Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Retained primitive reflexes; pediatric feeding disorder.
Treatment: Occupational Therapy.

The insurer denied the Occupational Therapy.  The denial is upheld.

This is a female. She underwent initial OT (occupational therapy) evaluation. The therapist mentioned the Peabody Developmental Motor Scales, Second Edition (PDMS-2), and indicated that the patient performed in the average range; however, she failed to report scaled or standard scores. As such, the evaluation was entirely subjective and descriptive, devoid of objective, measurable data. The parent raised concerns for symptoms of pediatric feeding disorder (PFD), but the therapist failed to perform an oral motor / feeding evaluation. The therapist documented the patient allegedly having "retained primitive reflexes," but provided no evidence to support their presence. The request is for OT (occupational therapy) to address multiple targeted areas for which no standardized testing was administered. Goals are broad, non-specific, subjective, and/or not directly measurable.

No, the requested occupational therapy is not medically necessary.

Developmental reflexes (i.e., primitive reflexes) appear at a certain time during brain development, and normally disappear with progressive maturation of cortical inhibitory functions. They are mediated at subcortical levels. Assessment of developmental reflexes is important in the newborn period and during infancy [NICE].

Common developmental reflexes, their descriptions, and time of appearance and resolution are as follows [NICE]:

1)  Moro (startle). Appears at 32 weeks' gestational age, is well established by 37 weeks' gestational age, and resolves by age 3 to 6 months.
2) Asymmetric tonic neck reflex. Appears at 35 weeks' gestational age, is well established by age 1 month, and resolves at age 3 to 4 months.
3) Trunk incurvation (Galant). Is well established at 38 to 40 weeks' gestational age and resolves at age 1 to 2 months.
4)   Palmar and plantar grasp. Are well established by 32 weeks' gestational age and resolve at age 3 to 6 months.
5) Rooting. Appears at 38 to 40 weeks' gestational age. Resolves at age 2 to 3 months.
6) Parachute. Appears at 8 to 9 months of age. Persists throughout life.

Developmental reflexes are abnormal if [Gabis]:

1) They are absent at an age when they should normally be present (e.g., a newborn with moderate to severe neonatal encephalopathy, neonatal shock).
2) They are asymmetric, suggesting unilateral weakness.
3) They persist beyond a time they should have normally resolved (i.e., "retained primitive reflexes"), as this suggests impaired maturation of descending cortical inhibitory projections.

Conditions in which "retained primitive reflexes" may be seen include the following [Gabis, NICE]:

1)  Cerebral palsy (severe)
2)  Choreoathetosis

Thus, the use of the term "retained primitive reflexes" by the OT (occupational therapist) in this patient, who has none of the above conditions, is not consistent with the scientific literature. Thus, OT (occupational therapy) to treat "retained primitive reflexes" is not medically necessary, appropriate, or standard of care.

Expert consensus recognizes intensive intervention in outpatient, day hospital programs, and inpatient settings as the standard of care for patients who have pediatric feeding disorder (PFD) [Goday]. This level of support may come from a speech-language pathologist, occupational therapist, or other qualified feeding skills expert. In some cases, it occurs in an interdisciplinary setting. Therapy allows monitoring for potential complications (eg, aspiration, severe weight loss or weight faltering [i.e., "failure to thrive"] and/or allergic reactions) associated with the introduction of new food types and textures, advancement of oral volumes, and reduction of enteral nutrition among children with little or no experience eating. None of this is documented in this patient.

Sharp and colleagues published a meta-analysis of the peer-reviewed literature [Sharp]. The systematic search yielded 11 studies involving 593 patients. Nine articles presented outcomes based on retrospective (non-randomized) chart reviews; 2 studies involved randomized controlled trials. All samples involved children with complex medical and/or developmental histories who displayed persistent feeding concerns requiring formula supplementation. Behavioral intervention and tube weaning represented the most common treatment approaches. Core disciplines overseeing care included psychology, nutrition, medicine, and speech-language pathology/occupational therapy. The overall effect size for percentage of patients successfully weaned from enteral tube feeding was 71% (percent) (95% CI [confidence interval] 54%-83%). Treatment gains endured following discharge, with 80% of patients (95% CI 66%-89%) weaned from tube feeding at last follow-up. Treatment also was associated with increased oral intake, improved mealtime behaviors, and reduced parenting stress. This patient does not receive enteral feeds.

Intensive outpatient feeding therapy is appropriate as indicated by ALL the following [APA, Sharp, Goday]:

1) The child has severe pediatric feeding disorder (PFD) defined as 1 or more of the following:
 a)	Severely self-restricted oral diet deficient in key macro- or micronutrients that puts the patient at risk for or has resulted in nutrient deficiency or malnutrition. [Not met. This is not documented.]
 b)	Feeding behaviors negatively impacts daily function in 2 or more settings. [Not met. This is not documented]
 c)	Developmentally or cognitively inappropriate dependence on 1 or more of the following: [Not met. Neither of the following is documented.]
d)	Enteral (i.e., tube) feeds with inability to wean infant or toddler formula has caused weight faltering (i.e., failure to thrive), defined as 1 or more of the following: [Not met. This is not documented.]
e)	Sustained weight/length (W/L) ratio or body mass index (BMI) <5th percentile [Not met. This is not documented.]
f) W/L (weight/length) ratio or BMI (body mass index) chronically declining for 6 months or longer and has crossed at least 2 percentile lines on an age-appropriate growth chart [Not met. This is not documented.]
g)	Needed type and frequency of treatment is available and is appropriate to be conducted in an intensive outpatient feeding program [Met.]
h)	Therapeutic goals are concise, specific, objective, and/or measurable to allow a reasonable determination of response to intervention [Met.]
i) Patient has developmentally appropriate cognitive capacity and ability to improve because of treatment [Met.]
j)	Patient is clinically stable enough for treatment at this level [Met.]
k)	Parent/caregiver training is included in the care plan [Met.]

The clinical records submitted for review fail to document the patient meeting all of the above criteria. Thus, occupational therapy for the purposes of initial feeding therapy is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.