Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe feeding problems.
Treatment: Telehealth treatment/video intense feeding therapy, swallowing dysfunction. 
The insurer denied the Telehealth treatment/video intense feeding therapy, swallowing dysfunction.
The determination is overturned.

The patient has a history of severe feeding problems, failure to thrive, gastroesophageal reflux disease and solid food refusal. She was enrolled in an intensive feeding program and showed steady improvement. Her weight remains at the 7th percentile and height at the 9th percentile.
The requested service is continuation of the intensive feeding program via telehealth and this is under review for medical necessity.
Continuation of the intensive feeding program is medically necessary for this child. This patient has a complex condition and has feeding problems, food aversion, failure to thrive and inappropriate diet for age. She has made significant progress so far since joining the feeding program. The requested feeding program is proven to be safe and effective in improving the member's condition. The service is provided by a multidisciplinary team that includes speech therapy, occupational therapy, psychology and nutrition service. The team is supervised by a pediatric gastroenterologist.
According to Clark, Racheal R., et al: "Admission to intensive programs can be beneficial for these high-risk populations. These benefits include the capacity to rapidly wean children from feeding tubes, access to medical and dietary professionals throughout, and a highly-controlled environment to make behavior change. Intensive programs also typically involve multiple feeding sessions per day and a treatment team approach in which multiple providers (e.g., psychology, speech, occupational therapy, nutrition) deliver services concurrently. This high frequency of feeding sessions can result in rapid improvement in behavior (e.g., volume, variety, mealtime problem behavior) and offer greater monitoring of the child across multiple providers".
According to Silverman, Alan: "It is increasingly evident that tele-health can improve access to rehabilitation services and specialists; prevent unnecessary delays in receiving care, including weather events impacting travel; and facilitate coordinated care and inter-professional collaboration. The World Health Organization (WHO) affirms the efficacy of tele-health as an effective service delivery model for rehabilitation professionals (i.e., tele-rehabilitation)".
Given the current coronovirus disease 2019 (COVID-19) pandemic, the telehealth option is the safest and most appropriate setting for this service. The current peer reviewed literature support the use of tele health platforms for providing intensive feeding program.
According to Peterson, Kathryn M., et al:" Providing services virtually may have health benefits for the child. Many children with feeding disorders are vulnerable to recurrent illness or are immunocompromised. Thus, they are at increased risk for contracting an illness each time they leave home. Exposure to other children in the clinic who may be sick is an unnecessary risk when telehealth services are available. This benefit is particularly relevant during the current pandemic, as COVID-19 is highly contagious. Some caregivers have reported that they are more comfortable with telehealth appointments because they reduce their child's exposure to other children and possible risk of infection."
Therefore, the requested service is consistent with the generally accepted practice and proven to be beneficial.
The patient has improved with the previous treatment sessions but has not achieved her nutritional and feeding goals.
Therefore, continuation of the intensive feeding program via telehealth is medically necessary.