80053
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Electrocardiogram (ECG) results to identify cardiac abnormalities (sinus bradycardia, signs of hypokalemia, arrhythmias) when clinically indicated.
- Psychiatric assessment documentation for concurrent psychiatric illness, suicide risk assessment, and psychosocial evaluation.
- For enteral (nasogastric) feeding/re-feeding: documentation of malnutrition status, indication for tube feeding, feeding protocol used, prophylactic phosphate supplementation if used, monitoring of refeeding syndrome parameters, and documentation of short-term weight gain and adverse events.
- For pharmacotherapy: documentation of prior treatments and response (e.g., failure of psychotherapy or other agents where relevant), dosing/titration and monitoring of adverse effects (e.g., for lisdexamfetamine monitoring of vital signs, heart rate, weight; for topiramate monitoring cognitive effects and tolerability), and contraindications (e.g., bupropion contraindication for BN).
Key Coverage Criteria
- Treatment: Pharmacotherapy for the treatment of bulimia (e.g., selective serotonin reuptake inhibitors such as fluoxetine, tricyclic anti-depressants, trazodone, topiramate).
- Treatment: 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.)
- Management of members with anorexia or bulimia (Medically Necessary services and procedures listed below).
- Assessment: Blood count and serum chemistry (e.g., CBC, electrolytes, BUN/creatinine).
- Assessment: Bone density measurement (for evaluation of anorexic members).
- Assessment: Electrocardiography.
1 Active Policy
AETNA-CPB-0511 — Eating Disorders
Related Codes
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