Residential Treatment of Bulimia Nervosa COVERAGE OPTUM™ DETERMINATION

Transcription

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
Table of Contents:
Instructions for Use
1
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”).
Coverage Determination Guideline
Confidential and Proprietary, © OptumHealth 2013
Optum is a brand used by United Behavioral Health and its affiliates.
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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
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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
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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.
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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.
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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).
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
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.
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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
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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).
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
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).
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
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).
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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.
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
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
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.
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
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.
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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
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
Page 16 of 18
90832 plus pharmacological add-on code
(90863)
90834
(90863)
90837
(90863)
90839
90846
90847
90849
90853
Limited to specific diagnosis codes?
307.51
family (interactive)
family (pharmacological management)
family member
family member (interactive)
family member (pharmacological management)
family member
family member (interactive)
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.
Page 17 of 18
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Residential Treatment of Bulimia Nervosa COVERAGE OPTUM™ DETERMINATION

Transcription

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