To expedite the review process, be sure to review our medical necessity criteria expectations for admission, continued stay and discharge.

Medical necessity criteria

Below is a general outline that our care managers will follow when reviewing Eating Disorder (ED) Cases; however depending on the specifics, the care manager may ask for additional information. For Concurrent Reviews, Care Managers will then need to obtain all clinical information that was not given during the initial review.

DSM Diagnosis Information

• Include any Clinical Disorders, Personality Disorders, Intellectual Disability, or General Medical Conditions

Clinical Presentation

• Reason for admission (MH & SA HX, SU issues, mental health status, stressors)
• Clinical factors that support your requested level of care
• Medications: Types, dosage, frequency, titration plan and who prescribed
• Current ED symptom use: Restricting, purging, binging and/or exercising (frequency and duration)
• Current ED behaviors and food rituals during meals/caloric intake including supplements
• Current weight changes (% of IBW/BMI/Pediatric Growth Charts)
• Any medical issues including daily vitals, orthostatic changes and updated labs
• Progress in treatment including motivation/participation
• If in a Partial Program, describe how patient is using the skills outside of treatment hours

Treatment Intervention/ Planning

• Individual/group therapy to address triggers/barriers to recovery
• Learning effective coping skills
• Nutritional planning and education
• Individualized meal planning including meal passes and/or off campus meals
• Family therapy/Family week involvement

Discharge Planning

• Identify discharge plan
• 7-day follow up appointments
• Set up with Outpatient Nutritionist
• Identify any barriers to follow-up
• Has the outpatient provider been notified of the admission?
• Please provide the discharge information during last review or if no further authorization is needed, you may leave the information on the designated staff’s voicemail.