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COVERAGE
DETERMINATION
GUIDELINE
OPTUM™
By United Behavioral Health
Residential Treatment of Anorexia Nervosa
Guideline Number: BHCDG222012
Product:
Approval Date: October, 2010
2001 Generic UnitedHealthcare COC/SPD
Revised Date: December, 2012
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
15
Definitions
16
References
17
Custodial Care Coverage Determination
Guideline
Coding
17
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
Family Based Treatment Technology
Assessment, Optum Clinical Technology
Assessment Committee, 2012
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 Optum or U.S. Behavioral Health Plan,
California.
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
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Oputm is a brand used by United Behavioral Health and its affiliates.
Page 1 of 19
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 of a conflict, the enrollee's specific benefit document
supersedes these guidelines.
All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements
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, Anorexia Nervosa is a form of eating disorder whose essential
features include a refusal to maintain a minimally normal body weight, an intense fear of
gaining weight, and a significant disturbance in the perception of the shape or size of one’s
body (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR),
2000).

The Mental Health/Substance Use Designee maintains that residential treatment of Anorexia
Nervosa should be consistent with nationally recognized scientific evidence as available, and
prevailing medical standards and clinical guidelines.

Members with Anorexia Nervosa should be treated in the least restrictive level of care that is
most likely to prove safe and effective. Choice of residential treatment for Anorexia is driven
by the severity of symptoms present, the level of risk to the member, and the combination of
severity of physical and psychological complications. Additionally the presence of at least
one of the following:
o
Severe and deteriorating symptoms of Anorexia 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
Significant impairment in psychological, social, occupational, educational, or
other area of functioning is interfering with the member’s ability to safely and
adequately care for themselves in a less restrictive level of care (DSM-IV-TR,
2000).
o
Active symptoms of a co-occurring condition are undermining the member’s
treatment and ability to safely manage Anorexia symptoms in a less restrictive
environment (Optum Level of Care Guidelines (LOCGs), 2012).
o
No imminent risk of harm is present however the severity of the presenting
symptoms may compromise the safety of the member and others without 24-hour
clinical supervision and management (Optum Level of Care Guidelines (LOCGs),
2012).
o
The patient is sufficiently stable from a medical and psychiatric standpoint and
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 2 of 19
does not require 24-hour nursing care and monitoring and is able to participate in
a structured milieu (e.g., IV fluids, N.G. tube, or multiple daily lab tests are not
needed.) (American Psychiatric Association, Eating Disorders (APA), 2006).
o
Community support services that might otherwise augment ambulatory treatment
of anorexia nervosa and avoid the need for RTC 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 weight loss and
a decrease in the intake of food despite participation in treatment (NICE, 2006).

The goal of residential treatment for Anorexia Nervosa is to stabilize the presenting
symptoms, to enhance members’ motivation and cooperation with healthy eating patterns,
and to participate in treatment so that 24-hour clinical supervision and monitoring is no longer
required.

The Mental Health/Substance Use Disorder Designee maintains that residential treatment of
Anorexia is not for the purpose of providing custodial care, but for active 24-hour care that is
(LOCGs, 2012):
o
Supervised and evaluated by a physician;
o
Provided under an individualized treatment or diagnostic plan;
o
Reasonably expected to improve the member’s condition;
o
Unable to be provided in a less restrictive setting;
o
Focused on the presenting symptoms; and
o
Stabilizing the member’s condition to the extent that the member can be safely
treated in a lower level of care.
Best Practices detailed in this guideline include:

Medical/Psychiatric Evaluation and Diagnosis

Treatment Planning

Interventions:

o
Medical Management
o
Nutritional Rehabilitation
o
Psychosocial Interventions
o
Pharmacotherapy
Discharge Planning
Residential treatment for Anorexia 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
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 3 of 19
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 Anorexia 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 Anorexia
symptoms (e.g., pattern of restriction, exercise, use of laxatives, current
weight and BMI) (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.
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 Anorexia symptoms and behaviors
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 4 of 19
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 Anorexia
and should evaluate the following (Optum Quick Reference Guide (QRG),
2012):
o Systemic Functioning: Vital signs, level of hydration and rate of weight
loss.
o Cardiovascular Functioning: Bradycardia and cardiomyopathy which
can determine if the symptoms are acute or chronic.
o Central Nervous System: Hypothermia, apathy, depression anxiety,
obsession, irritability and poor concentration may indicate
comorbidities requiring medication intervention.
o Endocrine/Metabolic Functioning: Fatigue, cold intolerance and
diuresis.
o Gastrointenstinal Functioning: Abdominal pain, bloating, constipation
with gastric distension, parotid enlargement, tooth decay and gum
inflammation in Anorexia with vomiting.
o Reproductive Functioning: Arrested sexual development, menstrual
irregularity, fertility problems, and pregnancy complications.
o Hematological Functioning: Bruising, cold intolerance, decreased
white blood cell counts.
o Skin Reactions: Hair loss, dry and brittle hair, and yellowing of skin.
o Skeletal Structure: Decreased bone density, fractures and arrested
growth.
o The medical evaluation may indicate that the following laboratory tests
be conducted:

Full Blood Count (CBC)

Potassium Levels

Thyroid Levels

Electrolytes

Magnesium Levels

Phosphorus Levels
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
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Page 5 of 19

Liver Function Tests

Random Blood Glucose

ECG: Required in all cases and is essential if symptoms/signs
of cardiac compromise, bradycardia, electrolyte abnormality or
BMI less than15 kg/m2. (Or equivalent on centile chart.)

Additional tests may be needed to rule out the medical causes
of amenorrhea and weight loss:
– Thyroid Function Tests, Follicle Stimulating Hormone,
Luteinizing Hormone, Prolactin, Chest X-Ray.
o Due to the risk of physical morbidity, an assessment of the risk and
close liaison with an experienced physician are indicated in the
identification and treatment of the physical complications of this
condition. Some signs and symptoms of high risk include (APA, 2006):

Low BMI, menstrual disturbance in females, type I diabetes,
gastrointestinal issues, signs of starvation, repeated vomiting,
osteoporosis, infertility, poor growth in children, the history of
consultation over weight concerns for members who are not
overweight, and a history poor response to treatment (APA,
2006).

Although weight and BMI are important physical indicators, they
should not be considered the sole indicators of physical risk
(National Institute for Health and Clinical Excellence (NICE),
2004).

With the member’s permission and where applicable, information such as
symptom progression, treatment history and treatment efficacy should be
obtained from the member’s family (APA, 2006).

Efforts should be made to engage the family into the member’s treatment
(APA, 2006).

An assessment of the family should include (APA, 2006):
o Assessing family dynamics and attitudes toward eating, exercise and
appearance.
o Identifying family reactions to the member’s symptoms and impact on
the family.
o Providing education to the family about eating disorders and available
treatments.

The findings from the medical and psychiatric evaluations are to support a
diagnosis of Anorexia Nervosa (307.1) (APA, 2006).
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
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Page 6 of 19

The provider should determine whether the member’s Anorexia is acute or
chronic by identifying (Eating Disorder Panel, 2012):
o The member’s baseline weight (even if not ideal body weight or BMI);
o Any irreversible medical problems such as osteoporosis that need to
be managed;
o Number of years with living Bulimia in addition to the member’s
chronological age; and
o Number of treatment attempts and outcomes in addition to any
interventions that have been successful or partially successful for the
member.

If the member is identified as having a chronic form of Anorexia, an overall
clinical picture of the member should be gathered developing tailored and
realistic individual goals and treatment expectations with the member that
may include (Eating Disorder Panel, 2010):
o Returning the member to their baseline weight or a safe individualized
weight goal guided by laboratory results rather than by ideal body
weight or BMI; and
o Identifying a level of functioning that is compatible with the member’s
baseline level of functioning and the ability to function within the
context of the member’s lifestyle.

Members may require a medical clearance prior to admission to determine if
the member’s medical needs can be managed in a residential setting. This
medical clearance should indicate laboratory test results within in normal
limits for the following (Eating Disorder Expert Panel, 2010):
o Electrolytes;
o Liver function;
o Vital signs;
o Cardiac function; and
o Blood counts

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 an Anorexia expert may be indicated (Eating
Disorder Panel, 2012).

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).
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 7 of 19
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 (LOCGs, 2012).
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 (LOCGs, 2012).
o The treatment plan should always address co-occurring behavioral and
medical conditions including substance disorders.
o The treatment plan should consider the member’s age and stage of
development.

Treatment goals should focus on healthy eating and where necessary, weight
gain supported by specific treatment strategies that address the member’s
symptoms, and take into account the member’s preferences and readiness
for change. The treatment plan must 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.
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 eating disorder and any cooccurring conditions 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
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 8 of 19
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 48 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).

Treatment plan updates should reflect that active treatment is being delivered,
as indicated by documentation of changes in the type, amount, frequency,
and duration of the treatment services rendered as the member moves
toward expected outcomes. The treatment plan should be updated frequently
enough to address changes in the member’s condition. Lack of progress and
its relationship to active treatment and reasonable expectation of
improvement should also be noted.
Preferred Forms of Treatment

Medical Management
o The treatment team should align care with outpatient and behavioral
health providers (NICE, 2004).
o If the RTC is equipped, medical interventions to address the sequelae
of starvation may be implemented (APA, 2006).
o Monitoring and managing vital signs especially during refeeding, cooccurring medical conditions, and medication precautions,
contraindications, and side effects when the RTC is equipped to
manage such interventions (APA, 2006).
o Consider an inpatient or 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 a physician with expertise in the treatment of medically at-risk
members (NICE, 2004).
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
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Page 9 of 19
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 regular physical monitoring of weight gain as well as adverse
symptoms (NICE, 2004).

Nutritional Rehabilitation
o Nutritional rehabilitation should be introduced in order to initiate the
restoration of weight and healthy eating patterns in the residential
setting (APA, 2006).
o Nasogastric refeeding should be an intervention of last resort for
members unable to cooperate with oral refeeding or if there is a grave
medical danger. Refeeding should be carried out within applicable
medical and regulatory guidelines and only when the RTC program is
equipped to manage such care (APA, 2006).
o Assess fluid and electrolyte balance when there has been a preadmission pattern of vomiting and use of laxatives. Gradually taper use
of laxatives (APA, 2006).
o Members should be closely monitored at every meal (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). Provide regular physical monitoring of vitals
signs and weight gain as well as adverse symptoms (APA, 2006).
o If the RTC is equipped, cardiac monitoring should be provided,
especially at night for members. If the RTC is unable to provide such
monitoring, consultation and services provided by a cardiac/eating
disorder physician should be available. (APA, 2006).
o The use of supplements such as calcium, vitamin D and Zinc may be
introduced as a component of the nutritional rehabilitation plan (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)
o Psychotherapy may include individual, family and group therapy
approaches with the following considerations:
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 10 of 19

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 Anorexia such
as over exercising or purging (NICE, 2004).

Education about the Anorexia, its treatment, and approaches to
self-care should be provided alongside psychotherapy (NICE,
2004).

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).

Family therapy is an essential component of treatment in
promoting healthy eating patterns and providing a supportive
recovery environment, especially with children and adolescents
or for families with family or marital problems that are
contributing to the maintenance of Anorexia in the member
(APA, 2006).
– Family-Based Treatment (FBT), also known as
Maudsley Therapy may be coordinated as part of the
discharge plan from a residential setting for members
who are 12-18 years of age (Optum Behavioral
Sciences, Maudsley Technology Assessment
(Maudsley Tech Assessment), 2012).
– FBT is aimed at facilitating parental empowerment to
disrupt Anorexia maintaining behaviors and may often
be implemented as an alternative to inpatient or
residential treatment for members who are medically
stable (Maudsley Tech Assessment, 2012)
– Members who are medically stable may be referred to
FBT upon discharge from a residential setting as long
as a parent or responsible adult is committed to
participating in the member’s treatment, the member
is able to function and participate in treatment in an
outpatient setting (Maudsley Tech Assessment,
2012).
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Coverage Determination Guideline
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Page 11 of 19
o Active family participation in therapy is an essential component of
treatment in promoting healthy eating patterns and providing a
supportive recovery environment.

For children and adolescents, family involvement is imperative
in order to successfully treat the patient. Family and/or
caregiver interventions should be included in the therapeutic
process and treatment plan as family members are vital to the
successful treatment, transition and/or discharge to the next
most appropriate level of care. Participation in treatment should
be at least 2-3 times per week unless clinically contraindicated
(Optum QRG, 2012).

Every effort should be made to locate a residential treatment
facility that meets the patient’s clinical needs that is accessible
to parents and family members in order for full participation in
visits, family sessions and other contact identified in the
treatment plan (Optum, QRG, 2012).

If the residential treatment 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.

For chronic forms of Anorexia, 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).

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 chronic
course of Bulimia (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 During the acute phase of treating Anorexia Nervosa consider whether
pharmacotherapy should be initiated only after the cognitive and
affective sequelae of starvation have been addressed (APA, 2006).
o Medications may be used to provide relief from common co-occurring
symptoms such as depression or anxiety Include (APA, 2006):
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
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Page 12 of 19

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).
Discharge Planning


o Discharge may be indicated for members receiving residential care for
the treatment Anorexia Nervosa when:

Supervision of food intake during and after meals is no
longer required (External Panel of Experts, 2010).

The patient is physically and psychologically stable as to not
require the structure and supervision of 24-hour monitoring
(External Panel of Experts, 2010).

Individuals who have the ability to adhere to a healthy eating
plan even in situations where triggers and psychosocial
stressors are present (External Panel of Experts, 2010).

There is a transition and/or aftercare plan in place for
treatment to occur at the next most appropriate level of care
(External Panel of Experts, 2010).

There is a plan to address the treatment of any co-occurring
conditions.
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
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Coverage Determination Guideline
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Page 13 of 19
observation available in a residential setting 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.

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 anorexia nervosa must be reviewed against the
language in the enrollee's benefit document. When the residential treatment of
anorexia 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:
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
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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, 2009 & 2011
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.
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 15 of 19

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 (as revised from time to time), 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.

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.
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 16 of 19
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
Anorexia Nervosa Anorexia Nervosa is a form of eating disorder whose
essential features include a refusal to maintain a minimally normal body weight,
an intense fear of gaining weight, and a significant disturbance in the perception
of the shape or size of his/her body.
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.
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.
Refeeding Increasing nutritional intake and restoring weight to within a normal
range in the treatment of anorexia nervosa.
Refeeding Syndrome Refeeding Syndrome - Metabolic disturbances that occur
as a result of reinstitution of nutrition to members who are starved or severely
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 17 of 19
malnourished. These metabolic disturbances can, in turn, cause severe medical
complications including cardiac failure, edema, and coma.
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. Eating Disorder External Panel of Subject Matter Experts, 2010.
9. 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.
10. Optum Clinical Technology Assessment Committee, Family Based Treatment
Technology Assessment, 2012).
11. 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
Limited to specific diagnosis codes?
307.1
x
YES □ NO
Anorexia Nervosa
Limited to place of service (POS)?
x
YES □ NO
Mental Health Residential Treatment
Limited to specific provider type?
□
YES
x
NO
Limited to specific revenue codes?
x
YES
□
NO
Residential Treatment of Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 18 of 19
1001
Residential Treatment Center
HISTORY
Revision Date
12/18/12
Name
L. Urban
Revision Notes
Version 2-Final
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 Anorexia Nervosa
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2012
Oputm is a brand used by United Behavioral Health and its affiliates.
Page 19 of 19