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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 10/11/2007 Title: Management of Eating Disorders
Revision Date: 11/01/2018 Document: BI209:00
CPT Code(s): None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Treatment of Eating Disorders (primarily anorexia nervosa and bulimia) will be covered under the mental health provisions of the policy. Coverage of medical complications is subject to medical necessity determination.

2)    Hospital admission for eating disorders is indicated only for serious life threatening conditions and requires pre-authorization.


Medical Statement

Inpatient and outpatient services for eating disorders that are provided through a structured eating disorders program are considered mental health services due to their focus on behavioral modification.

 

Services for eating disorders that are primarily medical in nature will be covered as a medical service if the member is under the care of a non-mental health practitioner in an acute bed for the treatment of a medical complication as outlined below. The following criteria supersede the Milliman criteria on this process.

1)    Medical admission in eating disorders may be indicated for urgent need for re-feeding as indicated by BOTH of the following:

a)    Body mass index less than 14 or weight less than 75% of average body weight for height, age, and sex; AND

b)    Unstable physical condition as indicated by EITHER of the following:

i)     Current rate of weight loss greater than 2 pounds (or 1 kilogram) per week for 2 or more weeks; OR

ii)    Serious physiological effects of malnutrition as indicated by ANY TWO of the following:

(1)  Heart rate less than 40 beats per minute; OR

(2)  Core body temperature less than 35 degrees C (96 degrees F); OR

(3)  Orthostatic vital sign changes; OR

(4)  Recent syncope; OR

(5)  Prolonged corrected QT interval; OR

(6)  Severe muscle weakness;  OR

(7)  Serum phosphorus less than 1.5 mg/dL (0.5 mmol/L ;) OR

(8)  Electrolyte abnormality that cannot be corrected (to near normal) in an emergency department or other ambulatory setting (eg, serum potassium less than 2.5 mEq/L; serum sodium less than 130 mEq/L).

 

Continued hospital stay will be permitted only for the acute management of the metabolic complications and during re-feeding to the point where weight loss has ceased. Patients should be discharged when their medical status is stable (i.e., metabolic and nutritional crisis has been resolved), and treatment can be provided in an outpatient setting.

 

2)    Mental Health admission may be indicated for EITHER of the following:

a)    Failure of treatment at a lower level of care as indicated by BOTH of the following:

i)     Ongoing participation in appropriate treatment at the most intensive available lower level of care; AND

ii)    Failure to progress as indicated by EITHER of the following:

(1)  Absence of recent weight gain; OR

(2)  Frequent (e.g., daily) purging by emesis, laxatives, or other means.

OR

b)    Imminent danger to self due to ANY ONE of the following:

i)     Imminent risk for recurrence of a suicide attempt or act of serious self-harm as indicated by BOTH of the following:

(1)  Very recent suicide attempt or deliberate act of serious self-harm; AND

(2)  Absence of sufficient relief of the action`s precipitants.

OR

ii)    Current plan for suicide or serious self-harm.

OR

iii)   Persistent thoughts of suicide or serious self-harm that cannot be adequately monitored at a lower level of care due to ANY ONE of the following:

(1)  Insufficient behavioral care provider availability; OR

(2)  Inadequate patient support system; OR

(3)  Patient characteristics such as high impulsivity or unreliability.

 

Expectations for Acute Inpatient Eating Disorders Treatment:

a)    A documented current diagnosis of Anorexia Nervosa, Bulimia Nervosa, or Other Specified Eating Disorder, per the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, and evidence of significant distress/impairment.

b)    Evaluation by a Board Certified/Board Eligible Psychiatrist within 24 hours of admission who also reviews and approves the appropriateness for this level of care and consideration of alternative less restrictive levels of care.

c)    Daily active, comprehensive care by a treatment team that works under the direction of a Board eligible/Board certified psychiatrist.

d)    Physician follow-up occurs daily or more frequently as needed.

e)    A medical assessment and physical examination is completed and indicated blood and urine specimens are obtained for laboratory analysis within 24 hours of admission.

f)     All medical and psychiatric evaluations should include consideration of the possibility of relevant co-morbid conditions.

g)    Within 48 hours of admission, outreach will be done with existing providers and family members to obtain needed history and clinical information, unless clinically contraindicated.

h)   The facility will rapidly assess and address any urgent behavioral and/or physical issues.

i)     Ongoing academic schooling is provided for children and adolescents to facilitate a transition back to the child’s previous school setting. Young children (12 years and younger) will be admitted to a unit exclusively for children.

 

Discharge Planning:

The Treatment Plan is not based on a pre-established programmed plan or time frames. An Individualized Treatment Plan is completed within 24 hours of admission. This plan

includes:

1)    A focus on the issues leading to the admission. If this is a readmission, clarity on what will be done differently during this admission that will likely lead to improvement that has not been achieved previously.

2)    The goal is to improve symptoms, develop appropriate discharge criteria and planning involving coordination with community resources to allow a smooth transition back to outpatient services, family integration, and continuation of the recovery process.

3)    For individuals with a history of multiple re-admissions and treatment episodes, the treatment and discharge plan needs to include clear interventions to identify and address the reasons for previous non-adherence/poor response and clear interventions for the reduction of future risks. 

4)    Discharge Planning will start at the time of admission and include all of the following:  

a)  Coordination with family, outpatient providers, and community resources to allow a smooth transition back to home, family, work or school and appropriate treatment at a less restrictive level of care.

b)  Timely and clinically appropriate aftercare appointments with at least one appointment within 7 days of discharge.

5) Prescriptions for any necessary medications, in a quantity sufficient to bridge any gap between discharge and the first scheduled follow-up psychiatric/medical appointment.

   

 

Criteria for Continued Stay:

All of the following must be met:

1) The individual continues to meet all elements of Medical Necessity.

2) One or more of the following criteria must be met:

a) The treatment provided is leading to measurable clinical improvements in the acute symptoms and/or behaviors that led to this admission and a progression toward discharge from the present level of care, but the individual is not sufficiently stabilized so that he/she can be safely and effectively treated at a less restrictive level of care.

b) If the treatment plan implemented is not leading to measurable clinical improvements in the acute symptoms and/or behaviors that led to this admission and a progression toward discharge from the present level of care, there must be ongoing reassessment and modifications to the treatment plan that address specific barriers to achieving improvement when clinically indicated.

c) The individual has developed new symptoms and/or behaviors that require this intensity of service for safe and effective treatment.

3) All of the following must be met:

a) The individual and family are involved to the best of their ability in the treatment and discharge planning process.

b) Continued stay is not primarily for the purpose of providing a safe and structured environment.

c) Continued stay is not primarily due to a lack of external supports. 

 

Please refer to BI449 Residential Treatment for Mental Health and Substance Use Disorders for residential care facility treatment criteria.


Limits

QualChoice considers the following services/procedures experimental and investigational for the diagnosis and treatment of anorexia and bulimia because of insufficient evidence in the peer-reviewed literature.

    • Brain imaging
    • Catechol-O-methyltransferase (COMT) Val158Met polymorphism genotyping
    • Estrogen receptor 1 gene (ESR1) polymorphism testing (for anorexia)
    • Evaluation of olfaction
    • Individual Optimal Nutrition (ION) analysis/profile
    • Measurement of blood levels of peripheral brain derived neurotrophic factor (BDNF) (for bulimia)
    • Measurement of plasma levels of hypothalamic neuropeptides (e.g., kisspeptin, nesfatin-1, phoenixin, and spexin) (for anorexia)
    • Measurement of plasma levels of adiponectin as a prognostic biomarker for bulimia
    • Measurement of serum concentration of brain derived neurotrophic factor (for anorexia)
    • Measurements of serum zinc levels
    • Serotonin transporter gene (5-HTTLPR) polymorphism testing (for anorexia and bulimia)
    • Acamprosate calcium (Campral) for the treatment of binge eating disorder
    • Acupuncture
    • Bisphosphonates and other anti-resorptive agents in the management of osteopenia in anorexic members
    • Bright light therapy for the treatment of eating disorders (including light therapy for the treatment of night eating syndrome)
    • Bupropion (Zyban) for the treatment of bulimia and binge eating disorder (bupropion only)
    • Cholinesterase inhibitors (e.g., donepezil) for the treatment of anorexia
    • Chromium for the treatment of binge eating disorder
    • Deep brain stimulation (treatment-refractory anorexia)
    • Dehydroepiandrosterone for the treatment of anorexia.
    • Estrogen for the treatment of anorexia (including transdermal estradiol patch)
    • E-therapy (via Internet and mobile-device applications) for the treatment of eating disorders
    • Food-specific inhibition training for the treatment of binge eating disorder
    • Ghrelin agonists (for anorexia)
    • Glucagon-like peptide-1 receptor agonists (for bulimia)
    • Intranasal naloxone for the treatment of binge eating disorder
    • Melatonergic medications for the treatment of night eating syndrome
    • Neural therapy (superficial injection of local anesthetic; for bulimia)
    • Oral contraceptives in preventing bone loss in amenorrheic persons with an eating disorder
    • Oxytocin
    • Qsymia (phentermine and topiramate ER; for bulimia)
    • Relaxation therapy
    • Repetitive transcranial magnetic stimulation
    • The Mandometer treatment
    • Transcranial direct current stimulation.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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