Clinical UM Guideline


Subject:  Eating Disorder Treatment
Guideline #:  CG-BEH-05Current Effective Date:  02/17/2014
Status:RevisedLast Review Date:  02/13/2014

Description

The medical necessity criteria outlined in this guideline for each level of care relating to eating disorder treatment includes three categories; Severity of Illness, Intensity of Service and Continued Stay. Severity of Illness criteria includes descriptions of the Covered Individual'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.

This document addresses eating disorder treatment for:

Please see the following related document(s) for additional information:

Clinical Indications

Acute Inpatient

Medically Necessary:

To qualify, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have one of 1-3 and both 4 and 5 to qualify:

  1. Medical Complications attributable to the eating disorder, which typically include the following:
    1. Vital Sign abnormalities: For adults, pulse rate less than 40, orthostatic pulse change greater than 20, blood pressure less than 90/60, orthostatic blood pressure change greater than 10-20, temperature less than 96-97° F. For children/adolescents, pulse rate less than 50 daytime, 45 nighttime, orthostatic pulse change greater than 20, blood pressure less than 80/50, orthostatic blood pressure change greater than 10-20 and temperature less than 96-97° F.
    2. Electrolyte abnormalities, including hypokalemia or hypophosphatemia.
    3. Cardiac compromise, including dysrhythmias or prolonged QTc.
    4. Organ damage requiring treatment, including renal, hepatic, gastrointestinal (GI) or cardiovascular.
    5. Acute dehydration as shown by physical and lab findings requiring medical rehydration.
      OR
  2. For Anorexia Nervosa, body mass index (BMI) less than 15 or less than 75% of individually estimated ideal body weight range, or, rapid weight loss combined with active refusal to eat on a trajectory showing that this BMI or weight will occur within a few days. For Bulimia Nervosa or Eating Disorder not otherwise specified (NOS) medical abnormalities (see SI 1) must be demonstrated and can be safely treated in a psychiatric unit and do not require intensity of a medical unit.
    OR
  3. Severe eating disorder comorbid with psychiatric symptoms that would in themselves require inpatient treatment, such as suicidal ideation with intent or a feasible plan or other conditions that would meet Inpatient Psychiatric Severity of Illness criteria (if other Eating Disorder Inpatient criteria not met, Inpatient Psychiatric service should be used); AND
  4. Worsening symptoms and behaviors despite current treatment in a structured outpatient eating disorder (ED) service (IOP or PHP, or 2-3 times a week outpatient [OP] treatment involving an ED behavioral health [BH] clinician, nutritionist and a qualified physician where intensive services not geographically available) with the likelihood that Inpatient treatment will result in improvement– this criterion not necessary if the Covered Individual is actively resistant to treatment, actively uncooperative and/or has severely impaired insight and does not recognize any need for treatment; AND
  5. Supervision required during and after all meals and in the evening to prevent restricting or excessive exercising/purging behaviors; for children/adolescents, family not able to supervise due to severe conflict or treatment resistance.

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 (7) 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 Covered Individual's primary care physician (PCP), providing treatment to the Covered Individual, 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 1-2 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 continue to meet "SI/IS" Criteria and have 1 or 2 and 3-5 to qualify:

  1. Progress in treatment is documented including: weight gain, increasing adherence with meal plan, medical stabilization, stabilization of acute psychiatric symptoms, cooperation with discharge planning; for treatment of low body weight with medical instability complicated by need for involuntary treatment, very poor insight and motivation or active treatment resistance and poor family/social support, level of weight gain may need to surpass admission criteria and reach a level that is consistent with medical and physical indications of malnutrition having stabilized and weight/BMI in low normal range; OR
  2. Lack of progress or persistent symptoms/behaviors have resulted in changes to the treatment plan to address treatment resistance that has a likelihood of achieving progress; AND
  3. The Covered Individual 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; AND
  4. For children/adolescents or dependent adults, family is actively involved in treatment and responsive to treatment recommendations; AND
  5. For Covered Individuals with chronic, persistent Eating Disorders where normal weight range or absence of binge/purge or non-purge bulimic symptoms has not been present for over one (1) year, the Covered Individual 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)

Medically Necessary:

To qualify, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have all of the following to qualify:

  1. If Anorexia Nervosa and weight restoration is goal, BMI between 15-18 or weight between 75%-85% of estimated ideal weight range and no signs or symptoms of acute medical instability that would require daily physician evaluation; AND
  2. Comorbid psychiatric disorders are controlled or stable enough for the primary focus of treatment to be the eating disorder; AND
  3. For Anorexia Nervosa, continued restricting and purging is leading to weight loss that is likely to lead to medical instability and need for inpatient treatment with the likelihood that residential treatment will result in improvement; for Bulimia Nervosa, continued purging or excessive exercising is likely to cause medical instability or dehydration that would need inpatient treatment; or for either condition, the Covered Individual has had multiple inpatient admissions within the past six (6) months with a failure to stabilize with outpatient aftercare; AND
  4. Significant functional disruption from usual/baseline status in at least two domains (school/work, family, activities, activities of daily living [ADLs]) related to the eating disorder; AND
  5. Based on past treatment history, usual level of functioning and comorbid psychiatric disorders, there is a reasonable expectation that the Covered Individual will benefit from this level of care; AND
  6. Living environment and support are characterized by either significant deficits or significant conflict or problems that would undermine goals of treatment such that treatment at a lower level of care is unlikely to be successful, and this can potentially be improved with treatment.

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 Covered Individual's language, cognitive, speech and/or hearing abilities; AND
  4. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  5. Within seven (7) 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 (1) 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 Covered Individuals 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 1-2 pounds per week documented; AND
  2. Progress toward treatment goals is documented as shown by motivation on the part of the Covered Individual and family, adherence to treatment recommendations including weight gain and acceptance of recommended dietary caloric intake if low body weight was a reason for admission and control of binging and purging or non-purging bulimic symptoms, but treatment goals that would allow continued treatment at a lower level of care have not been achieved; if progress not achieved than 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, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have all of the following to qualify:

  1. If Anorexia Nervosa and weight restoration is goal, BMI between 15-18 or weight between 75%-85% of estimated ideal weight range and no signs or symptoms of acute medical instability that would require daily physician evaluation, and no cardiovascular or metabolic impairment that would require daily nursing monitoring, including vital signs and frequent lab tests; AND
  2. Comorbid psychiatric disorders are controlled or stable enough for the primary focus of treatment to be the eating disorder; AND
  3. For Anorexia Nervosa, continued restricting and purging is leading to weight loss that is likely to lead to medical instability and need for Inpatient treatment despite receiving structured outpatient ED treatment (IOP or PHP, or 2-3 times a week OP treatment involving an ED BH clinician, nutritionist and a qualified physician  where intensive services not geographically available) with the likelihood that residential treatment will result in improvement; for Bulimia Nervosa, continued purging or excessive exercising is likely to cause medical instability or dehydration that would need inpatient treatment despite receiving the same level of outpatient treatment described above; or for either condition, the Covered Individual has had multiple inpatient admissions within the past six (6) months with a failure to stabilize with outpatient aftercare; AND
  4. Significant functional disruption from usual/baseline status in at least two domains (school/work, family, activities, ADLs) related to the eating disorder; AND
  5. Based on past treatment history, usual level of functioning and comorbid psychiatric disorders, there is a reasonable expectation that the Covered Individual will benefit from this level of care; AND
  6. Living environment and support are characterized by either significant deficits or significant conflict or problems that would undermine goals of treatment such that treatment at a lower level of care is unlikely to be successful, and this can potentially be improved with treatment; AND
  7. ED PHP criteria also met but no facility within geographic access.

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 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 Covered Individual's language, cognitive, speech and/or hearing abilities; AND
  4. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  5. Within 7 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 (1) 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 Covered Individuals will be prepared to receive the majority of their treatment in a community setting; AND
  10. Treatment would include the following at least once a day and each lasting 60-90 minutes:  community/milieu group therapy, group psychotherapy, and activity group therapy.

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 1-2 pounds per week documented; AND
  2. Progress toward treatment goals is documented as shown by motivation on the part of the Covered Individual and family, adherence to treatment recommendations including weight gain and acceptance of recommended dietary caloric intake if low body weight was a reason for admission and control of binging and purging or non-purging bulimic symptoms, but treatment goals that would allow continued treatment at a lower level of care have not been achieved; if progress not achieved than 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, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have all of the following to qualify:

  1. Eating disorder behaviors and body weight are at levels where acute medical intervention is not needed, but without at least six (6) hour daily structured treatment at least five (5) days a week the Covered Individual is likely to regress to needing a higher level of care; AND
  2. Motivation, self care skills and recognition of a need for treatment are sufficient for the Covered Individual to reduce eating disorder behaviors and/or gain weight with outpatient treatment, but has not achieved progress with IOP or outpatient treatment at a twice weekly frequency; AND
  3. If anorexic, restricting and if anorexic or bulimic, binging and purging or non-purging behaviors are present for at least three (3) hours every day and are causing significant functional impairment in at least two domains (work/school, family relations, activities); AND
  4. The Covered Individual has adequate support in their living environment and has access to this level of care; AND
  5. Comorbid psychiatric conditions are stable enough for outpatient treatment and appropriate treatment is being provided to maintain this stability and is not the primary focus of treatment.

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Multidisciplinary treatment provided at least six (6) hours a day. The frequency of attendance per week may vary according to clinical needs and progress; AND
  2. A nutritional assessment is done on admission and if low body weight is a reason for admission then specific dietary intake and target weight goals are identified, with once weekly measurement of weight and daily charting of calorie intake/percentage of dietary intake goals; AND
  3. A treatment plan includes targets of cognitive behavioral skills for controlling restricting for Covered Individuals with anorexia, which may include supervised meals, and controlling binging, purging and non-purging behaviors for Covered Individuals with anorexia and bulimia, and progress in gaining and utilizing skills is documented; AND
  4. Evaluation by a qualified physician done upon admission and at least weekly visits are documented; AND
  5. Medical and substance use evaluations are either done on admission or if transferring from another intensive level of care, those evaluations are obtained and recommended interventions incorporated into the treatment plan and appropriate interventions are documented as needed; AND
  6. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  7. Community supports and resources are identified and the treatment plan includes developing or increasing their use; AND
  8. Family therapy is provided at least once per week for children/adolescents and dependent adults and involvement of family members in groups and educational programs is documented (unless contraindicated); AND
  9. Discharge planning including either development of a new outpatient treatment team or coordination with the existing team; AND
  10. The Covered Individual resides in a community setting while receiving partial hospitalization services and is not in a 24-hour residential treatment setting. Hours outside of the program are not supervised by any program staff members; AND
  11. The treatment is individualized and not determined by a programmatic timeframe. It is expected that Covered Individuals will be prepared to receive the majority of their treatment in a community setting; AND
  12. Treatment would include the following at least once a day and each lasting 60-90 minutes: community/milieu group therapy, group psychotherapy, and activity group therapy.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify

  1. Progress is documented but treatment goals have not been reached and continued progress and benefit from treatment is likely as shown by the Covered Individual's and family's participation, attendance and evidence of motivation and acceptance of treatment recommendations, and if progress is not being achieved then the treatment plan is being adjusted in such a manner as to likely achieve progress or treatment goals are adjusted that are likely to be achieved.

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, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have all of the following to qualify:

  1. Eating disorder behaviors and body weight are at levels where acute medical intervention is not needed, but without three (3) hour daily structured treatment at least three (3) days a week the Covered Individual is likely to regress or return to needing a higher level of care; AND
  2. Motivation, self care skills and recognition of a need for treatment are sufficient for the Covered Individual to reduce eating disorder behaviors and/or gain weight with outpatient treatment, but has not achieved progress with outpatient treatment up to twice weekly; AND
  3. The Covered Individual has adequate support in their living environment and has access to this level of care; AND
  4. Comorbid psychiatric conditions are stable enough for outpatient treatment and appropriate treatment is being provided to maintain this stability and is not the primary focus of treatment.

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Services are provided by appropriately licensed clinicians for a minimum of three (3) hours/ three (3) days per week; AND
  2. A nutritional assessment is done on admission and if low body weight is a reason for admission then specific dietary intake and target weight goals are identified, with once weekly measurement of weight and daily charting of calorie intake/percentage of dietary intake goals; AND
  3. A treatment plan includes targets of cognitive behavioral skills for controlling restricting for Covered Individuals with anorexia, which may include supervised meals, and controlling binging, purging and non-purging behaviors for Covered Individuals with anorexia and bulimia, and progress in gaining and utilizing skills is documented; AND
  4. Medical, psychiatric and substance use evaluations are either done on admission or if transferring from another intensive level of care, those evaluations are obtained and recommended interventions incorporated into the treatment plan and appropriate interventions are documented as needed; AND
  5. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  6. Community supports and resources are identified and the treatment plan includes developing or increasing their use; AND
  7. Family therapy is provided at least once per week for children/adolescents and dependent adults and involvement of family members in groups and educational programs is documented (unless contraindicated); AND
  8. Discharge planning including either development of a new outpatient treatment team or coordination with the existing team; AND
  9. The treatment is individualized and not determined by a programmatic timeframe. It is expected that Covered Individuals will be prepared to receive the majority of their treatment in a community setting; AND
  10. The Covered Individual resides in a community setting while receiving intensive outpatient program services and is not in a 24-hour residential treatment setting.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Benefit from treatment is likely as shown by the Covered Individual's and family's participation, attendance and evidence of motivation and acceptance of treatment recommendations, and if progress is not being achieved then the treatment plan is being modified in such a manner as to likely achieve progress.

Not Medically Necessary:

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

 

Outpatient Treatment

MedicallyNecessary:

To qualify, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have all of the following to qualify:

  1. Medically stable; AND
  2. Greater than 85% healthy body weight or BMI greater than 18, unless transferred from a higher level of care where previously assessed to be stable as indicated by normal vital signs, no need for intravenous (IV) or nasogastric feeding, normal lab tests or abnormalities that do not require active medical intervention; AND
  3. Fair to good motivation to recover and cooperative with treatment; AND
  4. Self sufficient in eating/gaining weight and controlling behaviors; AND
  5. Others able to provide adequate support and structure; AND
  6. Lives near treatment setting.

Note: The severity of illness factors important for distinguishing between PHP, IOP and outpatient is the Covered Individuals' 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. Face to face sessions; AND
  2. Treatment plan to address issues involved in the eating disorder including healthy weight and changing body image with specific objective and measurable goals; AND
  3. Coordination with other disciplines to assure nutritional, psychiatric, medical, and substance abuse evaluation and treatment as appropriate; AND
  4. Community resources assessed and recommended, as appropriate; AND
  5. Family therapy is a part of child/adolescent treatment and marital/family therapy for adults by a licensed provider, unless clinically contraindicated; AND
  6. Development of an aftercare/discharge plan; AND
  7. Frequency of visits greater than one time per week is indicated only for crisis stabilization for a period not to exceed 4 weeks unless clinically contraindicated; AND
  8. The frequency of maintenance therapy is less than one time per week; AND
  9. Substance use evaluation and intervention has been completed when appropriate.

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 Covered Individual 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 disorder treatment should not be primarily for the avoidance of incarceration of the Covered Individual 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 Covered Individual's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the Covered Individual'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 Covered Individual'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 Covered Individuals at inpatient facilities. In these guidelines, 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 Covered Individuals 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 Covered Individual 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. Covered Individuals must attend a minimum of 6 hours per day when participating in a partial hospitalization program. Covered Individuals 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 Covered Individuals 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 Covered Individuals with an active psychiatric or substance related illness 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 Covered Individual individually, in family therapy, or in a group modality.

References

 Peer Reviewed Publications:

  1. Kahn, DA, Carpenter D, Docherty JP, Frances A. (1996): The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry, 57 (Suppl 12A).
  2. McEvoy JP, Scheifler PL, Frances A. Treatment of schizophrenia 1999. The expert consensus guideline series. J Clin Psychiatry. 1999; 60 Suppl 11:3-80.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Agency for Healthcare Research and Quality. Management of eating disorders. Technology Assessment Number 135. 2006 April. No. 06-E010. Available at: http://archive.ahrq.gov/downloads/pub/evidence/pdf/eatingdisorders/eatdis.pdf. Accessed on January 13, 2014.
  2. American Academy of Child & Adolescent Psychiatry. Practice Parameters. Available at: http://www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters. Accessed on January 13, 2014.
  3. American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on January 13, 2014.
  4. American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on January 13, 2014.
  5. Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.
  6. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 07-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.
  7. Depression in Primary Care: Detection and Diagnosis. Volume 1. Detection and Diagnosis Clinical Guideline Number 5. AHCPR Publication No. 93-0550: April 1993.
  8. Fishman MJ, Shulman GD, Mee-Lee D, et al. ASAM patient placement criteria: supplement on pharmacotherapies for alcohol use disorders. 1st ed. Philadelphia: Lippincott Williams & Wilkins. 2010.
  9. Hoffman NG, Mee-Lee D, Halikas JA. Patient placement criteria for the treatment of psychoactive substance use disorders. Chevy Chase: American Society of Addiction Medicine. 2001.
  10. Manual of Psychiatric Peer Review (1974). American Psychiatric Association.
  11. Mattson M. Manual of psychiatric quality assurance: American Psychiatric Association committee on quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992.
  12. 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 January 13, 2014.
  13. Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. Intensive outpatient treatment for alcohol and other drug abuse. 1994. DHHS Publication No. (SMA) 94B2077.
  14. Treatment of Major Depression. Volume 2. Treatment of Major Depression Clinical Practice Guideline Number 5. AHCPR Publication No. 93-0551: April 1993.
  15. Weiner RD. Manual of psychiatric quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992. Electroconvulsive therapy guidelines and criteria.
  16. Weiner RD. Practice of electroconvulsive therapy: recommendations for treatment, training, and privileging (A task force report of the American Psychiatric Association). 2nd ed. Arlington: American Psychiatric Publishing. 2001.
Index

Anorexia Nervosa
Bulemia Nervosa
Eating disorder

History

Status

Date

Action

Revised02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) 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.