Clinical Policy: Pediatric Oral Function Therapy

Reference Number: CP.MP.188
Date of Last Revision: 10/25

See Important Reminder at the end of this policy for important regulatory and legal information.

Description

Goals of oral function therapy are to identify the child’s optimal feeding methods, maximize safety and avoid the risk of medical complications and help the child achieve age-appropriate functional skills. The therapist will work with the child and the family to create a customized plan to maximize quality of life and prevent future issues.¹²

Policy/Criteria

I. It is the policy of health plans affiliated with Centene Corporation® that initial pediatric oral function therapy is medically necessary when meeting all of the following:
A. One of the following:

1. Anatomic or neurologic condition contributing to failure to meet developmental milestones of growth and development, including either of the following:  
    a. Reduction in weight or cessation of weight gain over the previous two months;  
    b. Crossing two or more major weight percentiles downward;  
2. Pediatric feeding disorder, swallowing impairment, or avoidant/restrictive food intake disorder (ARFID) that causes a significant change in feeding behavior, which compromises the child’s nutritional status, including either of the following:  
    a. Reduction in weight or cessation of weight gain over the previous two months;  
    b. Crossing two or more major weight percentiles downward;  
3. Under five years of age and failing to meet developmental milestones of growth and development, including either of the following:  
    a. Significant weight loss or cessation of weight gain over the previous two months;  
    b. Crossing two or more major weight percentiles downward;  
4. Under five years of age and growth and developmental milestones have been met, but only via any of the following methods, and the transition to nutritionally and calorically appropriate foods is warranted:  
    a. Nutritional support consisting of high-calorie foods or nutritionally deficient foods;  
    b. Parenteral nutrition;  
    c. Gastrostomy feedings;  
5. Demonstrates signs and symptoms of aspiration or penetration of liquids into the respiratory tract, resulting in respiratory issues such as pneumonia and respiratory distress;  
6. Factor affecting neuromuscular coordination such as prematurity, low birth weight, hypotonia or hypertonia;  
7. Limited food intake due to a neurodevelopmental disability, such as autism, that can cause hypersensitivity to textures;  
8. Limited food intake due to hypersensitivity to textures secondary to limited food availability or exposure in early development;

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Pediatric Oral Function Therapy

9. Complex medical conditions with concern for feeding difficulty (e.g., heart disease, pulmonary disease, allergies, gastroesophageal reflux disease, delayed gastric emptying);
   B. All of the following:

   1. Adequate treatment for any contributing underlying medical conditions, if present, has occurred without resolution of the feeding problem;
   2. Documentation of an individualized treatment plan with achievable and measurable short and long term goals of therapy and estimated length of treatment.

Background

Feeding disorders are problems with a range of eating activities that may or may not include problems with swallowing. Pediatric Feeding Disorder (PFD) is “impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.”²⁻³ PFD can be characterized by one or more of the following behaviors²:

• Avoiding or refusing one’s food intake
• Accepting a restricted variety or quantity of foods or liquids
• Displaying disruptive or inappropriate mealtime behaviors for developmental level
• Failing to master self-feeding skills expected for developmental level
• Failing to use developmentally appropriate feeding devices and utensils
• Experiencing less than optimal growth

Avoidant/Restrictive Food Intake Disorder (ARFID) is an eating or feeding disturbance characterized by a lack of interest in food or eating, avoidance of eating due to sensory characteristics of food, or aversion to consequences of eating.² ARFID is demonstrated by persistent failure to meet age-appropriate nutritional and/or energy needs and is associated with one or more of the following²:

• Significant weight loss or failure to achieve expected weight gain
• Significant deficiency in nutrition
• Dependence on enteral feedings or oral nutritional supplements
• Marked interference with psychosocial functioning

Although dysphagia is a frequently occurring impairment for children with disabilities, feeding and swallowing disorders can occur in children of all ages and occur for many different reasons.¹⁻² Clinical assessments of feeding and swallowing, which are primarily completed by speech-language pathologists or occupational therapists, consist of examination of the face and oropharynx, respiratory rate and pattern, posture and position, cranial nerve and reflexes, and

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vocal quality.⁴ Reasons for feeding and swallowing disorders and disabilities may be temporary, permanent, or progressive.¹⁻²

Common causes of pediatric feeding and swallowing disorders include the following²:

• Complex medical conditions
• Developmental disability
• Factors affecting neuromuscular coordination
• Genetic syndromes
• Medication side effects
• Neurological disorders
• Sensory issues as a primary cause or secondary to limited food availability or exposure in early development
• Structural abnormalities
• Behavioral factors
• Socio-emotional factors

Coding Implications

This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

Reviews, Revisions, and Approvals

| Updated background. References reviewed and updated. Replaced all instances of member with member/enrollee. Removed ICD-10 codes. | 05/21 | 05/21 |

| Annual review completed. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Expanded criteria I.D.1.-3. and included parenteral nutrition and/or gastrostomy feedings as options for nutritional support. | 05/22 | 05/22 |

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Pediatric Oral Function Therapy

| Annual review. Updated Criteria I.A. to include anatomic conditions and removed “severe” and “complex” verbiage. Minor rewording in Criteria section with no impact on criteria. Listed disorders and impairments in Criteria I.B. for clarity. Added Criteria I.H. to include complex medical conditions with concern for feeding difficulty. Background updated with no impact on criteria. References reviewed and updated. | 05/23 | 05/23 |

| Annual review. References reviewed and updated. Reviewed by external specialist. | 05/24 | 05/24 |

| Annual review. Updated “sensory issue” to “neurodevelopmental disability” in Criteria I.G. for clarity. Added Criteria I.H. regarding limited food intake due to hypersensitivity…Background updated to align with updated criteria. Reviewed codes and descriptions. References reviewed and updated. Reviewed by internal specialist. | 04/25 | 04/25 |

| Updated Criteria I. to specify initial pediatric oral function therapy. Added Criteria I.B. regarding adequate treatment for any contributing underlying medical conditions, and documentation of an individualized treatment plan…Added Criteria II. regarding requirements for continuation of pediatric oral function therapy. | 10/25 | 10/25 |

3. Goday PS, Huh SY, Silverman A, et al. Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework. J Pediatr Gastroenterol Nutr. 2019;68(1):124 to 129. doi:10.1097/MPG.0000000000002188
4. Das S, Boesch RP. Aspiration due to swallowing dysfunction in children. UpToDate. www.uptodate.com. Updated November 09, 2023. Accessed February 25, 2025.

Important Reminder

This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical

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practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.