Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism and Feeding Problems.
Treatment: Intensive feeding therapy.
The insurer denied the Intensive feeding therapy.
The denial is overturned.

The patient is a male child with autism, speech delay, and severe feeding difficulties. He was unable to transition to spoon-fed cereal or purees via spoon. He was transitioned from formula and breast milk to regular milk then began taking Pediasure and Ensure. He was able to advance to a sippy cup without difficulty. He currently does not take anything from a spoon. He will drink water from a bottle but refuses juice. Attempts at dissolvable solids lead to gagging. He puts toys in his mouth but has not swallowed any.

The patient's diet consists of six bottles of Pediasure and two cups of regular milk. He tolerates several flavors and brands of enteral nutritional drinks but is restricted to one sippy cup. He can touch food with his hands but does not put it in his mouth. He has no issues with vomiting or constipation. He was diagnosed with autism.

With his current diet, the patient has maintained adequate weight gain. He is meeting his estimated nutritional needs per an evaluation by the dietitian. When the patient was evaluated by the speech therapist, presentation of an empty spoon resulted in agitation and hitting his own head with a closed fist. Oral motor evaluation revealed tongue thrust and absent skills to consume an age-appropriate diet.

The patient was diagnosed with a severe feeding disorder characterized by the following: sippy cup dependence, food refusal, and oral motor delays. Intensive services with a multi-disciplinary team were recommended to improve both his skills and his intake volume. The following goals were established at that evaluation: less than 15% negative feeding behaviors per meal; consume goal volume puree meals in 30 minutes or less; accept presentation of liquids via Honey Bear Squirt Bottle; parents will administer the feeding protocol with 85% accuracy for optimum carryover to other environments. At that time he was placed on the waiting list for either the outpatient program or the day treatment program.

The patient currently receives ABA (applied behavior analysis), occupational therapy, and speech therapy in school. There have been no improvements in his feeding behaviors with these therapies. The intensive program has been recommended to address his severe eating disorder and feeding difficulties.

Yes, the requested intensive feeding program is medically necessary and appropriate for this child.
A feeding disorder is an inability to consume adequate and appropriate nutrition by mouth. While feeding disorders may ultimately lead to eating disorders, they are not the same. Feeding disorder symptoms include inadequate fluid intake, food refusal, difficulty swallowing, inability to feed oneself, prolonged feeding time, choking or gagging and emesis, inappropriate mealtime behaviors and selecting food by its type or texture. About 25 percent of all children, and up to 80 percent of developmentally disabled children, exhibit feeding disorders. Severe and persistent feeding disorders occur in 3 to10 percent of children, particularly those with chronic conditions. The etiology of feeding disorders is multifactorial, and includes medical, nutritional, behavioral, psychological and environmental factors. If not dealt with appropriately, feeding disorders can lead to cognitive decline, malnutrition, growth retardation, increased susceptibility to illness and even death.

This child has a severe feeding disorder. As a school-aged child, he is unable to tolerate anything but liquid enteral nutrition by mouth. While he is getting adequate calories according to the dietitian, he is refusing any pureed foods by mouth, will not tolerate a spoon in his mouth, and has restricted use of his method of taking nutrition. The severity of his feeding disorder is jeopardizing his growth and development. So far, he has not responded to ABA (applied behavior analysis), occupational therapy, or speech therapy. His mother was observed to utilize many tools to attempt to feed him without success. At this time, he requires an intensive feeding program that is multi-disciplinary in scope and practice to provide support in all areas affected. The requested program is medically necessary and appropriate.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.