Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Prematurity born at 28 weeks' gestation, chronic lung disease, autism, failure to thrive, severe feeding difficulties with extremely restricted eating and food refusal.
Treatment:  Special Feeding Program.

The insurer denied the Special Feeding Program.  The denial is overturned.

The patient is a pre-adolescent male child with medical history significant for prematurity born at 28 weeks' gestation, chronic lung disease, autism, failure to thrive, severe feeding difficulties with extremely restricted eating and food refusal, with a body mass index (BMI) of 0.2% (percent). He is currently dependent upon Pediasure. He takes a maximum of 24 ounces of Pediasure a day along with occasional meltable solids. He has severe oral defensiveness, and any attempts to feed are met with biting, hitting, and yelling. He has impaired oral-motor skills, but they are functional for eating. His intake does not support healthy growth and development and does not meet nutritional or hydration needs. He takes a daily average of 75% of necessary calories, protein, and fluids. With his recent weight gain and growth in stature, his body mass index has decreased from seven percent to 0.2%.

The patient has been receiving feeding therapy to address his feeding issues since age 18 months, including multidisciplinary teams and an admission to an intensive day patient feeding program that resulted in regression and refusal to take Pediasure. The current recommendation is feeding therapy in combination with applied behavioral analysis (ABA) to improve feeding abilities, approach an age-appropriate diet, and decrease dependence on Pediasure.

The proposed special feeding program is medically necessary.

A feeding disorder is an inability to consume adequate and appropriate nutrition by mouth. While feeding disorders may ultimately lead to eating disorders, they are not the same. Feeding disorder symptoms include inadequate fluid intake, food refusal, difficulty swallowing, inability to feed oneself, prolonged feeding time, choking or gagging and emesis, inappropriate mealtime behaviors and selecting food by its type or texture. About 25 percent of all children, and up to 80 percent of developmentally disabled children, exhibit feeding disorders. Severe and persistent feeding disorders occur in three to ten percent of children, particularly those with chronic conditions. The etiology of feeding disorders is multifactorial, and includes medical, nutritional, behavioral, psychological and environmental factors. If not dealt with appropriately, feeding disorders can lead to cognitive decline, malnutrition, growth retardation, increased susceptibility to illness and even death. Avoidant/restrictive food intake disorder is a type of eating disorder that is similar to anorexia because of the limitations in intake but without the dysmorphic body image. Severely restrictive eating may be manifest by weight loss, nutritional deficiency, interference in psychosocial functioning, and dependence on oral or enteral supplementation. There may be co-existing autism, anxiety, or other psychiatric illness. 

This male child, born prematurely, with autism and failure to thrive, has a severely restrictive eating pattern that has persisted despite a variety of interventions. He requires an intensive feeding program that incorporates behavioral interventions to address challenges presenting at mealtime. The requested program utilizes applied behavioral analysis (ABA) along with feeding therapy to address identified areas of concern: significant food refusal, dependence on supplemental formula, extremely limited diet, self-directed feeding with inconsistent intake, functional but impaired oral motor skills, food jagging, extreme selectivity and rigidity within mealtimes, and challenges advancing to an age-appropriate diet. Admission into the day patient feeding program is therefore medically necessary and appropriate for this child who has a severely restrictive eating pattern.