Appeal type: Medical necessity
Decision: Overturned

This is a patient who has been diagnosed with autism spectrum disorder and a severe feeding disorder. 
The patient was delivered by emergency Cesarean section for failure to progress at 40 weeks gestation, following an uncomplicated pregnancy. She weighed 8 pounds 14 ounces. She was breast and bottle fed. She developed a skin rash, and was diagnosed with a cow's milk allergy. This was removed from her diet. Baby cereal was introduced, and she advanced to a variety of baby cereals. Jar food was introduced. She would not accept spooned foods, and stayed on formula. Her grandmother started to make vegetable smoothies for her. An attempt was made to introduce a holistic diet, transitioning from formula to coconut milk, but she was found to be allergic to coconut. She did not transition back to regular formula, refusing to drink it. By 1 year of age she would accept some solid foods, such as Ramen noodles, but would have "Food jags" where she would only accept certain foods for a time, then refuse to eat them. She would only drink from a particular bottle with a NUK nipple. She was, and still is, sensitive to textures and temperature of food. She refuses to eat or drink when in an unfamiliar environment, or when unfamiliar people are present. On the Vineland Adaptive Behavioral Scales IIIrd Edition, her composite score was 32. She was evaluated by a gastroenterologist for abdominal pain. This resolved when milk was reintroduced to her diet. Laboratory testing was normal (complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, amylase, lipase, C-reactive protein (CRP)). Genetic testing performed showed an 866.5 kb deletion on chromosome 8p23.2p23.1 of uncertain clinical significance.
She has been prescribed Intuniv (guanfacine) but this resulted in insomnia. She is now taking Quillivant (methylphenydate), which she has tolerated better. She eats slightly less, but this improves with sleep.
She lives with her parents, younger brother, and maternal grandmother. She is in a special education, behavioral based classroom with 6 children, 1 teacher and 2 aides. She has a 1:1 aide. She receives 3x30 minutes per week each of speech therapy and occupational therapy, and 15 hours of applied behavioral analysis (ABA) therapy each week. The health plan's determination is overturned.
This patient has autism spectrum disorder and a severe feeding disorder. She has severe food refusal, and a very limited repertoire of foods. She has tantrum behavior at mealtimes. She has made progress, adding 13 new foods to her repertoire since starting intensive therapy.
Children with autism spectrum disorder are at risk of significant nutritional disorders and malnutrition when their diet is extremely restricted due to severe food refusal. This can occur despite maintenance of a normal weight and height. The reviewer has cared for an autistic child with kwashiorkor due to refusal to eat protein in their diet.
Tang et al [1] describe that severe feeding disorder and food aversion can result in malnutrition despite the child's weight being within a normal range. They describe a patient with anemia, hypoalbuminemia and hypoproteinemia secondary to severely restricted dietary intake.
A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders by Sharp et al [2] concluded that "intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties". Marshall et al [3] also concluded that feeding therapy involving either operant conditioning or systematic desensitization intervention resulted in more improvements in dietary variety/intake, and more reductions in difficult mealtime behaviors in children with autism spectrum disorder. Therefore, the requested services are medically necessary for this patient.