websites for Additional Information
  1. Centers for Disease Control. Growth charts. September 2010. Available at: http://www.cdc.gov/growthcharts/. Accessed on April 29, 2914.
Index

Anorexia Nervosa
Bulimia Nervosa
Eating disorder

History

Status

Date

Action

Revised08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised08/08/2014Behavioral Health Subcommittee review. Multiple clarifications to Medical Necessity Criteria. Updated Description, Discussion/General Information and References. Title changed to "Feeding and Eating Disorder Treatment."
Revised02/13/2014MPTAC review.
Revised02/07/2014Behavioral Health Subcommittee review. Removed indications of Axis from Clinical Indications. Updated References.
New08/08/2013MPTAC review.
New07/26/2013Behavioral Health Subcommittee review. Initial document development. Clarification to Clinical Indications Partial Hospitalization Program, Intensity of Service. Updated References. The Behavioral Health Medical Necessity Criteria effective January 1, 2013 was split apart into specific subject matter clinical UM guidelines.