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.