Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oropharyngeal Dysphagia. 
Treatment: Feeding Therapy Program. 

The insurer denied coverage for feeding therapy program. 

The denial is upheld. 

The patient is a child with a past medical history notable for Down's syndrome, behavioral feeding difficulties, failure to thrive (resolved), developmental delay, chronic constipation (improved), congenital hydronephrosis, hearing loss and delayed oral motor skills that was referred to Pediatric feeding program to address his feeding difficulties. The patient had early issues with feeding that lead to intensive feeding intervention early on. He tolerates liquids well (Pediasure 1.5 with fiber) with acceptable growth along his own curve (height better than weight). He has not required supplemental nasogastric tube feeds. He accepts oral purees and select solids including pretzels, veggie sticks and scant graham crackers. He does not aspirate or have laryngeal penetration (MBS [modified barium swallow] study and UGI [upper gastrointestinal] series) or have a history of recurrent pneumonias. His last reported weight was 32 kilograms (18th percentile for age) and his height is 138.4 centimeters (57th percentile for age).  Recommended was made for multidisciplinary day feeding program for 8 weeks to transition to an age-appropriate solid diet. 

This child has feeding issues with delays in his transition to oral solids and self-feeding. He has adequate and consistent growth in both height and weight achieved through well tolerated oral liquid nutritional supplementation (Pedisure 1.5 with fiber - 3 cans daily) via cup. His constipation appears to have affected his feeding efforts in the past but is now well controlled. His feeding issues appear largely behavioral in nature with selective food preferences and poor self-feeding mechanics. 

This child has been labeled with oropharyngeal dysphagia. According to a review of oropharyngeal dysphagia from UpToDate the authors state the following: 

"There is limited evidence to support the use of swallow rehabilitation therapy. Studies are limited to the evaluation of specific maneuvers in individual patients or in small series of patients. However, despite this limited evidence, given the low cost and biologic plausibility that dietary and swallow training can reduce dysphagia and aspiration, we recommend dietary therapy in selected patients with mild oropharyngeal dysphagia." 

This particular patient does not appear at risk for aspiration with tolerance of fluids/thin liquids. 

This child would benefit from chronic feeding therapy to achieve a more age-appropriate diet. It is not clear that he has any medical conditions that would require a multidisciplinary team to monitor or intervene. It appears he has had multiple prior feeding therapies, but his caregivers have not made progress despite training. This child appears safe to eat (no aspiration history, tolerating liquids) but there clearly is a delay in his progression to solids and self-feeding that appears behavioral. He does not appear to be at risk of malnutrition with adequate growth for years without supplemental feeds. 

An intensive daily feeding therapy program does not appear medically necessary as feeding therapy can be achieved in a less restrictive environment. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for feeding therapy program is upheld. Medical necessity is not substantiated.