National Eating Disorders Association

Medical necessity criteria continue to change over time and can differ between insurance companies. This American Psychiatric Association chart will give you a good sense of the levels of care, but consumers should be aware that weight, co-occurring conditions, and motivation for change are all considered when clinical programs and insurance consider level of care.

These guidelines are intended for use by treatment professionals in determining appropriate level of care. Please feel free to print and distribute to clinicians, insurance officials, and others involved in these decisions with your loved one.

American Psychiatric Association Level of Care Guidelines for Patients with Eating Disorders

  Level One: Outpatient Level Two: Intensive Outpatient Level Three: Partial Hospitalization (Full-day Outpatient Care) Level Four: Residential Treatment Level Five: Inpatient Treatment
Medical Status Medically stable to the extent that more extensive medical monitoring, as defined in levels 4 and 5, is not required Medically stable to the extent that intravenous fluids, nasogastric tube feedings, or multiple daily laboratory tests are not needed For adults:
Heart rate <40 bpm; blood pressure <90/60 mmHg; glucose <60 mg/dl; potassium <3 mEq/L; electrolyte imbalance; temperature <97.0°F; dehydration; liver, kidney, or cardiac compromise requiring acute treatment; poorly controlled diabetes

For children and adolescents:
Heart rate near 40 bpm; orthostatic blood pressure changes (>20 bpm increase in heart rate or >10 mmHg to 20 mmHg drop); blood pressure <80/50 mmHg; low potassium, phosphate, or magnesium levels

Suicidality If suicidality is present, inpatient monitoring and treatment may be needed depending on the estimated level of risk Specific plan with high lethality or intent; admission may also be indicated in patient with suicidal ideas or after a suicide attempt or aborted attempt, depending on the presence or absence of other factors modulating suicide risk
Weight as percentage of healthy body weight Generally >85% Generally >80% Generally >80% Generally <85% Generally <85%; acute weight decline with food refusal even if not <85% of healthy body weight
Motivation to recover, including cooperativeness, insight, and ability to control obsessive thoughts Fair-to-good motivation Fair motivation Partial motivation; cooperative; patient preoccupied with intrusive, repetitive thoughts >3 hours/day Poor-to-fair motivation; patient preoccupied with intrusive repetitive thoughts 4–6 hours a day; patient cooperative with highly structured treatment Very poor to poor motivation; patient preoccupied with intrusive repetitive thoughts; patient uncooperative with treatment or cooperative only in highly structured environment
Co-occurring disorders (substance use, depression, anxiety) Presence of comorbid condition may influence choice of level of care Any existing psychiatric disorder that would require hospitalization (i.e., severe depression, addiction, self-harm)
Structure needed for eating/gaining weight Self-sufficient Self-sufficient Needs some structure to gain weight Needs supervision at all meals or will restrict eating Needs supervision during and after all meals or nasogastric/ special feeding modality
Ability to control compulsive exercising Can manage compulsive exercising through selfcontrol Some degree of external structure beyond self-control required to prevent patient from compulsive exercising; rarely a sole indication for increasing the level of care
Purging behavior (laxatives and diuretics) Can greatly reduce incidents of purging in an unstructured setting; no significant medical complications, such as cardiac or other abnormalities, suggesting the need for hospitalization Can ask for and use support from others or use cognitive and behavioral skills to inhibit purging Needs supervision during and after all meals and in bathrooms; unable to control multiple daily episodes of purging that are severe, persistent, and disabling, despite trials of outpatient care, even if routine laboratory test results reveal no obvious abnormalities
Environmental stress Others able to provide adequate emotional and practical support and structure Others able to provide at least limited support and structure Severe family conflict or problems or absence of family so patient is unable to receive structured treatment in home; patient lives alone without adequate support system
Geographic availability of treatment program Patient lives near treatment setting Treatment program is too distant for patient to participate from home