BHCP Eating Disorders Medical Necessity Criteria



BHCP Eating Disorders Medical Necessity Criteria

Acute Inpatient Level of Care

Medical Necessity Criteria for Admission:

1. There is a DSM-IV diagnosis of Anorexia Nervosa (307.1) or Bulimia Nervosa, Purging Type (307.51) or Eating Disorder NOS (307.5). Compulsive overeating and obesity do not meet medical necessity criteria. Bulimia Nervosa, Non-Purging Type must be accompanied by repetitive,

behaviors such as fasting, excessive exercising, or other means of offsetting excessive caloric intake which seriously impair functioning or is accompanied by medical complications.

2. At least one of the following:

a. The presence of a psychiatric condition presenting a risk of harm to self and/or others, and which

requires treatment in a structured 24-hour inpatient unit.

b. Body weight is less than 75% of IBW or BMI is less than 16. For children and adolescents, a

rapid, continuing, recent weight decline due to food refusal.

c. Medical complications of an eating disorder that require 24-hour medical monitoring that may

include but are not limited to:

Disturbances in heart rate, blood pressure, glucose, potassium, electrolyte balance,

temperature and hydration; clinically significant compromise in liver, kidney or

cardiovascular function and/or poorly controlled diabetes.

d. Weight loss or fluctuation of more than 15% in one month that is unexplained by any other

medical condition or patient is rapidly approaching a weight at which medical instability has

occurred in the past.

e. The patient’s eating disorder is not responding to a reasonable trial of treatment in a less

intensive setting (residential, partial hospital, IOP) or there is clinical evidence that would

strongly indicate that the patient would not respond to a less intensive level of care.

Medical Necessity Criteria for Continued Stay:

1. All medical necessity criteria and service components for inpatient level of

care are met.

2. Discharge goals are not yet achieved, but progress (e.g. medical stabilization,

weight gain, increase in BMI, increased caloric intake) in treatment is

occurring in a timely manner and is documented in the medical record, or the

treatment plan is being changed to address continuing symptoms interfering

with achieving discharge goals.

3. Clinical evidence based on the course of treatment in the program that the patient is at

imminent risk of at least one of the medical necessity criteria indicated in the

patient’s admission evaluation if discharged. If calorie or body weight goals have been

achieved, there must be clear rationale as to why discharge would lead to rapid and

significant caloric reduction and weight loss.

4. For continued stay to be considered medically necessary, compliance with

treatment, identifiable progress towards measurable goals established for

discharge, and identifiable progress toward implementing discharge plans

must be demonstrated.

5. If the patient is not improving within reasonably expected time frames, there

must be a thorough assessment of reasons for the lack of or slow

improvement, and specific modifications made to the treatment plan to address and

improve the clinical course.

6. For children, adolescents or dependent adults, every reasonable effort has been made

to involve the family in treatment.

7. Medical and/or medication stabilization goals which can be reasonably achieved in

this setting have not been met and discharge to a less intensive level of care would put the

patient at risk.

Residential Level of Care

Medical Necessity Criteria for Admission:

1. There is a DSM-IV diagnosis of Anorexia Nervosa (307.1) or Bulimia Nervosa, Purging Type (307.51) or Eating Disorder NOS (307.5).

a. Compulsive overeating and obesity do not meet medical necessity criteria.

b. Bulimia Nervosa, Non-Purging Type must be accompanied by repetitive behaviors such

as fasting, excessive exercising, or there is evidence of other means of offsetting

excessive caloric intake which seriously impair functioning or is accompanied by medical

complications.

2. Weight is below 85% of IBW, or BMI is below 18, or there has been a recent, rapid

weight loss of 20% or more of IBW.

3. The patient is medically stable.

4. The patient is sufficiently psychiatrically stable so that inpatient psychiatric

care is not indicated.

5. The eating disorder behavioral, nutritional and psychological symptoms continue to severely

impair functioning. Patients with Anorexia Nervosa or Bulimia Nervosa, Purging Types, binge

eating and purging are occurring at least 3x daily, resulting in significantly impaired functioning.

6. If there has been abuse of substances (e.g., diuretics, emetics, laxatives) it has not been

effectively brought under control on an outpatient basis.

7. The patient’s symptoms have not been effectively brought under control after at least 1-2 months

at PHP or OP level of care, and the medical necessity criteria noted above are met.

Medical Necessity Criteria for Continued Stay:

1. The patient continues to meet criteria for a DSM-IV-TR diagnosis of

Anorexia Nervosa (307.1) or Bulimia Nervosa, Purging Type (307.51) or

Eating Disorder NOS (307.5).

2. Residential Discharge goals are not yet achieved, but progress in treatment

(including a weight gain of 1-2 pounds per week toward achieving IBW, if

low body weight was present on admission) is occurring in a timely manner

and is documented in the medical record, or the treatment plan is being

changed to address continuing symptoms interfering with achieving discharge

goals.

3. For continued stay to be considered medically necessary, compliance with

treatment, identifiable progress towards measurable goals established for

discharge, and identifiable progress toward implementing discharge plans

must be demonstrated.

Indications for Discharge to a Less Intensive Treatment Setting:

1. Treatment goals are largely met although there may be continued

preoccupation with eating disorder symptoms, but not to the degree that could

not be managed at a lower level of care.

2. Progress toward all goals is met, or if not achieved, the treatment plan is

revised and goals are achievable in a less intensive setting.

3. Using nationally recognized best practices, it is generally estimated that

approximately 7 days after achieving basic weight goals will allow sufficient

time for assessing the psychological and behavioral stability of the patient and

readiness for discharge.

4. The patient and/or the family have been assessed as unwilling or unable to

adhere to the individualized treatment plan, despite intensive therapeutic

interventions.

5. Documented deterioration in the patient’s clinical condition require

consideration of transfer to other levels of care.

Partial Hospitalization Program Level of Care

Medical Necessity Criteria for Admission:

1. The patient has a DSM-IV-TR diagnosis of Anorexia Nervosa (307.1) or

Bulimia Nervosa, Purging Type (307.51) or Eating Disorder NOS

(307.5).Bulimia Nervosa, Non-Purging Type, must be accompanied by

repetitive behaviors such as fasting, excessive exercising, or there is other means of

offsetting excessive caloric intake which seriously impair functioning or is accompanied by

medical complications. Compulsive overeating and obesity do not meet medical necessity

criteria.

2. The clinical status of the patient does not require acute medical intervention,

but a structured therapeutic program of at least 6 hours per day, 5 days per

week, is needed to provide effective treatment and prevent regression leading

to the need for a higher level of care.

3. The patient is motivated, self-care skills and acknowledgement of a need for treatment

are present. The patient has been unable to reduce eating disorder

behaviors, gain weight or achieve progress with IOP or outpatient treatment through

twice per week appointments.

3. Co-occurring psychiatric conditions are sufficiently stable for outpatient treatment,

appropriate treatment is being provided to maintain stability and this is not the

primary focus of treatment.

4. The patient has an ability, or has achieved an improved ability, to sufficiently

control eating disorder behaviors, such as refrain from acting on eating

disorder behavior impulses while at home in the evenings or on weekends.

5. The patient has adequate support in their living situation and has reasonable access

to this level of care.

Medical Necessity Criteria for Continued Stay:

1. Progress in treatment is occurring, or the treatment plan is reviewed and

amended, to eliminate barriers to achieving discharge goals.

2. The patient is motivated, and along with the family, is actively engaged in the

treatment process.

3. Attempts to decrease the intensity of daily service have been unsuccessful, as

documented in the clinical record, and continued stay at this level of care is

needed to prevent deterioration in the patient’s condition.

Indication for Discharge or Transfer to a Less Intensive Level of Care:

1. Progress toward all goals is met, or if not achieved, the treatment plan is

revised and goals are achievable in a less intensive setting.

2. Treatment goals are largely met, although preoccupation with eating disorder

symptoms continue, but not to the degree that could not be well managed at a lower

level of care.

Intensive Outpatient Program Level of Care

Medical Necessity Criteria for Admission:

1. The patient has a DSM-IV-TR diagnosis of Anorexia Nervosa (307.1) or

Bulimia Nervosa, Purging Type (307.51) or Eating Disorder NOS

(307.5).Bulimia Nervosa, Non-Purging Type, must be accompanied by

repetitive behaviors such as fasting, excessive exercising, or there is other means of

offsetting excessive caloric intake which seriously impair functioning or is accompanied by

medical complications. Compulsive overeating and obesity do not meet medical necessity

criteria.

2. The clinical status of the patient does not require acute medical intervention,

but a structured therapeutic program of at least 3 hours per day, 3 days per

week, is needed to provide effective treatment and prevent regression leading

to the need for a higher level of care.

3. The patient is motivated, self-care skills and acknowledgement of a need for treatment

are present. The patient has been unable to reduce eating disorder

behaviors, gain weight or achieve progress with outpatient treatment through

twice per week appointments.

4. Co-occurring psychiatric conditions are sufficiently stable for outpatient treatment,

appropriate treatment is being provided to maintain stability and this is not the

primary focus of treatment.

5. The patient has an ability, or has achieved an improved ability, to sufficiently

control eating disorder behaviors, such as refrain from acting on eating

disorder behavior impulses while at home.

6. The patient has adequate support in their living situation and has reasonable access

to this level of care.

Medical Necessity Criteria for Continued Stay:

1. Progress in treatment is occurring, or the treatment plan is reviewed and

amended, to eliminate barriers to achieving discharge goals.

2. The patient is motivated, and along with the family, is actively engaged in the

treatment process.

3. Attempts to decrease the intensity of daily service have been unsuccessful, as

documented in the clinical record, and continued stay at this level of care is

needed to prevent deterioration in the patient’s condition.

Indication for Discharge or Transfer to a Less Intensive Level of Care:

1. Progress toward all goals is met, or if not achieved, the treatment plan is

revised and goals are achievable in a less intensive setting.

2. Treatment goals are largely met, although preoccupation with eating disorder

symptoms continue, but not to the degree that could not be well managed at a lower

level of care.

Outpatient Treatment Level of Care

Medical Necessity Criteria for Admission:

1. The patient has a DSM-IV-TR diagnosis of Anorexia Nervosa (307.1) or

Bulimia Nervosa, Purging Type (307.51) or Eating Disorder NOS

(307.5).Bulimia Nervosa, Non-Purging Type. Compulsive overeating and obesity do not

meet medical necessity criteria.

2. The patient is medically stable and any co-occurring mental health issues are well managed

through supportive community providers.

3. The patient is above 85% healthy body weight or a BMI over 18, unless transferred

from a higher level of care where previously assessed to be stable and requires

no medical interventions.

4. Fair to good motivation to recover, cooperative with treatment, self-sufficient in

eating or gaining weight and controlling eating disorder behaviors.

5. Reasonable ability to access and utilize available community support systems.

Medical Necessity Criteria for Continued Stay:

1. Patient must continue to meet admission criteria noted above.

2. Progress with eating disorders symptoms and behaviors is documented demonstrating

that patient is benefiting from treatment. If progress is not occurring then the treatment

plan is being re-evaluated and restructured with achievable treatment goals.

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