Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Esophageal reflux, tongue-tied, low tone, constipation, food allergy. 
Treatment: Home health care for 1 feeding therapy visit. 

The insurer denied coverage for home health care for 1 feeding therapy visit. 

The denial is overturned. 

The patient has a past medical history notable for intrauterine growth delay, failure to thrive, developmental delay, anterior tongue-tied, gastroesophageal reflux, cow's milk allergy/intolerance, oropharyngeal dysphagia, low tone and constipation that was referred to Pediatric Day Feeding Program for assessment of feeding difficulties. The patient had early issues with feeding that lead to inpatient admission as an infant. His clinical feeding assessment at that time reportedly demonstrated uncoordinated swallowing treated with slow rate nipple use, compression bottle and enteral pacing with improvement. He tolerates liquids well (Elecare) with acceptable growth along his own curve (height better than weight). He has partially transitioned to oral purees, yogurt and apple sauce but refuses to take solids or self-feed. He does not aspirate or have a history of recurrent pneumonias. 

This child has feeding issues with delays in his transition to oral solids and self-feeding. In addition, he has had slow growth with weight consistently below the 5th percentile for age despite 27 kcal/ounce [kilocalories per ounce] amino acid-based formula. He has a number of medical issues that may predispose to feeding difficulties (esophageal reflux, tongue-tied, low tone, constipation, food allergy). Together these factors suggest that a feeding evaluation to tease out the actual cause(s) of his feeding difficulties and to craft a plan for addressing the problem(s) seems prudent. 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 biologic plausibility that dietary and swallow training can reduce dysphagia and aspiration, we recommend dietary therapy in selected patients with mild oropharyngeal dysphagia." 

In children with neurological impairment or with developmental oral motor delays, oromotor therapy by a speech and language therapist may be beneficial. Children with autistic spectrum disorders are at high risk of feeding difficulties, mainly selective eating, and require a specialized multidisciplinary feeding team approach for nutritional support, coupled with sensory integration therapies (e.g., tactile stimulation, oral motor desensitization, and shaping and fading)." 

An evaluation to determine the exact sub-type of feeding difficult seems appropriate and in the best interest of the patient. Although this child appears safe to eat (no aspiration history, tolerating liquids) there clearly is a delay in his progression to solids and self-feeding. A one-time feeding evaluation is medically necessary to generate a management plan that could avoid further growth delays and to optimize his nutritional state. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for home health care for 1 feeding therapy visit is overturned. Medical Necessity is substantiated.