COVERAGE DETERMINATION GUIDELINE OPTUM™ By United Behavioral Health Residential Treatment of Bulimia Nervosa Guideline Number: BHCDG512012 Product: Approval Date: February, 2011 2001 Generic UnitedHealthcare COC/SPD Revised Date: March, 2014 2007 Generic UnitedHealthcare COC/SPD Table of Contents: 2009 Generic UnitedHealthcare COC/SPD Instructions for Use 1 2011 Generic UnitedHealthcare COC/SPD Plan Document Language 2 Indications for Coverage 3 May also be applicable to other health plans and products Related Coverage Determination Guidelines: Coverage Limitations and Exclusions 14 Definitions 14 References 15 Custodial Care Coverage Determination Guideline Coding 16 Related Medical Policies: Level of Care Guidelines American Psychiatric Association, Practice Guideline for the Treatment of Patients with Eating Disorders, 2006 National Institute for Health and Clinical Excellence. Eating Disorders, 2004. Coverage Determination Protocol, Management of Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, and Eating Disorder NOS, 2009 Optum Eating Disorders Quick Reference Guide, 2012 Eating Disorder Workgroup: Panel of External Subject Matter Experts INSTRUCTIONS FOR USE This Coverage Determination Guideline provides assistance in interpreting behavioral health benefit plans that are managed by Optum. This Coverage Determination Guideline is also applicable to behavioral health benefit plans managed by Pacificare Behavioral Health and U.S. Behavioral Health Plan, California doing business as Optum of California (“Optum-CA”). Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 1 of 18 When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee’s document (e.g., Certificates of Coverage (COCs), Schedules of Benefits (SOBs), or Summary Plan Descriptions (SPDs) may differ greatly from the standard benefit plans upon which this guideline is based. In the event that the requested service or procedure is limited or excluded from the benefit, is defined differently, or there is otherwise a conflict between this document and the COC/SPD, the enrollee's specific benefit document supersedes these guidelines. All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements that supersede the COC/SPD and the plan benefit coverage prior to use of this guideline. Other coverage determination guidelines and clinical guideline may apply. Optum reserves the right, in its sole discretion, to modify its coverage determination guidelines and clinical guidelines as necessary. While this Coverage Determination Guideline does reflect Optum’s understanding of current best practices in care, it does not constitute medical advice. PLAN DOCUMENT LANGUAGE Before using this guideline, please check enrollee’s specific plan document and any federal or state mandates, if applicable. INDICATIONS FOR COVERAGE Key Points According to the DSM, Bulimia Nervosa is a form of eating disorder whose essential features include recurrent binge eating (i.e., eating in a discrete period of time an amount of food that is larger than most people would consume during a similar period of time) and inappropriate compensatory behaviors to prevent weight gain (e.g., self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting or excessive exercise) The binge eating and inappropriate compensatory behaviors both occur an average of twice a week for 3 months and the disturbance does not occur exclusively during an episode of Anorexia Nervosa (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), 2000). The two subtypes of Bulimia Nervosa include: o Purging Type: During the current episode of Bulimia Nervosa, the member has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. o Non-Purging Type: During the current episode of Bulimia Nervosa, the member has used other inappropriate compensatory behaviors such as fasting, excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. Optum maintains that residential treatment of Bulimia Nervosa should be consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines. Members with Bulimia Nervosa should be treated in the least restrictive level of care that is most likely to prove safe and effective. Treatment for Bulimia Nervosa is typically provided in an outpatient setting however; the choice of residential care should be driven by the member’s overall severity of Bulimia Nervosa symptoms level of risk and the severity of physical and psychological complications in addition to at least one of the following: o Severe and deteriorating symptoms of Bulimia Nervosa place the member at high risk for hospitalization if the member does not receive the 24-hour structure, monitoring and supervision provided by a residential treatment program. o The member demonstrates a lack of control over episodes of binging, purging and Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 2 of 18 compensatory behaviors and requires close supervision during and after all meals until a support system can be recruited and the clinical need for 24-hour supervision is no longer required. o The presence of serious impairment in psychological, social, occupational, educational, or other area of functioning, interfering with the member’s ability to safely and adequately care for themselves in a less restrictive level of care (DSM-IVTR, 2000). o The member is not at imminent risk of serious harm to self or others and is sufficiently stable from a medical and psychiatric standpoint and does not require 24hour nursing care and monitoring (intravenous fluids, feeding or multiple daily labs) and is able to participate in a structured milieu (APA, 2006). o Active symptoms of a co-occurring condition are undermining the member’s treatment and ability to safely manage Bulimia Nervosa symptoms in a less restrictive environment (Optum Level of Care Guidelines (LOCGs), 2012). o Community support services that might otherwise augment ambulatory treatment of Bulimia Nervosa and avoid the need for hospitalization are unavailable (LOCGs, 2012). o Adequate treatment at a lower level of care has not produced improvement or there is a history of poor response to treatment due to continued binge eating and/or purging and compensatory behaviors (NICE, 2006). The goals of residential treatment for Bulimia Nervosa are to stabilize the presenting medical and behavioral signs and symptoms to the extent that 24-hour clinical supervision and management is no longer required. The Mental Health/Substance Use Disorder Designee maintains that residential treatment of Bulimia Nervosa is not for the purpose of providing custodial care (Psychiatric Inpatient Treatment Regulations & Guidance Manual, Chapter 16, Centers for Medicare & Medicaid Services (CMS Manual), 2006) , but for active 24-hour care that is: o Supervised and evaluated by a physician (CMS Manual, 2006); o Provided under an individualized treatment or diagnostic plan (CMS Manual, 2006); o Reasonably expected to improve the member’s condition (CMS Manual, 2006); o Unable to be provided in a less restrictive setting (CMS Manual, 2006); o Focused on the presenting symptoms (CMS Manual, 2006); and o Stabilizing the member’s condition to the extent that the member can be safely treated in a lower level of care (CMS Manual, 2006). Best Practices for the treatment of Bulimia Nervosa in a residential setting: Evaluation and Diagnosis Treatment Planning Preferred Forms of Treatment include the following: o Nutritional Rehabilitation o Psychosocial Interventions o Pharmacotherapy Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 3 of 18 o Medical Interventions o Education and Informed Consent o Discharge Planning Residential treatment for Bulimia Nervosa is comprised of 24-hour structured specialized services as described throughout this guideline that are typically provided in a freestanding residential treatment center. Residential programs provide psychosocial, psychoeducation and transition services for patients who require ongoing 24-hour supervision following an acute episode (LOCGs, 2012). The requested residential service or procedure for the treatment of a mental health condition must be reviewed against the language in the enrollee's benefit document. When the requested residential service or procedure is limited or excluded from the enrollee’s benefit document, or is otherwise defined differently, it is the terms of the enrollee's benefit document that prevails. Benefits include the following services provided in a residential setting: Diagnostic evaluations and assessment Treatment planning Referral services Medication management Individual, family, therapeutic group and provider-based case management services Crisis intervention Best Practices for the treatment of Bulimia Nervosa in a residential setting: The specific precipitant(s)/reason(s) for admission should be identified as part of a general risk assessment that identifies the member’s current Bulimia Nervosa symptoms (APA, 2006). Medical and Psychiatric Evaluation and Diagnosis A psychiatric evaluation should be completed and include the following (APA, 2006): o Mental status and determination of the member’s current level of functioning. o Determine potential risk of harm including suicidality and self-harming behaviors. o Identification of impairments in school, work, social and daily functioning. o History of trauma, abuse or other significant life events. Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 4 of 18 o Family support or conflicts in addition to family psychiatric history and other social and cultural factors. o The member’s ability to comprehend and the capacity to make valid treatment decisions are to be evaluated. In these cases, a guardian or a legal representative may substitute to provide informed consent. o Identification of cognitive deficits that may prevent the member from fully engaging in treatment until nutritional balance is achieved. o An evaluation of potential short-term or long-term effects on cognitive functioning as a result of Bulimia Nervosa symptoms and behaviors o A detailed report of food intake, rituals or routines during a single day in the member’s life may help provide specific information as to the member’s eating behaviors. o The evaluation of suicidality, impulsivity, compulsivity, mood, anxiety and substance use to identify co-occurring psychiatric or substance use conditions. A medical evaluation should be completed to determine the physical complications and consequences associated with the symptoms of Bulimia Nervosa and should evaluate the following (Quick Reference Guide (QRG), 2012): o Cardiovascular functioning: Weakness and palpitations due to potassium loss, cardiomyopathy especially in those who use syrup or ipecac to induce vomiting, cardiac arrhythmias, bradycardia, hypotension, and postural changes. This should be monitored closely by the RTC when the program is equipped or monitored by a cardiologist skilled in managing patients with Bulimia Nervosa. o Central nervous system: Hypothermia, apathy, poor concentration with a decrease in white and gray matter, and decreased memory and poor new learning. Nervous system functioning may impact the level of engagement in treatment and in post-discharge care. o Gastrointestinal functioning: Heartburn, gastritis, esophogitis, esophageal or gastric tears, esophageal rupture, abdominal pain, enlarged salivary glands, pancreatitis, toxic mega colon due to laxative abuse, and liver damage. Any issues should be identified and treated accordingly. o Metabolic/Weight Fluctuations: Poor skin turgor, edema with dehydration and electrolyte abnormalities (decrease in potassium, magnesium, calcium and phosphate) as a result of vomiting and laxative abuse. o Oral/Dental: Dental decay with erosion of enamel, enlarged salivary glands and tooth loss. Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 5 of 18 o Reproductive functioning: Fertility problems with scanty or absent menstrual periods. o The medical evaluation may indicate that the following laboratory tests be conducted (Eating Disorder Panel, 2010): Full Blood Count (CBC) Electrolytes (sodium, potassium and chloride levels) Magnesium Levels Phosphorus Levels Amylase (carbohydrate enzymes) Alkaline Levels due to vomiting (metabolic alkalosis) Acidity Levels due to laxative abuse (metabolic acidosis) o Although a physical exam may appear normal, other common physical signs include fatigue, lethargy, bloating, constipation, abdominal pain, calluses on the back of hands, swelling of the hands and feet, erosion of dental enamel, low BMI and menstrual disturbance (APA, 2006). o The RTC may be equipped to manage medical concerns, however depending on the severity of medical needs a medical admission or the involvement/consultation of a Bulimia Nervosa expert may be indicated (Eating Disorder Panel, 2012). Family Evaluation A complete clinical picture of the member involves the evaluation of the family key to the member’s treatment, recovery/resiliency and relapse prevention (APA, 2006). The family evaluation should include all relevant family members and assess: o Family history of eating disorders, substance use disorders and psychiatric disorders (APA, 2006); o Family structure, functioning, and conflicts (APA, 2006); o Family attitudes toward eating, exercise and appearance (APA, 2006); o The member’s symptom progression, treatment history and treatment efficacy from the family’s perspective (APA, 2006); o The family’s history of engagement and involvement in the member’s treatment (APA, 2006); o Direct observations of family/member interactions. o The family’s ability and willingness to actively participate in family therapy and the member’s treatment including implementation of the treatment plan in the home setting after discharge (APA, 2006). Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 6 of 18 The findings from the medical and psychiatric evaluations are to support a diagnosis of Bulimia Nervosa (307.51). The provider should determine whether the member’s Bulimia Nervosa is persistent by assessing: o The length of time the member has had Bulimia Nervosa; and o The history of and response to treatment. A persistent form of Bulimia Nervosa is typically characterized by an enduring course of illness despite appropriate treatment. If the member is identified as having a persistent form of Bulimia Nervosa, the provider may need to consider whether treatment in the proposed level of care can be reasonably expected to improve the member’s condition. If so, the treatment plan may need to focus on helping the member regain a baseline level of functioning rather than achieving a cessation of symptoms. All relevant general medical services including assessment, treatment, and specialty medical consultation services are to be available as needed and provided with an urgency that is commensurate with the member’s medical need (LOCGs, 2012). Treatment Planning Within the first 48 hours of admission the provider and, whenever possible, the member should document clear, reasonable and objective treatment goals and timeframes that stem from the member’s diagnosis, and are supported by specific treatment strategies which address the member’s acute symptoms and the precipitant for admission (CMS Manual, 2006). o The treatment plan and appropriateness of level of care should be continuously reassessed if new information becomes available or if the member’s status changes (CMS LCD, 2012). o The treatment plan should always address co-occurring behavioral and medical conditions including substance disorders (LOCGs, 2012). o The treatment plan should consider the member’s age and stage of development (LOCGs, 2012). Treatment goals should focus on healthy eating and where necessary, weight gain and include objectives, actions and timeframes to address all of the following (LOCGs, 2012): o Inventorying the member’s motivation and readiness to change as well as the member’s strengths and other psychosocial resilience factors such as the member’s support network. o A determination as to whether the member has an advance directive, a recovery plan, and a plan for managing relapse. Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 7 of 18 o How symptom reduction and rapid stabilization will be achieved. o How co-occurring behavioral health and medical conditions, if any, will be managed. o How the member’s ability to manage their condition will be improved such as by providing health education, and linking the member with peer services and other community resources. o How risk issues related to the member’s presenting condition, cooccurring behavioral health or medical conditions will be managed including how the member’s motivation will be maintained/enhanced, provision of close supervision of weight and eating behavior, addressing medication effects or possible side effects, and collaborating with the member to develop/revise the advance directive or relapse prevention plan. Contacting the member’s family and/or social support network, with the member’s documented consent, within the first 48 hours of admission to regularly participate in the member’s treatment and discharge planning when such participation is essential and clinically appropriate (LOCGs, 2012). Parents/guardians of child and adolescent members should be contacted within 24 hours of admission, and should participate in the member’s treatment at least 1 time per week unless clinically contraindicated. Optimally, the member’s family and/or social support group should participate in treatment twice per week when the member is a child or adolescent (LOCGs, 2012). Contacting the member’s outpatient provider and primary care provider, with the member’s documented consent, within the first 48 hours of admission if the member was in treatment prior to admission to obtain information about the member’s presenting condition and its treatment (LOCGs, 2012). Initially identifying the next appropriate level of care within 24 hours of admission including an anticipated date of discharge and actions to be taken to facilitate the member’s transition, and what behaviors will be observed to indicate that the member is ready for discharge (LOCGs, 2012). The provider and, whenever possible, the member collaborate to update the treatment plan in response to changes in the member’s condition, or provide compelling evidence that continued treatment in the current level of care is required to prevent acute deterioration or exacerbation of the member’s current condition (CMS, 2012). Preferred Forms of Treatment Nutritional Rehabilitation Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 8 of 18 o Nutritional rehabilitation to begin the restoration of weight if necessary and healthy eating patterns, reducing dietary restriction and urges to binge and purge (APA, 2006). o Assess fluid and electrolyte balance when vomiting is frequent or there is frequent use of laxatives (APA, 2006). o If the member has been abusing laxatives, these should be tapered gradually (APA, 2006). o When the member’s body weight is below 85% of ideal body weight, aim for an average weekly weight gain of 2-4 pounds. There may variations in weight gain expectations, but the goals should be to increase weight at a rate that is realistic for the member (Eating Disorder Panel, 2010). o Provide close physical supervision and monitoring to include the management of adverse symptoms (APA, 2006). Psychosocial Interventions o A structured symptom-focused treatment regimen with the expectation of weight gain should be provided in the residential setting (NICE, 2004) For members with a persistent form of Bulimia Nervosa, the treatment plan may need to focus on helping the member regain a baseline level of functioning rather than achieving a cessation of symptoms. o Psychotherapy may include individual, family and group therapy approaches with the following considerations: Psychotherapy should only be initiated after the cognitive and affective sequelae of starvation have been addressed by refeeding, if indicated. Attempts to conduct formal psychotherapy with starving members who may be negativistic, obsessive, or mildly cognitively impaired may be ineffective (APA, 2006). The focus of psychotherapy should be on weight gain, healthy eating, and reducing other symptoms related to Bulimia Nervosa such as laxative abuse, over exercising or purging (NICE, 2004). Education about the Bulimia Nervosa, its treatment, and approaches to self-care should be provided alongside psychotherapy (NICE, 2004). Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 9 of 18 Individual therapy such as Cognitive Behavioral and Interpersonal therapy, or a combination of these approaches have the most evidence and consensus for use with adults (NICE, 2004; APA, 2006). o Family therapy is essential to promoting a supportive recovery environment upon discharge by addressing familial factors that are contributing to the maintenance of Bulimia Nervosa in the member as identified in the family evaluation (APA, 2006). Family and/or caregiver interventions should be included in the treatment plan as family members are vital to the successful treatment, discontinuation or transition to the next most appropriate level of care. Participation in treatment should be at least 1 times per week unless clinically contraindicated (Optum QRG, 2012). Family sessions may include psychoeducational, problemsolving, crisis management work, and specific interventions with the member. The focus is on Bulimia Nervosa and how this impacts family relationships, emphasizing the necessity for the family to take a central role in supporting the member’s treatment (NICE, 2007). For children and adolescents, family therapy is the most effective intervention. Families who become actively involved in a blame-free atmosphere, in helping patients eat more and resist compulsive exercising and purging is preferred (APA, 2006). Every effort should be made to locate a facility that meets the patient’s clinical needs that is accessible to parents and family members in order for full participation in family sessions and other contact identified in the treatment plan (Optum, QRG, 2012). If the facility that best meets the patient’s needs is not easily accessible to the family due to distance or transportation concerns, all efforts should be made by the treatment facility to engage the family in face-to-face sessions and visits in addition to frequent telephonic sessions and contact as appropriate. o For a persistent form of Bulimia Nervosa, interventions that help the member achieve their baseline level of functioning and an ability to function within the context of the lifestyle may become the primary goals of treatment (Eating Disorder Panel, 2010). Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 10 of 18 As part of the discharge plan, referrals to group therapy, selfhelp programs and support groups as an adjunct to treatment may also be considered to help members cope with the persistent course of Bulimia Nervosa (APA, 2006). – It is important to discuss and caution against the use of “pro-ana” “pro-mia” internet sites as a source of support as these sites encourage and promote eating disordered lifestyles (APA, 2006). Pharmacotherapy o Medications may be used to provide relief from common co-occurring symptoms such as depression or anxiety Include (APA, 2006): SSRIs have the most evidence for efficacy with the fewest adverse effects for symptoms of depression and anxiety. Bupropion and Tricyclic antidepressants should be avoided due to an increased risk of seizures and potential toxicity or overdose in underweight members. o Consider the member’s physical condition and potential adverse effects prior to choosing an agent (APA, 2006). o Medications should not be used as a sole or primary treatment, but as an adjunct to psychotherapy, medical management or nutritional management when applicable (NICE, 2004). o Antipsychotic medications, particularly second-generation antipsychotics, can be useful during the weight-restoration phase or in the treatment of other associated symptoms, such as marked obsessionality, anxiety, limited insight, and psychotic-like thinking (APA, 2006). Antipsychotics such as olanzapine may promote weight gain in adults and in adolescent members and may improve associated symptoms (APA, 2006). Medical Management o Where care is shared between primary medical providers, medical specialists and/or behavioral health providers, there should be a clear agreement between treating providers for monitoring members with this condition (NICE, 2004). o Consider a medical admission if the member is at high physical risk or is at moderate risk and the member’s weight continues to fall (APA, 2006). o Involve or consult with a physician with expertise in the treatment of medically at-risk members (NICE, 2004). Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 11 of 18 o Aim for an average weekly weight gain of 2-4 pounds per week in residential settings in order to avoid refeeding syndrome, however this goal may vary according to the member (NICE, 2004). o Provide regular physical monitoring of weight gain as well as adverse symptoms (NICE, 2004). Discharge Planning o The discharge plan is derived from the member’s response to treatment, prior history of treatment, and the availability of services in the member’s community (LOCGs, 2012). o Members whose clinical condition improves, who no longer pose an impending threat to self or others, and who do not still require 24-hour observation available in a residential should be stepped down to a lower level of care (CMS, 2012). o The discharge plan must include the anticipated discharge date and the following (LOCGs, 2012): The next level of care, its location, and the name(s) and contact information of the provider(s) who will deliver treatment; The rationale for the referral; The date and time of the first appointment for treatment as well as the first follow-up psychiatric assessment within 7 days of discharge; The recommended modalities of care and the frequency of each modality; The names, dosages and frequencies of each medication, and a schedule for appropriate lab tests if pharmacotherapy is a modality of post-discharge care Linkages with peer services and other community resources. The plan to communicate all pertinent clinical information to the provider(s) responsible for post-discharge care, as well as to the member’s primary care provider as appropriate. The plan to coordinate discharge with agencies and programs the member has been involved, when appropriate and with the member’s documented consent. A prescription for a supply of medication sufficient to bridge the time between discharge and the scheduled follow-up psychiatric assessment. Confirmation that the member or authorized representative understands the discharge plan. Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 12 of 18 Confirmation that the member or authorized representative was provided with written instruction for what to do in the event that a crisis arises prior to the first post-discharge appointment. State and federal mandates supersede the generic Certificate of Coverage and compliance with applicable legislation is required. The residential treatment of Bulimia Nervosa must be reviewed against the language in the enrollee's benefit document. When the residential treatment of Bulimia Nervosa is limited or excluded from the enrollee’s benefit document, or is otherwise defined differently, it is the terms of the enrollee's benefit document that prevails. In Some Situations Optum May Offer: Peer Review: Optum will offer a peer review to the provider when services do not appear to conform to this guideline. The purpose of a peer review is to allow the provider the opportunity to share additional or new information about the case to assist the Peer Reviewer in making a determination including, when necessary, to clarify a diagnosis. Second Opinion Evaluation: Optum facilitates obtaining a second opinion evaluation when requested by an enrollee, provider, or when Optum otherwise determines that a second opinion is necessary to make a determination, clarify a diagnosis or improve treatment planning and care for the enrollee. Referral Assistance: Optum provides assistance with accessing care when the provider and/or enrollee determine that there is not an appropriate match with the enrollee’s clinical needs and goals, or if additional providers should be involved in delivering treatment. Residential admissions require pre-service notification. Notification of a scheduled admission must occur at least five (5) business days before admission. Notification of an unscheduled admission (including Emergency admissions) should occur as soon as is reasonably possible. In the event that the Mental Health/Substance Use Disorder Designee is not notified of a residential admission, benefits may be reduced. Check the member’s specific benefit plan document for the applicable penalty and provision for a grace period before applying a penalty for failure to notify the Mental Health/Substance Use Disorder Designee as required. Covered Health Service(s) – UnitedHealthcare 2001 Those health services provided for the purpose of preventing, diagnosing or treating a sickness, injury, mental illness, substance abuse, or their symptoms. A Covered Health Service is a health care service or supply described in Section 1: What's Covered--Benefits as a Covered Health Service, which is not excluded under Section 2: What's Not Covered--Exclusions. Covered Health Service(s) – UnitedHealthcare 2007 and 2009 Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 13 of 18 Those health services, including services, supplies, or Pharmaceutical Products, which we determine to be all of the following: Provided for the purpose of preventing, diagnosing or treating a Sickness, Injury, mental illness, substance abuse, or their symptoms. Consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines as described below. Not provided for the convenience of the Covered Person, Physician, facility or any other person. Described in this Certificate of Coverage under Section 1: Covered Health Services and in the Schedule of Benefits. Not otherwise excluded in this Certificate of Coverage under Section 2: Exclusions and Limitations. In applying the above definition, "scientific evidence" and "prevailing medical standards" shall have the following meanings: "Scientific evidence" means the results of controlled clinical trials or other studies published in peer-reviewed, medical literature generally recognized by the relevant medical specialty community. "Prevailing medical standards and clinical guidelines" means nationally recognized professional standards of care including, but not limited to, national consensus statements, nationally recognized clinical guidelines, and national specialty society guidelines. The Mental Health/Substance Use Disorder Designee maintains clinical protocols that include the Level of Care Guidelines and Best Practice Guidelines which describe the scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding residential treatment. These clinical protocols are available to Covered Persons upon request, and to Physicians and other behavioral health care professionals on ubhonline. COVERAGE LIMITATIONS AND EXCLUSIONS Inconsistent or Inappropriate Services or Supplies – 2001, 2007, 2009 & 2011 Services or supplies for the diagnosis or treatment of Mental Illness that, in the reasonable judgment of the Mental Health/Substance Use Disorder Designee, are any of the following: Not consistent with generally accepted standards of medical practice for the treatment of such conditions. Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 14 of 18 Not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and are therefore considered experimental. Not consistent with the Mental Health/Substance Use Disorder Designee’s level of care guidelines or best practice guidelines as modified from time to time. Not clinically appropriate for the member’s Mental Illness or condition based on generally accepted standards of medical practice and benchmarks. Additional Information: The lack of a specific exclusion that excludes coverage for a service does not imply that the service is covered. The following are examples of services that are inconsistent with the Level of Care Guidelines and Best Practice Guidelines (not an all inclusive list). Services that deviate from the indications for coverage summarized in the previous section. Confinement in a residential facility without appropriate management of acute symptoms. Confinement in a residential facility for the sole purpose of awaiting placement in a long-term facility. Confinement in a residential facility that does not provide adequate nursing care and monitoring, or physician coverage. Please refer to the enrollee’s benefit document for ASO plans with benefit language other than the generic benefit document language. DEFINITIONS Bulimia Nervosa Bulimia Nervosa is a form of eating disorder whose essential features include recurrent binge eating with a lack of control over eating and inappropriate compensatory behaviors to prevent weight gain such as selfinduced vomiting, misuse of laxatives, diuretics, enemas or other medications; fasting or excessive exercise. Cognitive behavior therapy (CBT) A psychological intervention that is designed to enable people to establish links between their thoughts, feelings or actions and their current or past symptoms and to re-evaluate their perceptions, beliefs or reasoning about the target symptoms. The intervention should involve at least one of the following: (1)monitoring thoughts, feelings or behavior with respect to the symptom; (2) being helped to use alternative ways of coping with the target symptom; (3) reducing stress. Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 15 of 18 Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) A manual produced by the American Psychiatric Association which provides the diagnostic criteria for mental health and substance use disorders, and other problems that may be the focus of clinical attention. Unless otherwise noted, the current edition of the DSM applies. Interpersonal psychotherapy A specific form of psychotherapy that is designed to help members identify and address current interpersonal problems. It was originally developed for the treatment of depression. Nutritional Counseling A form of treatment in which the primary goal is the modification of what the member eats as well as relevant eating habits and attitudes. It is usually implemented by dietitians REFERENCES 1. Generic UnitedHealthcare Certificate of Coverage, 2001 2. Generic UnitedHealthcare Certificate of Coverage, 2007 3. Generic UnitedHealthcare Certificate of Coverage, 2009 4. Generic UnitedHealthcare Certificate of Coverage, 2011 5. Level of Care Guidelines 6. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Eating Disorders, 2005. Retrieved from http://www.psychiatryonline.com/pracGuide/pracGuideTopic_12.aspx 7. Coverage Determination Protocol, Management of Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, and Eating Disorder NOS, 2009 8. National Institute for Health and Clinical Excellence. Eating disorders: Core interventions in the treatment and management of anorexia nervosa, Bulimia Nervosa and related eating disorders, 2004. Retrieved from http://www.nice.org.uk/CG009. 9. Eating Disorder Panel of Subject Matter Experts, 2010 & 2012. 10. Optum Eating Disorders Quick Reference Guide, 2012. CODING The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this guideline are for reference purposes only. Listing of a service code in this guideline does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document. Limited to specific CPT and HCPCS codes? □ YES x NO 90791 Psychiatric diagnostic evaluation 90791 plus interactive add-on code (90875) Psychiatric diagnostic evaluation (interactive) 90832 Psychotherapy, 30 minutes with patient and/or family 90832 plus interactive add-on code (90875) Psychotherapy, 30 minutes with patient and/or Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 16 of 18 90832 plus pharmacological add-on code (90863) 90834 90834 plus interactive add-on code (90875) 90834 plus pharmacological add-on code (90863) 90837 90837 plus interactive add-on code (90875) 90837 plus pharmacological add-on code (90863) 90839 90839 plus interactive add-on code (90875) 90846 90847 90849 90853 90853 plus interactive add-on code (90875) Limited to specific diagnosis codes? 307.51 family (interactive) Psychotherapy, 30 minutes with patient and/or family (pharmacological management) Psychotherapy, 45 minutes with patient and/or family member Psychotherapy, 45 minutes with patient and/or family member (interactive) Psychotherapy, 45 minutes with patient and/or family member (pharmacological management) Psychotherapy, 60 minutes with patient and/or family member Psychotherapy, 60 minutes with patient and/or family member (interactive) Psychotherapy, 60 minutes with patient and/or family member (pharmacological management) Psychotherapy for crisis, first 60 minutes Psychotherapy for crisis, first 60 minutes (interactive) Family psychotherapy without the patient present Family psychotherapy, conjoint psychotherapy with the patient present Multiple-family group psychotherapy Group psychotherapy (other than of a multiplefamily group) Group psychotherapy (other than of a multiplefamily group) (interactive) x YES □ NO Bulimia Nervosa Limited to place of service (POS)? x Limited to specific provider type? □ Limited to specific revenue codes? x YES □ NO Residential Treatment 1001 YES □ NO Mental Health Residential Treatment Center YES x NO HISTORY Revision Date 1/15/2012 3/19/2013 Name L. Urban J. Niewenhous Revision Notes Version 2-3 Version 2-4 The enrollee's specific benefit documents supersede these guidelines and are used to make coverage determinations. These Coverage Determination Guidelines are believed to be current as of the date noted. Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 17 of 18 Residential Treatment of Bulimia Nervosa Coverage Determination Guideline Confidential and Proprietary, © OptumHealth 2013 Optum is a brand used by United Behavioral Health and its affiliates. Page 18 of 18
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