Download Eating Disorders - Behavioral Healthcare Program

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.