Aetna considers the following services and procedures medically necessary for the management of members with anorexia or bulimia.

1. Assessment:

   • Medical evaluation (complete medical history and physical examination)
   • Blood count and serum chemistry (e.g., CBC, electrolytes, BUN/creatinine)
   • Urinalysis
   • Liver function tests
   • Electrocardiography

   • Psychiatric/psychological consultation and testing

2. Treatment:

   • Nutritional counseling (see CPB 049 - Nutritional Counseling)
   • Psychotherapy (e.g., cognitive behavioral therapy, family psychotherapy, interpersonal psychotherapy, and psychodynamic psychotherapy)
   • Pharmacotherapy for the treatment of bulimia (e.g., selective serotonin reuptake inhibitors such as fluoxetine, tricyclic anti-depressants, trazodone).**
   • Pharmacotherapy for the treatment of anorexia (e.g., selective serotonin reuptake inhibitors and anti-psychotics).**

** Note: Coverage of particular drugs within each class may be subjected to formulary restrictions, where applicable.

Aetna considers the following services/procedures experimental and investigational for the diagnosis and treatment of anorexia and bulimia.

1. Assessment:

   • Brain imaging

2. Treatment:

   • Bisphosphonates and other anti-resorptive agents in the management of osteopenia in anorexic members
   • Naltrexone, lithium, and bupropion (Zyban) for bulimia
   • The Mandometer treatment
   • Repetitive transcranial magnetic stimulation.

Eating disorders are characterized by marked disturbances in eating behavior. There are two severe forms of eating disorders -- anorexia nervosa and bulimia nervosa. Anorexia usually commences in the years between adolescence and young adulthood, with 90% of the patients being female. In the female gender, anorexia has a prevalence of approximately 1% with a lifetime mortality rate of 15 to 20%. There are three classical symptoms associated with this eating disorder: (i) refusal to maintain a minimally normal body weight (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to attain expected weight gain during period of growth, leading to body weight less than 85% of that expected), (ii) disturbance of body image and intense fear of being fat, and (iii) in post-menarcheal females, amenorrhea (i.e., absence of 3 consecutive menstrual cycles). A diagnosis of anorexia should be considered for a young woman with symptoms of an eating disorder, amenorrhea, and a body mass index of 17.5 kg/m² or lower. Similar considerations apply to a male patient with unexplained weight loss.

Bulimia is more common than anorexia. In females, bulimia has a prevalence of 2 to 5%, but a lesser mortality rate. It is characterized by four key symptoms: (i) over-concern with weight and body shape, (ii) recurrent episodes of binge eating, (iii) recurring subsequent purging, restriction, or excessive exercise, and (iv) binge eating and subsequent inappropriate compensatory behaviors, occurring a minimum average of twice a week for at least three months. In contrast to patients with anorexia, individuals with bulimia are generally in normal weight range, although recurrent weight changes are frequently observed.

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.

A complete blood count may reflect anemia due to nutritional deficiency. Serum electrolyte imbalances may occur in patients with bulimia. Other laboratory tests include blood urea nitrogen/creatinine levels, serum measurements of calcium, magnesium, phosphorus, urinalysis, and liver function tests. An electrocardiogram may aid to identify cardiac abnormalities such as sinus bradycardia, as well as signs of hypokalemia or ipecac-induced myopathy. In general, brain imaging and bone mineral density studies are not necessary. A psychiatric assessment of patients with an eating disorder is appropriate for identification of any concurrent psychiatric illness, evaluation of the risk of suicide, and exploration of the psychosocial context of the symptoms.

Treatments for patients with eating disorders include nutritional counseling; psychotherapy such as cognitive behavioral therapy, family psychotherapy, interpersonal psychotherapy, and psychodynamic psychotherapy; as well as pharmacotherapy. Nutritional counseling, with a reasonable, graduated eating plan tied to specific weight goals, as well as psychotherapy are essential. Medication plays an important, but limited role in the management of eating disorders. In general, drug therapy is not effective in treating anorexia -- zinc, cyproheptadine, anti-depressants, and neuroleptic agents -- have not been shown to improve symptoms.

On the contrary, pharmacotherapy is moderately effective in treating bulimia. High-dose (60-mg) fluoxetine (Prozac) and other selective serotonin re-uptake inhibitors such as trazodone (Desyrel) have been shown to be helpful in treating bulimia. Tricyclic antidepressants such as imipramine (Tofranil) and desipramine (Norpramin) have been demonstrated to reduce binge eating and vomiting in bulimic patients. Monoamine oxidase inhibitors such as phenelzine (Nardil) should not be used as initial pharmacotherapy for bulimia because of their considerable side effects. Bupropion (Zyban) is contraindicated in the treatment of bulimia because of increased risk of seizures. Neither naltrexone nor lithium has been shown to be effective in treating bulimia. The role of bisphosphonates (e.g., alendronate and risedronate) and other anti-resorptive agents in the management of osteopenia in anorexic patients has not been established. In a randomized controlled trial, Golden et al (2005) concluded that in adolescents with anorexia nervosa, weight restoration is the most important determinant of bone mineral density, but treatment with alendronate did increase the bone mineral densities of the lumbar spine and femoral neck within the group receiving alendronate, but not compared with placebo in the primary analysis. Until additional studies have demonstrated efficacy and long-term safety, the use of alendronate in this population should be confined to controlled clinical trials. Dietary supplements are usually not recommended for anorexia. In a randomized controlled study, Barbarich, et al. (2004) concluded that supplement strategies are not a substitute for adequate nutrition and are ineffective in increasing the efficacy of fluoxetine in underweight anorexia nervosa subjects. Tube or intravenous feeding is rarely needed or recommended unless the patient's condition is life threatening.

An evidence review on the management of eating disorders prepared for the Agency for Healthcare Research and Quality (AHRQ) (Berkman, et al., 2006) stated that no medications are available that effectively treat patients suffering from anorexia nervosa, but a few behavioral therapies may help prevent a relapse and offer other limited benefits. A Cochrane review on anti-depressants for anorexia nervosa (Claudino, et al., 2006) also concluded that a lack of quality information precludes definite conclusions or recommendations being rendered on the use of anti-depressants in acute anorexia nervosa. Future studies testing safer and more tolerable anti-depressants in larger, well-designed studies are needed to provide guidance for clinical practice.

The review by AHRQ also noted that both medications (e.g., fluoxetine, tricyclic anti-depressants) and behavioral therapies were found helpful in treating bulimia nervosa; however, there was no clear information about how to combine medications with behavioral treatments (Berkman, et al., 2006).

In a clinical trial, Miljic, et al. (2006) evaluated the effects of ghrelin, a gastric hormone, on appetite, sleepiness, and neuroendocrine responses in patients with anorexia nervosa. Twenty-five young women, including 9 patients diagnosed with anorexia nervosa with very low body weight, 6 patients who partially recovered their body weight but were still amenorrheic, and 10 constitutionally thin female subjects, without history of eating disorder, weight loss, with regular menstrual cycles, were included in the study. Each patient received 300-min intravenous infusion of ghrelin 5 pmol/kg/minute and was asked to complete visual analog scale (VAS) questionnaires hourly. Main outcome measures were VAS scores for appetite and sleepiness, growth hormone (GH), prolactin, and cortisol responses were measured. At baseline, patients with anorexia nervosa had significantly higher ghrelin, GH, and cortisol levels and significantly lower leptin than constitutionally thin subjects. Responses of GH to ghrelin infusion were blunted in patients with anorexia nervosa. Ghrelin administration did not significantly affect appetite but tended to increase sleepiness in patients with anorexia nervosa. These investigators concluded that ghrelin is unlikely to be effective as a single appetite stimulatory treatment for patients with anorexia nervosa. These results suggested that patients with anorexia nervosa are less sensitive to ghrelin in terms of GH response and appetite than healthy controls. Ghrelin effects on sleep need further studies.

The Mandometer treatment is a controversial program for patients with eating disorders. It is a residential program that averages approximately12 months in duration. While management of patients with eating disorder has often included psychiatric treatment, advocates of the Mandometer treatment assert that standard psychiatric treatment is largely ineffective for these patients. They believe anorexia and bulimia to be essentially the same disorder. The Mandometer treatment for both anorexics and bulimics consists of re-teaching eating habits with a computerized, hand-held Mandometer (it gives continuous biofeedback about food intake over the course of meals), re-learning sensations of satiety, external heating by resting in warm rooms and using warm jackets, restriction of physical activity, and social re-construction to restore normal social interactions without the use of psychoactive drugs.

Evidence for the effectiveness of the Mandometer treatment came primarily from a Swedish group (Bergh et al, 1996; Bergh et al, 2002; Court et al, 2005). In a randomized controlled study, Bergh and colleagues (2002) assessed the effectiveness of the Mandometer treatment. A total of 16 patients, randomly selected out of a group composed of 19 patients with anorexia nervosa and 13 with bulimia nervosa, were trained to eat and recognize satiety by using computer support. They rested in a warm room after eating, and their physical activity was restricted. The patients in the control group (n = 16) received no treatment. Remission was defined by normal body weight (anorexia), cessation of binge eating and purging (bulimia), a normal psychiatric profile, normal laboratory test values, normal eating behavior, and resumption of social activities. Fourteen patients went into remission after a median of 14.4 months (range of 4.9 to 26.5 months) of treatment, but only 1 patient went into remission while waiting for treatment (p = 0.0057). Relapse is considered a major problem in patients who have been treated to remission. Thus, these researchers reported results on a total of 168 patients who have entered their treatment program. The estimated rate of remission was 75 %, and estimated time to remission was 14.7 months (quartile range 9.6 greater than or equal to 32). Six patients (7 %) of 83 who were treated to remission relapsed, but the others (93 %) have remained in remission for 12 months (quartile range of 6 to 36 months). Because the risk of relapse is maximal in the first year after remission, the authors suggested that most patients treated with this method recover. Furthermore, these investigators noted that although these results are promising, they realized the necessity to further develop their method. For example, it is necessary to examine if one of their interventions is more important than another, and if their procedures should be modified. More importantly, however, is that a randomized controlled trial comparing this method with the standard of care for eating disorders is needed. Court et al (2005) presented the case of a girl with severe anorexia nervosa who had previously been resistant to treatment, and who was subsequently treated successfully by the Mandometer program.

The clinical value of the Mandometer treatment for the management of patients with eating disorders has not been established. Its effectiveness need to be validated by well-designed studies.

In a single-center, randomized, double-blind, sham-controlled study, Walpoth et al (2008) examined the effectiveness of repetitive transcranial magnetic stimulation in the treatment of bulimia nervosa. A total of 14 women meeting DSM-IV criteria for bulimia (BN) were included in this trial. In order to exclude patients highly responsive to placebo, all patients were first submitted to a 1-week sham treatment. Randomization was followed by 3 weeks of active treatment or sham stimulation. The main outcome criterion was the change in binges and purges. Secondary outcome variables were the decrease of the Hamilton Depression Rating Scale (HDRS), the Beck Depression Inventory (BDI) and the Yale-Brown Obsessive Compulsive Scale (YBOCS) over time. The average number of binges per day declined significantly between baseline and the end of treatment in the two groups. There was no significant difference between sham and active stimulation in terms of purge behavior, BDI, HDRS and YBOCS over time. The authors concluded that these findings indicated that repetitive transcranial magnetic stimulation in the treatment of BN does not exert additional benefit over placebo.