Coverage policies related to bulimia nervosa and eating disorders
Eating disorder coverage policies of major health insurers that provide public access to their policies are listed below. Some insurers do not make their coverage policies available publicly, but members of a particular health plan may request or access policies through their health plan benefits explanation. Some policies are specific to bulimia nervosa; other policies make general reference to coverage for serious mental health disorders. Coverage limits depend on applicable federal and state mental health parity laws or mandates, the particular benefit plan an individual has, and 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 policies of many major health insurers as of late 2017.
Aetna’s Clinical Policy Bulletin 0511 pertains to coverage of eating disorders that primarily address bulimia and anorexia. Key components of treatment address medical and behavioral health aspects of eating disorders as follows:
- Nutritional counseling (see CPB 0049 – Nutritional Counseling)
- Pharmacotherapy for the treatment of anorexia (e.g., selective serotonin reuptake inhibitors and anti-psychotics)
- Pharmacotherapy for the treatment of bulimia (e.g., selective serotonin reuptake inhibitors such as fluoxetine, tricyclic anti-depressants, trazodone, topiramate)
- Pharmacotherapy for the treatment of binge-eating disorder (e.g., lisdexamfetamine dimesylate (Vyvanse)) (Note: Coverage may be excluded under plans that exclude coverage of medications to decrease or increase weight. Please check benefit plan descriptions.)
- Psychotherapy (e.g., cognitive behavioral therapy, family psychotherapy, interpersonal psychotherapy, and psychodynamic psychotherapy).
Aetna policy also notes that the majority of patients can be treated in outpatient settings, and they usually reserve hospitalization 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 also has a policy on the use of Antiemetic Injection Therapy policy 0724 (i.e., drugs that relieve nausea and vomiting) that outlines conditions, including bulimia nervosa, for which these drugs may be considered medically necessary.
Anthem Blue Cross and Blue Shield
Anthem Blue Cross and Blue Shield is the trade name of several health plans that operate in Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (parts of), New Hampshire, Nevada, Ohio, Virginia, and Wisconsin. Anthem coverage policy, Eating and Feeding Disorder CG-BEH-05, lists five levels of care for treatment of eating disorders and the criteria to be considered eligible for each level, along with services covered for each level of care. Those levels are Acute Inpatient; Residential Treatment Center, Partial Hospitalization; Intensive Outpatient, and Outpatient. For all levels, a diagnosis fitting criteria of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) and/or International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) system is required. Anthem covers treatment for eating disorders only when all of its medical necessity criteria are met. Comorbid disorders may influence choice of level of care. The levels of care are acute inpatient, residential treatment center, partial hospitalization program, intensive outpatient program, and outpatient treatment. Patients require different levels of care depending on their condition and a multidisciplinary approach. Anthem also refers to three other policies that may be relevant in individual cases, depending on the diagnosis, whether a dual diagnosis is part of the patient history, and other factors.
- CG-BEH-03 Psychiatric Disorder Treatment
- CG-BEH-04 Substance-Related and Addictive Disorder Treatment
- CG-MED-19 Custodial Care
Beacon Health Options
Beacon Health Options (formerly ValueOptions) combines 2 behavioral health companies– Beacon Health Strategies and ValueOptions– to serve people in all 50 states. It operates in several states as a third-party administrator and utilization review agent of behavioral health services for employers or other health plans. Some of its subsidiaries or affiliates operate as full- or limited-service health plans in various states. According to the company, Beacon, through its clinical care managers, “arranges for the provision of and access to a broad scope of behavioral health services, including treatment for eating disorders, for members through its provider networks, consisting of appropriately licensed and/or certified practitioners, facilities, providers, and programs offering varying levels of service.” Beacon Health Options’ Medical Necessity Criteria detail the criteria used for determining level of care needed, duration of care, and ongoing care after discharge. Criteria include the requirement for a DSM-5 or International ICD-10 diagnosis. The criteria are not disease-specific, but rather describe the provision of behavioral healthcare across care settings: Inpatient, Residential Treatment Centers, Partial Hospitalization, Intensive Outpatient, and Outpatient.
Blue Cross Blue Shield of Alabama
Blue Cross Blue Shield of Alabama (BCBSAL) has no publicly available coverage policies specific to eating disorders or bulimia nervosa. BCBSAL contracts with New Directions Behavioral Health (see below) to provide behavioral health services.
Blue Cross and Blue Shield of Florida
Blue Cross and Blue Shield of Florida (BCBSFL) has no policy specific to eating disorders. Rather, its Medical Coverage Guidelines describe coverage under a policy titled, “Psychiatric Services.” This policy can be found under the Medical Coverage Guidelines “Medicine” policy folder. This plan defines psychiatric or mental and nervous disorders as conditions that are listed in DSM-5. BCBSFL billing guidelines for physicians and other healthcare providers state that all types of behavioral health services are eligible for payment when provided under the direction of a physician. The policy notes, “Eating disorders (anorexia, bulimia) are reviewed under the same criteria as other psychiatric disorders based on member benefits and the severity of symptoms.”
Blue Cross and Blue Shield of Massachusetts
Blue Cross and Blue Shield of Massachusetts (BCBSMA) has no publicly available policy specific to eating disorders or psychiatric services and that identify covered levels of care. However, its website lists policies pertaining to specific interventions, such as biofeedback, that may be proposed to treat various psychiatric conditions. In a BCBSMA behavioral health policy relevant to bulimia nervosa, Outpatient Psychotherapy Policy Number 423, the policy states that psychotherapy may be used for:
Blue Cross Blue Shield of Michigan
Blue Cross Blue Shield of Michigan uses New Directions Behavioral Health’s Medical Necessity Criteria (see below) to make benefit determinations for mental health and substance abuse services. Levels of coverage include Acute Inpatient Hospitalization, Partial Hospitalization, Residential Treatment, Intensive Outpatient Treatment, and 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 New Directions Medical Necessity Criteria.
Blue Cross Blue Shield of Mississippi
Blue Cross Blue Shield of Mississippi has no publicly available coverage policies or level of care medical necessity criteria that address behavioral health, eating disorders, or bulimia. However, the health plan’s general Summary of Benefits and Coverage page suggests that Inpatient Services and Outpatient Services may be available for behavioral health conditions, subject to Care Management, Medical Necessity, and appropriateness of care requirements. To obtain coverage for some behavioral health services through Blue Cross Blue Shield of Mississippi, healthcare providers may need to obtain Pre-certification from the health plan.
Blue Cross Blue Shield of North Carolina
In some parts of the state and depending on the plan, Blue Cross Blue Shield of North Carolina (BCBSNC) may contract with Magellan Healthcare and Beacon Health Options to provide or administer some behavioral health services to its insured members. BCBSNC provides the following levels of behavioral healthcare for eating disorders, including Inpatient, Partial Hospitalization, Residential Treatment Centers, Intensive Outpatient, and Structured Outpatient Treatment Programs. BCBSNC has a Corporate Medical Policy on Residential Treatment that outlines its medical necessity criteria for admission to Residential Treatment for eating disorders, including bulimia nervosa
Blue Cross Blue Shield of Rhode Island
Blue Cross Blue Shield of Rhode Island (BCBSRI) has no publicly available coverage policies specific to eating disorders or bulimia. In Rhode Island, treatment of mental health and substance abuse disorders is governed by the Rhode Island General Law, a state mandate, and the Federal Mental Health Parity Act. The Rhode Island mandate, Insurance Coverage for Mental Illness and Substance Abuse, Chapter 27-38.2, provides that coverage for mental health and substance use disorder treatments may include Inpatient, Outpatient, Emergency Care, and Prescription Drugs and shall not be limited by any annual or lifetime dollar limitations. Further, the mandate requires all health insurers to cover state-mandated behavioral healthcare delivered by out-of-network providers where it can be established that the mandated behavioral health services are not available from a provider in the health insurer’s network. A BCBSRI Payment Policy on Behavioral Health Services Inpatient and Intermediate Levels of Care indicates that covered behavioral health treatments may include Inpatient Hospitalization and Inpatient Substance Use Disorder Detoxification, Residential Programs, and Intermediate Care Services, including Partial Hospitalization Program, Intensive Outpatient Program, and Adult Intensive Services, and Child and Family Intensive Services. The policy notes that Intermediate Care Services may include individual, family, and group therapy; medication consultation and management; case management coordination; emergency crisis evaluation available 24 hours a day, 7 days per week; and psychiatric assessment.
Blue Cross Blue Shield of Tennessee
Blue Cross Blue Shield of Tennessee (BCBSTN) has no publicly available coverage policies that specifically address bulimia or eating disorders. BCBSTN has several Behavioral Health Utilization Management Guidelines that outline coverage criteria for several levels of care, including Residential Care, Intensive Outpatient Program, and Partial Hospital Program.
The following policies may be relevant to treatment of eating disorders, including bulimia nervosa:
- Comprehensive Child and Family Treatment (CCFT): Intensive Outpatient Program
- Family Intervention Treatment Team (FITT) – For BlueCare Use Only
- Respite Care, Adult: Residential Care
- Respite Care, Child/Adolescent: Residential Care
- Sub-Acute Behavioral Health Level of Care, Adult: Partial Hospital Program
- Supported Housing: Residential Care
Blue Cross Blue Shield of Vermont
Blue Cross Blue Shield of Vermont (BCBSVT) has a Corporate Medical Policy on Nutritional Counseling, File code: RB.NC.01 that outlines the medical necessity criteria for coverage of nutritional counseling for eating disorders, including bulimia nervosa. The policy states, “Members with diagnoses of metabolic disease or eating disorders must provide medical information supporting the need for nutritional counseling beyond the initial three visits.” BCBSVT has no other publicly available coverage policies that specifically address other treatments for eating disorders or bulimia nervosa or that define appropriate levels of care for these conditions.
Blue Cross Blue Shield of Wyoming
Blue Cross Blue Shield of Wyoming has no publicly available coverage policies that apply to behavioral health, eating disorders, or bulimia nervosa or that define appropriate levels of care for these conditions.
Blue Shield of California
Blue Shield of California has no publicly available coverage policies that apply to behavioral health, eating disorders, or bulimia nervosa or that define appropriate levels of care for these conditions.
CareFirst Blue Cross Blue Shield
CareFirst contracts with Magellan Healthcare to provide behavioral health services. CareFirst has no publicly available policy specific to treatment of bulimia nervosa or eating disorders. A CareFirst Medical Policy Operating Procedure relevant to bulimia, 2.01.050A Professional Nutritional Counseling, states that nutritional counseling, when delivered by a registered licensed dietitian or other health professional functioning within his or her legal scope of practice, may be available beyond 12 visits per condition per year after medical review to determine medical necessity. The policy cites “follow-up and support of patients diagnosed with eating disorders such as anorexia nervosa or bulimia” as an example of “appropriate prolonged care beyond twelve visits.”
Cigna’s Behavioral Health arm provides benefits for eating disorders, including bulimia nervosa, as defined in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. Cigna levels of care for eating disorders and specifically for bulimia nervosa include the following: Acute Inpatient Treatment, Partial Hospital Treatment, Residential Treatment, Intensive Outpatient Treatment, and Outpatient Treatment. Cigna’s Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health and Substance Use Disorders state that coverage of treatments for eating disorders must meet its definition of medical necessity:
- In accordance with generally accepted medical practice standards,
- Clinically appropriate and considered effective for the patient’s condition, and
- Not primarily for the convenience of patient or physician, and not more costly than an alternative service or treatment at least as likely to produce a therapeutic or diagnostic equivalent.
Empire Blue Cross Blue Shield
Empire Blue Cross Blue Shield provides coverage for eating disorders, including bulimia nervosa, that are defined by the DSM-5 or ICD-10. Empire’s covered levels of care include Acute Inpatient, Residential Treatment Center, Partial Hospitalization Program, Intensive Outpatient Program, and Outpatient Treatment. Empire’s medical necessity criteria for admission to and continued stay in each level of care are described in its Clinical Utilization Management Guideline on Eating and Feeding Disorder Treatment, Guideline Number: CG-BEH-05. Empire also refers to three other policies that may be relevant in individual cases, depending on the diagnosis, whether a dual diagnosis is part of the patient history, and other factors.
- CG-BEH-03 Psychiatric Disorder Treatment
- CG-BEH-04 Substance-Related and Addictive Disorder Treatment
- CG-MED-19 Custodial Care
Excellus BlueCross BlueShield
Excellus BlueCross Blue Shield offers health plans in New York State. The health plan does have a Specialty Program for Coordinated Care for the Treatment of Eating Disorders, which features dedicated staff who arrange for an appropriate care level. Services provided through Excellus’ eating disorders program may include Outpatient Treatment with eating disorder specialists, Partial Hospitalization, and/or Inpatient Treatment. Excellus has two publicly available coverage policies on its website that address treatments for eating disorders. The Medical Policy on Standard Dialectical Behavior Therapy, Policy Number: 3.01.10 indicates under which conditions the treatment may be considered medically necessary for adults or adolescents with eating disorders, provided that individual plan language includes coverage for behavioral health services. Excellus has a related Medical Policy on Nutritional Therapy, Policy number 8.01.18, that indicates when nutritional therapy would be medically appropriate for treatment of eating disorders, including but not limited to anorexia and bulimia nervosa.
Hawaii Medical Service Association
Hawaii Medical Service Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Association, contracts with Beacon Health Options to provide behavioral health benefits to its insured members. Beacon provides the following levels of care for eating disorders: Inpatient, Partial Hospitalization, Residential Treatment, Intensive Outpatient, and Outpatient care. Beacon outlines its level of care criteria for admission to continuation of various care levels in the following Hawaii Level of Care Criteria documents: Inpatient Mental Health, Partial Hospital Program (PHP) – MH, Residential Treatment (RTC), Intensive Outpatient Programs (IOP) MH, and Outpatient Therapy including Medication Management. In addition, HMSA has two additional policies related to bulimia nervosa and eating disorders: Post-acute, Residential Treatment Facility and Community Care Foster Family Home Care, HMSA Policy MM.12.017; and Dietetic Treatment of Eating Disorders, HMSA Policy MM.12.025.
Health Care Service Corporation
Health Care Service Corporation (HCSC) is a large insurer that operates five Blue Cross Blue Shield (BCBS) plans in Illinois, Montana, New Mexico, Oklahoma, and Texas, and several affiliates and subsidiaries. HCSC has a Medical Policy on Mental Health Services, Number PSY301.000 (also found under Active Policies, then clicking on the Mental Health category, or searching for “mental” in the search box), that identifies individual psychotherapy, group therapy, family counseling, and pharmacotherapy as treatment modalities that “may be considered medically necessary if they are determined to be medically appropriate to the specific mental health condition.” Each of the five state BCBS plans state that they provide insured members with behavioral health services, including eating-disorder treatment, through their respective Behavioral Health Care Management Programs. Levels of behavioral healthcare provided include Inpatient, Partial Hospitalization, Residential Treatment Center, Intensive Outpatient, and Outpatient care. Case management and Eating Disorder Care Team specialty programs may be available. The insurers may require preauthorization for all Inpatient, Residential Treatment, Partial Hospitalization admissions, and Intensive Outpatient programs. More information on these programs is available on the following websites: BCBS of Illinois Behavioral Health Program, BCBS of Montana Behavioral Health Care Management Program, BCBS of New Mexico Behavioral Health Care Management Program, BCBS of Oklahoma Behavioral Health Care Management Program, and BCBS of Texas Behavioral Health Care Management Program. BCBS of Texas may contract with Magellan Health Care to provide behavioral health services in some of its health plans.
Health Net contracts with Managed Health Network to provide behavioral health benefits. The insurer does not have publicly available coverage policies specific for bulimia nervosa or eating disorders. MHN provides behavioral health coverage for the following levels of care: Inpatient Psychiatric Hospitalization, Partial Hospitalization, Residential Treatment, Intensive Outpatient Treatment, and Outpatient Treatment. MHN’s level of care and treatment criteria are outlined in the Managed Health Network Practitioner Manual.
HealthPartners is an integrated health plan and delivery system that may cover treatment for eating disorders, including bulimia nervosa, that meet the DSM-5 criteria for an eating disorder, based on language in specific health plan documents. The insurer’s Eating Disorder Coverage Criteria outline the covered levels of care, including Inpatient Care, Residential Care, and Outpatient Treatment. Health Partners requires prior authorization for all residential services, including those for the treatment of eating disorders. A behavioral health coordinator and a board-certified psychiatrist must also review all eating disorder assessments and relevant clinical information before admission for Residential Care. Health Partners uses the MCG Behavioral Health Care Guidelines to evaluate the appropriateness of requested levels of care, including Inpatient and Residential Care and Outpatient Treatment.
Highmark and its affiliates operate Blue Cross and Blue Shield health plans in Delaware, Pennsylvania, and West Virginia. All coverage is subject to the specific terms of an insured member’s plan. Highmark plans generally do not specify levels of care available for eating disorders as some other health plans might. The Highmark Commercial Medical Policy for Pennsylvania on Mental Illness Coverage, V-39-008, states that Pennsylvania’s Mental Health Benefit Mandate requires coverage for serious mental illnesses, including bulimia nervosa and anorexia, for at least 30 inpatient days/visits and 60 outpatient days/visits annually and that coverage of inpatient days/visits can be converted to outpatient days/visits on a one-for-two basis. The policy further states, “Mental Illness Coverage is typically provided as an outpatient and is only eligible for coverage as an inpatient in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.” The Highmark Commercial Medical Policy for West Virginia on Mental Illness Coverage, V-39-008, appears to be based heavily on the Pennsylvania policy cited above. The Highmark Commercial Medical Policy for Delaware, Mental Illness Coverage, V-39-002, states that the Delaware Mental Health Parity mandate addresses behavioral health coverage in individual and small group health plans (under 51 employees) that are not subject to federal Mental Health Parity law. According to the Delaware mandate, health plans delivered or issued for delivery in Delaware must provide coverage for the diagnosis and treatment of serious mental illness, including bulimia and anorexia, and drug or alcohol dependency, based on the most recent Diagnostic and Statistical Manual of Mental Disorders criteria. Highmark’s Delaware mental health policy includes similar language that favors outpatient treatment for eating disorders with less reliance on inpatient care, except under special circumstances. Highmark has related policies for medical nutrition that may be applicable to bulimia and eating disorders. The Commercial Medical Policy for Pennsylvania, Medical Nutrition Management Services (MNT), V-44-017, outlines coverage of nutritional management for anorexia and other eating disorders. Highmark has a similar Commercial Medical Policy for West Virginia, Medical Nutrition Management Services (MNT), V-44-015, which outlines coverage of nutritional management relevant to anorexia and other eating disorders. Likewise, the Highmark Commercial Medical Policy for Delaware, Medical Nutrition Management Services (MNT), V-44-006, outlines coverage of nutritional management for anorexia and other eating disorders.
The Humana Behavioral Health division manages the company’s behavioral health and substance abuse services. The company provides a brief outline of its Behavioral Health Benefits on its website but does not specify available levels of care or covered treatments specifically for eating disorders or bulimia. Humana Behavioral Health states that its care managers will authorize the appropriate levels of care. Depending on language within particular behavioral health benefit plans, available behavioral healthcare may be limited to providers in the Humana Behavioral Health network. On its website, the company indicates that insured members may be eligible to receive optional behavioral healthcare management services “if they have experienced multiple hospitalizations or have behavioral health needs that require frequent and ongoing assistance.” Humana’s Medical and Pharmacy Coverage Policies Home page does not address behavioral health or psychiatric conditions. However, a search for “bulimia” on this site does identify a Humana coverage policy on Vagus Nerve Stimulation (VNS) that classifies the technology as experimental/investigational for bulimia nervosa and therefore not covered for this indication.
Independence Blue Cross
Independence Blue Cross has no publicly available coverage policies that apply to behavioral health, eating disorders, or bulimia nervosa or that define treatments or appropriate levels of care for these conditions.
Kaiser Permanente Health Plan
Kaiser Permanente, an integrated healthcare delivery system and health plan, does not make its coverage policies public. Its website, however, states that it provides covered members with assessment, treatment, and support for a variety of mental and emotional health conditions, including eating disorders. 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 on the Behavioral Health Services section of the Kaiser Permanente website.
Magellan Health Services provides a full spectrum of managed mental health and substance abuse services. Magellan adopted the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Eating Disorders, Third Edition (2006), and related updates in Guideline Watch (August 2012): Practice Guideline for the Treatment of Patients with Eating Disorders 3rd Edition, to serve as an evidence-based framework for practitioners’ clinical decision making with adult patients who have an eating disorder. The Magellan Clinical Practice Guideline: Eating Disorders outlines its clinical strategy and goals for treatment of patients with bulimia nervosa and other eating disorders. The Magellan Care Guidelines define its medical necessity criteria and list levels of behavioral healthcare provided, including Acute Hospitalization, Subacute Hospitalization, Residential Treatment, Partial Hospitalization, Intensive Outpatient Programs, and Outpatient Treatment. All levels of care require a DSM-5 diagnosis.
Medica contracts with UnitedHealthcare/Optum™ to provide its behavioral health benefits. In its Coverage Determination Guideline: Treatment of Bulimia Nervosa, Guideline Number: BHCDG502016, Optum lists first-line treatments for bulimia to include nutritional rehabilitation, psychotherapy, and pharmacotherapy, as well as monitoring patients for medical complications. Optum’s policy further states, “Psychiatric hospitalization, day programs, partial hospitalization programs, and residential programs for eating disorders in should be considered only when outpatient interventions have been unsuccessful or are unavailable.” The policy also outlines Optum’s level of care criteria for admission to and continuation of Inpatient Care, Residential Treatment Center, Partial Hospitalization, Intensive Outpatient Program, and Outpatient Care.
Neighborhood Health Plan
Neighborhood Health Plan (NHP), a managed care organization and member of Partners HealthCare, contracts its behavioral healthcare benefits to Beacon Health Options. 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-5. NHP covers Inpatient, Outpatient, Intermediate or Diversionary Care, and Emergency Benefits for participating providers. Services for bulimia nervosa treatment depend on the exact plan a member has purchased. Information about the behavioral health services provided can be found in the NHP Commonwealth Care Member Handbook.
New Directions Behavioral Health
New Directions Behavioral Health (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 New Directions Medical Necessity Criteria. NDBH has adopted the Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines for the Treatment of Eating Disorders (2014).
Premera Blue Cross
Premera Blue Cross operates in Alaska and Washington state. Premera does not have a publicly available coverage policy relevant to eating disorders or bulimia nervosa. Premera partners with Quartet Health, Inc. to make behavioral healthcare more accessible to patients and integrated into primary care in Washington state through its web-based technology platform.
Regence Blue Cross and Blue Shield
Regence Blue Cross and Blue Shield uses the MCG Behavioral Health Care Guidelines to determine medical necessity for mental health and substance-related disorders. Regence currently lists no publicly available general coverage policies addressing eating disorders or bulimia on its website. However, one policy document, Behavioral Health, Policy No. 21: Supplement to MCG Discharge Criteria for Residential Treatment, notes that patients in residential care for bulimia nervosa, anorexia, or several other behavioral health disorders may be discharged if they are inadequately participating in the treatment program, or after 60 days of residential treatment without progress, are judged to be unlikely to improve with treatment. Two other documents, Surgery, Policy No. 74: Vagus Nerve Stimulation and Medicine, Policy No. 148: Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders state that Regence does not cover transcranial magnetic stimulation or vagus nerve stimulation for treating bulimia nervosa, citing the technologies as investigational and not medically necessary for this indication.
A related policy document, Behavioral Health, Policy No. 23: Supplement to MCG™ Criteria for Adult Substance-Related Disorders, Inpatient and Residential Behavioral Health Level of Care, notes that “After a combination of 3 or more residential or inpatient facility admissions for opioid detoxification treatment during the most recent 24 months, additional residential or inpatient admissions may be considered medically necessary only if a clinical rationale based upon the specific member’s particular circumstances clearly establishes a reasonable expectation of effectiveness despite the multiple previous, recent post-admission relapses.”
UnitedHealthcare administers behavioral health services to commercial health plans through its Optum division. Optum’s Coverage Determination Guideline: Feeding and Eating Disorders, Policy Number BH727FED_012017, states that available benefits for bulimia include: diagnostic evaluation, assessment, and treatment planning; treatment and/or procedures; medication management and other associated treatments; individual, family, and group therapy; provider-based case management services; and crisis intervention. Optum’s Coverage Determination Guideline: Feeding and Eating Disorders is carried out based on the organization’s Level of Care Guidelines: Mental Health Conditions, which address admission criteria for levels of care in several settings, including Outpatient, Intensive Outpatient, Day Treatment, Partial Hospitalization, Residential Treatment Center, and Inpatient Care.