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Coverage policies related to bulimia nervosa or eating disorders

ECRI undertook a systematic search to identify publicly available bulimia nervosa or eating disorder coverage policies of insurers. Some health plans' behavioral or mental health coverage policies are publicly available through their websites; others do not publish them; others publish their policies but they have no policies pertaining to bulimia or eating disorders. Some policies are specific to bulimia nervosa; others make general reference to coverage for mental health conditions and disorders. We describe below the general policies our searches identified and describe how those policies apply to coverage for bulimia nervosa treatment. Specific coverage limits depend on the applicable federal and state mental health parity laws or mandates, the particular benefit plan an individual has, and the contract language in that plan. Because many insurers do not make their policies publicly available, the summary below is neither comprehensive nor representative of all health plans. It reflects the policies that we identified through publicly available sources as of August 2012.

Aetna (available nationally)
Aetna has a clinical policy bulletin on coverage of eating disorders. The policy summarized below refers to the medical benefits component of bulimia nervosa treatment. Behavioral health services, such as psychotherapy began to be provided under Aetna Behavioral Health as of September 2009.

For bulimia nervosa, the clinical policy bulletin states the following:
"The majority of patients with eating disorders can be treated in the outpatient settings. Hospitalization is usually reserved for severely symptomatic patients such as individuals with extremely low body weight (75% or less of expected body weight) whose condition must be hemodynamically stabilized, or those with medical problems requiring intensive monitoring such as patients with electrolyte imbalances, cardiac arrhythmias, profound hypoglycemia, self-mutilation, impaired capacity for self-care, or active suicidal ideation. Furthermore, failure of outpatient treatment may also constitute grounds for inpatient treatment. It should be noted that patients with bulimia rarely need hospitalization unless binge-purge cycle has led to anorexia resulting in severe metabolic deficiencies such as severe electrolyte imbalances, or suicidal depression is present."

Aetna considers nutritional counseling, pharmacotherapy, and psychotherapy as medically necessary for the management of members with bulimia. It has a separate policy, #0049 Nutritional Counseling for this service. Aetna has precertification requirements for intermediate levels of care, residential treatment, and partial hospital and intensive outpatient treatment. The eligibility for these services also varies by the particular Aetna plan and contract that a member has. Depending on the case serverity, Aetna may assign a case manager to coordinate medical and behavioral health services by all providers involved in the care of the patient. Specific tests and treatments that are necessary for the diagnosis and medical management of bulimia nervosa are specified in the policy bulletin (number: 0511). Aetna's medical policy bulletins can be accessed through these links: http://www.aetna.com/cpb/medical/data/500_599/0511.html

Anthem Blue Cross and Blue Shield (available in CO, CT, GA, IN, KY, ME, MO, NV, NH, OH, VA, WI)
Anthem Blue Cross and Blue Shield publishes a coverage policy for eating disorders that lists several levels of care for treatment of eating disorders and the services covered for each level of care. For all levels, a DSM Axis I or ICD-9 Eating Disorder Diagnosis is required. Co-morbid disorders may influence choice of level of care. The levels of care are: acute inpatient, residential treatment center, residential treatment center without 24 hour nursing, partial hospitalization program, intensive outpatient program, and outpatient treatment. Patients require different levels of care depending on their condition and a multidisciplinary approach. Anthem specifies the particular requirements for each level in its Behavioral Health Medical Necessity Criteria guidelines. Access Anthem's Behavioral Health Medical Necessity Criteria guidelines at: http://www.anthem.com/provider/noapplication/f5/s1/t0/pw_e175444.pdf?refer=ahpprovider&state=in. See pages 27 - 38 for eating disorders policy.

APS Healthcare (available nationally)
APS Healthcare provides benefits for mental health diagnoses listed in the DSM-IV for patients with symptoms of sufficient severity to meet the required criteria for the requested level of care. APS Healthcare defines levels of care for mental health services as inpatient (acute care), partial hospitalization, intensive outpatient, outpatient, and residential treatment with criteria for each. APS Healthcare also provides a Provider Manual (that outlines clinical practice guidelines, which specifically includes treatment of eating disorders. Access APS Healthcare's Medical Necessity and Level of Care Determination Criteria and Provider Manual at: http://www.apshealthcare.com/site/files/cm/file/provider/aps_providermanual.pdf

Blue Cross and Blue Shield of Massachusetts (BCBSMA)
The state of Massachusetts enacted the Mental Health Parity Act, which required health plans to cover treatment of biologically based mental health conditions to the same degree as is provided for physically based conditions. As of July 1, 2009, the act specifically included inpatient, intermediate, and outpatient levels of services for eating disorders, defining eating disorders as biologically based illnesses. The BCBSMA medical policy bulletin specifically addressing treatments relevant to bulimia is titled "#423 Outpatient Psychotherapy," although it also refers to other levels of covered care including inpatient hospital, partial hospital, and residential care as well as outpatient psychotherapy and medication management. It states that psychotherapy may be used for:
  • Identification of the presence or absence of a disorder, as outlined in the current DSM, including assessment of the acuity and severity of a condition
  • Treatment plan formulation for identified disorder(s).
  • Identification of symptoms that contribute to a diminution in an individual's level of functioning and quality of life
  • Accepted therapeutic techniques used to stabilize or improve functioning.
Access the policy (number: 423) at: http://www.bluecrossma.com/common/en_US/medical_policies/423%20Outpatient%20Psychotherapy%20prn.pdf

CIGNA (available nationally)
Cigna's Behavioral Health arm provides benefits for DSM-IV diagnoses and lists specific guidelines for access to different levels of treatment. The level of care available to a member is determined by three main factors:
  1. Severity of illness
  2. Intensity of service needed for the patient's condition
  3. Consideration of relevant external factors that may affect a patient's access to care, such as financial difficulties, availability or lack of transportation, legal issues, and job status.
Cigna advises that all patients with an eating disorder must be assessed for co-morbid psychiatric disorders, including substance abuse disorders. If present, these disorders should be treated along with the patient's eating disorder. Cigna levels of care for eating disorders and specifically for bulimia nervosa include the following: inpatient hospitalization, partial hospitalization, residential care, outpatient care, and intensive outpatient care. Cigna also lists guidelines for continued treatment and for discharge in the level of care guidelines. Cigna's medical coverage policy states that it covers nutritional counseling, but does not cover dialectical behavioral therapy for the treatment of eating disorders. Cigna also offers free "Education Awareness" sessions intended to provide parents, family members and caregivers with information about the day-to-day care and issues that arise for a loved one with an eating disorder. Access the schedule of events at: http://apps.cignabehavioral.com/web/basicsite/consumer/educationAndResourceCenter/eatingDisorders/eatingDisordersAwareness.jsp

Access Cigna's Level of Care Guidelines for Behavioral Health and Substance Abuse and Cigna's Medical Coverage Policies for Dialectical Behavior Therapy and Nutritional Counseling at: http://www.cigna.com/ Nutritional guidelines at: http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0269_coveragepositioncriteria_nutritional_counseling.pdf
Level of Care Guidelines at: http://www.cignabehavioral.com/web/basicsite/provider/pdf/levelOfCareGuidelines.pdf
Member Benefits Guide at: http://apps.cignabehavioral.com/.

Employee Assistance Network (EAN)(available in North Carolina)
EAN states that a DSM-IV diagnosis is necessary for coverage. EAN offers inpatient with continued stay and intensive outpatient treatment options for those who meet the criteria laid out in the company's Levels of Care Criteria. Access EAN's Level of Care Criteria at: http://www.eannc.com/pdf/levels-of-care-criteria.pdf

Health Net (available in Northeast U.S. and West Coast U.S.)
Health Net contracts with Managed Health Network to provide behavioral health benefits. Health Net categorizes bulimia nervosa as a "severe mental illness," in its members' Benefits Guide, and refers to the MHN members' guide for all specific benefits and care criteria for treatment of bulimia nervosa. Health Net offers various levels of care including inpatient, partial-inpatient, residential, intensive outpatient, outpatient, and home care. The company lists criteria for these levels of care in National Medical Policy, number NMP468. Access Health Net's Benefits Guide and Medical Policy, number NMP468 at: https://www.healthnet.com/static/general/unprotected/pdfs/national/policies/CPG_Bulimia_Nervosa_Nov_11.pdf

Health Partners (MN)
HealthPartners is an integrated health plan and delivery system in which Health Partners Behavioral Health clinics and hospitals work together to offer coverage and treatment for behavioral health conditions. They state that they follow the guidelines of the American Psychiatric Association (APA) and adhere to APA's criteria for treatment of eating disorders. Those guidelines discuss levels of care (intensive inpatient programs to residential and partial hospitalization programs, and outpatient care). and how to choose a treatment center. They also discuss nutritional rehabilitation counseling as a "useful part of treatment." They provide assessment of emotional, behavioral and cognitive problems, individual, group and family therapy, educational classes, medication evaluation and management, and cognitive behavioral therapy in inpatient, outpatient, and residential settings depending on the patient's condition. Concurrent review of the patients is required for inpatient treatment at a non-contracted facility. Furthermore, nutrition counseling is not covered by Health Partners to treat eating disorders. They publish several policy bulletins on general management of adult and child behavioral health conditions and an Eating Disorder Levels of Care bulletin. Access Health Partner's Eating Disorder Levels of Care policy at: http://www.healthpartners.com/files/44644.pdf

Highmark Blue Cross and Blue Shield of Delaware
Highmark Blue Cross and Blue Shield of Delaware mention coverage of eating disorders in a policy about the 2008 federal Mental Health Parity Act. The plan covers Axis 1 diagnoses listed in the DSM-IV (including eating disorders) and uses Milliman Care Guidelines® to determine the medical necessity of psychiatric treatment. The plan covers services for acute inpatient, partial hospital, and outpatient treatment prescribed by a licensed and eligible provider in an approved treatment setting. https://www.highmarkbcbsde.com/ProviderPolicies/public_site/3.01.CA9_Mental_Health_and_Substance_Abuse_Coverage_under_Federal_Mental_Health_.htm

Horizon-Blue Cross and Blue Shield of New Jersey (available in New Jersey)
Horizon-Blue Cross and Blue Shield of New Jersey has no published policies specific to any eating disorder. However, cognitive behavioral therapy, which is a standard treatment for bulimia nervose, is a listed medical policy and coverage is provided according to certain criteria of medical necessity for the condition for which a physician prescribes it. The policy is published at the health plans website: https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf/

Humana (available in 15 states in the southeast and Midwest plus Puerto Rico)
Humana health plans in some states subcontract for behavioral health services. In other states benefits are administered by Humana and its wholly owned subsidiary LifeSynch, which offers integrated medical-behavioral healthcare management. Humana "coverage issues" policies on its website do not include any policies or criteria pertaining to bulimia nervosa or eating disorders. LifeSynch describes different health plan options for behavioral health: integrated medical/behavior healthcare, managed behavioral health, or psychiatric disability management. The company lists APA guidelines that it subscribes to, but the APA eating disorder guidelines are not among those listed and specific coverage policies are not listed. http://www.lifesynch.com/about/products/behavioral_healthcare/ Humana's coverage policies are accessible at: http://humana.com/ but do not address psychiatric conditions.

Inland Empire Health Plan (IEHP) (available in CA)
IEHP categorizes bulimia nervosa as a severe mental illness. As such, IEHP policy states that "inpatient mental health care days for the treatment of severe mental illnesses are not limited." Likewise, the plan does not place limits on outpatient mental health care days for severe mental illnesses. Thus, inpatient and outpatient treatments for bulimia nervosa at plan providers are covered. IEHP's coverage policy on Behavioral Health (http://ww2.iehp.org/NR/rdonlyres/A73CC4D3-9C08-4EC4-BB98-B6AF0E4650CE/0/B100toB200.pdf) in its Healthy Families Benefit Manual (pages B-100.1 - B-100.2): http://ww2.iehp.org/.

Kaiser Permanente Health Plan
Kaiser Permanente, an integrated healthcare delivery system and health plan, does not make its coverage policies public. Its website, however, provides information for its members on eating disorders, including bulimia nervosa, and diagnosis and treatment, including use of cognitive behavioral therapy. Various regions of the Kaiser network offer classes for beneficiaries and their families about eating disorders and treatment. The network also provides information about accessing behavioral health services in each of its nine geographic regions, with phone numbers to call for eating disorder services in each network area. These resources can be found by searching "mental health services" at the "health and wellness" section of the website: https://www.kaiserpermanente.org.

Lovelace Health Plan (available in NM)
Lovelace has several health plans under its umbrella and covers diagnosed psychiatric conditions as defined by the DSM-IV or the International Classification of Diseases-volume 9 (ICD 9), both of which include bulimia nervosa. Among Lovelace's requirements to authorize treatment are a DSM diagnosis, including all five axes; documented medical and psychiatric history; assessment of mental status, including suicidal ideation or psychosis; presenting problems; and all relevant conditions affecting health.

Depending on which plan a member has, behavioral health services are provided through OptumHealth New Mexico or through a statewide entity specified by the New Mexico Human Service department. OptumHealth does not provide specific details about its coverage for eating disorders.

Lovelace Health Plan's Provider Reference Guide: http://www.lovelacehealthplan.com/.
Optum Health New Mexico's Consumer Handbook: https://www.optumhealthnewmexico.com/.

Magellan Behavioral Health (available nationally)
Magellan Behavioral Health administers behavioral health benefits for many health plans, including many Blue Cross/Blue Shield plans. Magellan adopted the 2006 APA treatment guidelines for eating disorders and updated the review of the clinical literature through December 2010. Magellan's Medical Necessity Criteria list admissions criteria for various levels of treatment for eating disorders, including bulimia nervosa. Magellan offers residential hospitalization, partial hospitalization, and intensive outpatient levels of care. All levels of care require a DSM-IV diagnosis. Other requirements vary per the level of treatment sought, but include mental competence, level of response to treatment, level of intervention/monitoring needed, and the severity of other psychiatric conditions. Access Magellan's Medical Necessity Criteria at: https://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/MNC.asp

Medica (available in MN, WI, ND, SD)
Medica contracts with United Behavioral Health to provide its behavioral health benefits. In its Provider Administrative Manual, these benefits are stated to include: individual, family, and group therapy, psychiatric evaluation and medication, hospitalization when medically necessary, and attention deficit disorder diagnostic evaluations. They refer to United Behavioral Health (UBH) for all other policy information (see below). Medica's website https://www.liveandworkwell.com provides extensive resources and information on eating disorders, including bulimia. Access Medica's online Provider Administrative Manual at: http://medica.com/. Access United Behavioral Health's Coverage Determination Guidelines at: http://www.unitedbehavioralhealth.com.

MHN (available nationally)
MHN, a subsidiary of Health Net, administers managed behavioral health care plans. In the company's Level of Care and Treatment Criteria, MHN offers three levels of care, including adult half day partial hospitalization, adult psychiatric home care, and child/adolescent half day partial hospitalization. MHN also includes criteria for admission based on the general mental health of the patient and not specific disorders. For example, for adult half-day partial hospitalization, the patient must:
  1. Have a DSM-IV axis-I diagnosis
  2. Be experiencing moderate to severe symptoms and/or functional impairment
  3. Be able to be safely and effectively managed in a Partial Hospital setting without significant harm to self/others and decompensation
  4. Require up to four hours of intensive and structured treatment per day
  5. Require more intensive medical supervision than an intensive outpatient program
  6. Have a sufficiently stable environment, living situation, and social support system
  7. Have high enough functional capacity to allow for meaningful participation in treatment
For each level of care MHN specifies the types of therapy that can be provided (individual, group, and family psychotherapy) and how often they can be given, as well as criteria for continuing care and for discharge. MHN does not address their nutrition counseling coverage. Access MHN's Level of Care and Treatment Criteria at: https://www.mhn.com/static/pdfs/MHNLOC.pdf

Neighborhood Health Plan (NHP) (available in MA)
NHP, a managed care organization, contracts its behavioral health care benefits to Beacon Health Strategies. As a health plan in Massachusetts, it is subject to coverage requirements mandated by the state's mental health parity act for coverage of biologically based mental illnesses in the DSM-IV. NHP covers inpatient, outpatient, intermediate or diversionary, and emergency benefits for participating providers. Services for bulimia nervosa treatment depend on the exact plan a member has purchased. Information about the mental health services provided can be found in the NHP Commonwealth Care member handbook (http://www.nhp.org/PDFs/Members/CommCareHandbook_SFY10.pdf) on pg. 24 at: http://nhp.org/.

New Directions Behavioral Health (NDBH) (available nationally)
NDBH is a managed care behavioral health plan that covers acute inpatient hospitalization, partial hospitalization, residential treatment, outpatient treatment, and intensive outpatient treatment for members with an eating disorder, including bulimia nervosa. Criteria for admission, continued stay, and discharge differ for each level of care. These criteria are detailed in NDBH's Medical Necessity Criteria (pgs. 37 - 49) at: https://www.ndbh.com/docs/providers-behavioral-health-plan-providers/2012-nd-medical-necessity-criteria-2.pdf?Status=Master

United Behavioral Health (UBH) (available nationally)
UBH is a behavioral health plan operated by UnitedHealthcare since 1979, and offered by various commercial health plans. UBH benefit coverage is subject to state mandates in the areas in states in which it operates. UBH covers residential (guideline #: BHCDG512011), inpatient (BHCDG502011), partial (BHCDG562011), intensive outpatient (BHCDG532011), and outpatient (BHCDG562011) treatment options for bulimia nervosa. Forms of treatment preferred and covered by UBH include nutritional rehabilitation, psychosocial interventions, pharmacotherapy, medical internentions, education, and discharge planning. Access United Behavioral Health's Coverage Determination Guidelines at: http://www.unitedbehavioralhealth.com.

The Regence Group (TRG) Behavioral Health (available Idaho, Oregon, Utah, Washington)
TRG classifies eating disorders as a "subclass of complex biopsychosocial disorders characterized by severe disturbances in eating behavior." Bulimia nervosa is listed as a covered eating disorder. TRG covers inpatient treatment, residential treatment, and partial hospitalization treatment. TRG states that services provided for eating disorders must be "provided in a specialized program, unit, or facility which is either a component of or a stand-alone licensed and accredited hospital, and in which 24 hours medically supervised acute inpatient services are provided." The company's Administrative Manual for Behavioral Health references the American Psychiatric Association's (APA) Practice Guidelines for the Treatment of Eating Disorders as their adopted guidelines for clinical practice. Access the Regence Group's Levels of Care Manual and Administrative Manual for Behavioral Health at: http://www.wa.regence.com/provider/library/manual/core/washington-behavioral-health-mental-health-chemical-dependency.pdf

Value Options (available nationally)
Value Options, a subsidiary of FHC Health systems, provides behavioral health programs for its members. Its Provider Handbook lists clinical criteria for admission to inpatient, residential, and outpatient services (http://www.valueoptions.com/providers/Handbook/clinical_criteria.htm). To be eligible for benefits, a member must receive a DSM-IV axes I diagnosis and must fulfill general qualifications for each level of care. The company's Treatment Guidelines references the American Psychiatric Association's (APA) Treatment of Patients With Eating Disorders, Third Edition as their adopted clinical practice guidelines. Access Value Options' Treatment Guidelines at: http://www.valueoptions.com/providers/Handbook/treatment_guidelines.htm

Wellmark Blue Cross Blue Shield (IA, SD)
Wellmark's Behavioral Health Guide is available online. To determine the clinical criteria required for these services to apply, the InterQual® clinical criteria document, which is not publicly available, is referenced. For those meeting the criteria, Wellmark offers outpatient, partial hospitalization, and inpatient treatment options. Under noncovered services, Wellmark includes services provided at a residential treatment facility and behavioral modification. Access Wellmark Blue Cross Blue Shield's InterQual® and Behavioral Health Guide at: http://www.wellmark.com/Provider/MedPoliciesAndAuthorizations/PreService_InterQual.aspx

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Bulimia nervosa is an eating disorder in which a person engages in binge eating (eating a lot of food in a short time) followed by some type of behavior to prevent weight gain from the food that was eaten. This behavior can take two forms: self-induced vomiting, misuse of enemas, laxatives, diet pills (called purging) and excessive exercise, fasting, or diabetic omission of insulin (called non-purging). Some people with bulimia nervosa may also starve themselves for periods of time before binge eating again. Bulimia nervosa has important mental, emotional, and physical aspects that require consideration during treatment.

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