Anthem Blue Cross Connecticut CG-MED-37 Intensive Programs for Pediatric Feeding Disorders Form

This document addresses the use of intensive programs for pediatric feeding disorders. The term "feeding disorder" refers to a condition in which an individual is unable or refuses to eat, or has difficulty eating, resulting in failure to grow normally. Feeding disorders should not be confused with eating disorders, such as anorexia, which are more common in adolescence and adulthood. Some common types of feeding disorders in children include, but are not limited to, adipsia (the absence of thirst or the desire to drink); dysphagia (difficulty in swallowing); food refusal; inability to self-feed; taking too long to eat; choking, gagging, or vomiting when eating; inappropriate mealtime behavior; and picky eating according to food type and texture.

Note: Please see the following documents for more information regarding issues related to topics addressed in this guideline:

• CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
• CG-MED-08 Home Enteral Nutrition

Clinical Indications

Medically Necessary:

An evaluation* to confirm a suspected diagnosis of pediatric feeding disorder^† is considered medically necessary for children whose difficulties began under five (5) years of age who meet either of the following criteria:

1. Failure to meet developmental milestones of growth and development, including either of the following:
   1. Significant weight loss or reduction or cessation of weight gain over the previous 2 months; or
   2. Crossing 2 or more major weight percentiles downward; or
2. Growth and development milestones have been met, but only via nutritional support consisting of high-calorie foods, nutritionally deficient foods, or both, and transition to nutritionally and calorically appropriate foods is warranted.  

An evaluation* to confirm a suspected diagnosis of pediatric feeding disorder^† is considered medically necessary for children of any age who meet either of the following criteria:

1. Severe, complex neurologic or neuromuscular disorders are present and are felt to be contributing to failure in meeting developmental milestones of growth and development, including either of the following:
   1. Reduction or cessation of weight gain over the previous 2 months; or
   2. Crossing 2 or more major weight percentiles downward; or
2. Significant change in feeding behavior is felt to be compromising the child’s nutritional status, including any of the following:
   1. Reduction or cessation of weight gain over the previous 2 months; or
   2. Crossing 2 or more major weight percentiles downward.

*This evaluation should include:

• A thorough medical evaluation including neurologic, metabolic and gastrointestinal (specifically malabsorption and gastroesophageal reflux disease) clinical nutritional work-up as indicated; and
• An evaluation to identify any structural or functional abnormalities; and
• An evaluation of possible behavioral components.

^†Possible situations that could initiate an evaluation for a pediatric feeding disorder include:

• Child coughs, chokes or gags while eating or immediately after eating; or
• Child demonstrates a history of chronic pulmonary difficulties which may include diagnosis of aspiration pneumonia; or
• Vocal cord dysfunction; or
• Food is being suctioned out of the child’s airway; or
• Weight gain is poor and difficult and this is thought to be secondary to an oral-sensorimotor, pharyngeal, or swallowing dysfunction; or
• Difficulty initiating a swallow; or
• Structural abnormalities are present that may interfere with the development of a normal swallow; or
• Chronic food refusal; or
• “Pocketing” of food during meals; or
• Excessive length of time getting child to eat (meals lasting greater than 30 minutes); or
• Neuromotor involvement affecting oral-sensorimotor coordination and respiration; or
• Chronic poor growth or compromised nutritional status; or
• Difficulties transitioning from tube or gastrostomy tube feedings to oral feedings.

A reevaluation is considered medically necessary when there are any of the following:

1. New clinical findings; or
2. A rapid change in individual’s status; or
3. Failure to respond to therapy interventions (for example, speech and language, occupational therapy, physical, and behavioral therapy).

Note: There are several routine reassessments that are not considered reevaluations. These include ongoing reassessments that are part of each skilled treatment session, progress reports, and discharge summaries. Reevaluation is a more comprehensive assessment that usually includes the components of the initial evaluation, and may also include components such as:

• Data collection with objective measurements taken based on appropriate and relevant assessment tests and tools using comparable and consistent methods; or
• Making a judgment as to whether skilled care is still warranted; or
• Organizing the composite of current problem areas and deciding a priority/focus of treatment; or
• Identifying the appropriate intervention(s) for new or ongoing goal achievement; or
• Modification of intervention(s); or
• Revision in plan of care if needed; or
• Correlation to meaningful change in function; or
• Deciphering effectiveness of intervention(s).

The treatment of a pediatric feeding disorder is considered medically necessary when such a disorder has been diagnosed after appropriate evaluation and all of the following criteria are met:

1. A thorough medical evaluation, as described above, has been completed; and
2. Adequate treatment for any contributing underlying medical conditions, if present, has occurred without resolution of the feeding problem; and
3. A treatment plan, individualized to each child, is developed and includes diagnosis, problem list, proposed treatment plan with specific interventions, and estimated length of treatment.

Note: Other issues that may be addressed include specific dietary interventions or special formulas, positioning during feeding, behavioral interventions and family or caregiver education. Intensity of treatment may vary from short-term intermittent outpatient visits to more intensive treatment programs. Inpatient or intensive outpatient treatment programs may be warranted for severe cases, such as malnutrition or failure to thrive, unstable electrolyte disorders, potentially serious allergic reactions to food, significant difficulty transitioning from tube feedings to oral feedings, etc.

Not Medically Necessary: 

Evaluation and treatment for pediatric feeding disorders are considered not medically necessary when the criteria above have not been met.

A feeding disorder treatment program is considered not medically necessary for children who can eat and swallow with normal functioning, but who are “picky eaters” or have selective eating behaviors and yet continue to meet normal growth and developmental milestones, and other medically necessary criteria above have not been met.

Inpatient admission for a pediatric intensive feeding program is considered not medically necessary, except when the individual requires facility-based care related to acute medical complications of the feeding disorder (for example, malnutrition or failure to thrive, unstable electrolyte disorders, potentially serious allergic reactions to food, significant difficulty transitioning from tube feedings to oral feedings, etc.).

Duplicate therapy is considered not medically necessary.

Note: When individuals receive concurrent physical, occupational, behavioral, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.

Maintenance programs are considered not medically necessary.

Note: A maintenance program consists of treatments or activities that preserve the individual's present level range, strength, coordination, balance, pain, activity, function, etc. and prevent regression of the same parameters. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. In certain circumstances, the specialized knowledge and judgment of a qualified therapist may be required to establish a maintenance program, however, the repetitive therapy services to maintain a level would be considered not medically necessary.