Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Feeding disorder
Treatment: Intensive feeding therapy
The insurer denied coverage for intensive feeding therapy
The denial is upheld 

Intensive feeding therapy is not considered medically necessary at this time for this autistic child with a feeding disorder. The current diet may not be conducive to growth however, there is no documentation that the patient has had severe weight loss or is below average weight. There is lack of adequate documentation to justify a medical necessity exception to policy. 

"Objective: To assess models of care and conduct a meta-analysis of program outcomes for children receiving intensive, multidisciplinary intervention for pediatric feeding disorders.
Study design: We searched Medline, PsycINFO, and PubMed databases (2000-2015) in peer-reviewed journals for studies that examined the treatment of children with chronic food refusal receiving intervention at day treatment or inpatient hospital programs. Inclusion criteria required the presentation of quantitative data on food consumption, feeding behavior, and/or growth status before and after intervention. 

Results: The systematic search yielded 11 studies involving 593 patients. Nine articles presented outcomes based on retrospective (nonrandomized) 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. Treatment gains endured following discharge, 80% of patients (95% CI 66%-89%) weaned from tube feeding. Treatment also was associated with increased oral intake, improved mealtime behaviors, and reduced parenting stress.

Conclusions: Results indicate intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties" (Sharp, W. G. et al. 2017).

"Pediatric feeding disorders (PFDs) lack a universally accepted definition. Feeding disorders require comprehensive assessment and treatment of 4 closely related, complementary domains (medical, psychosocial, and feeding skill-based systems and associated nutritional complications). Previous diagnostic paradigms have, however, typically defined feeding disorders using the lens of a single professional discipline and fail to characterize associated functional limitations that are critical to plan appropriate interventions and improve quality of life" (Goday, P. S. et al. 2017).

"The purpose of this longitudinal observational study was to evaluate the effectiveness of a multidisciplinary inpatient treatment model for feeding disorders by analyzing long-term nutritional and health outcomes 12 months following discharge. Fifty patients completed the study. Average caloric intake by mouth as a percentage of goal for gastrostomy tube (GT)-dependent patients ((number of participants) n = 31) increased from pre-admit, week 1, and week 2 of the inpatient program (30%, 70%, and 84%, respectively), and was sustained from week 3 to 12-month follow-up (85% and 86%). Eighty-one percentage were discharged without GT support and 65% remained off GT support at 12 months. Oral supplement dependence for non-GT patients (n = 19) decreased from pre-admit, discharge, and 12-month follow-up (51%, 31%, and 19% of caloric intake). The present study demonstrated an effective approach for treatment of pediatric feeding disorders, including decreased reliance on oral supplementation and GT dependence" (Kim, C. et al. 2021).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for intensive feeding therapy is not substantiated.