Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eating Disorders 
Treatment: Nutritional.  
The insurer denied: Intensive Feeding program. Telehealth. 
The denial is overturned in whole. 

The patient is a female. She has a history of feeding problems, oral aversion, gastroesophageal reflux and poor weight gain. She was evaluated by a multidisciplinary feeding team.
The requested service is outpatient intensive feeding program (telehealth).

The health plan's determination is overturned in whole. 

The telehealth feeding program visit is medically necessary for this patient. This patient has a complex medical condition leading to feeding problems, oral aversion, poor weight gain and inappropriate diet for age. The use of intensive feeding therapy is consistent with the generally accepted practices and is proven to be safe and effective. The team includes a multidisciplinary group of speech therapy, occupational therapy, psychology, nutrition and pediatric gastroenterology. There is a great value to having all these services together in one setting in order to provider intensive therapy sessions. The available scientific evidence support the utility of such programs.

Per Williams, Caitlin, et al.: "One of the unique features of our program is capitalizing on skill building and intensive family education with daily modeling of appropriate interactions and techniques. This enables immediate feedback and support with engaged caregivers in every session. Having engaged caregivers involved in daily sessions appeared to enhance the parent's understanding of their child's individual strengths, weaknesses, and responses to interventions, which likely contributed to family carryover outside of sessions and therefore led to further progress. We observed that providing a comprehensive program integrating multiple interventions and fostering communication between key clinical providers on a regular basis also contributed to the success of outcomes. Having close and immediate collaboration between members of the team supported stable and well-controlled medical problems and facilitated a faster response with medical interventions when indicated. Such close and prompt collaboration is not a component of TT services".
According to Clark, Racheal R., et al.: " Pediatric feeding problems are highly prevalent in the general population and reportedly higher in populations of youth with disabilities. A variety of treatment approaches and settings have been explored yet challenges with generalization to home and community settings continue to be experienced. Telehealth enhanced interdisciplinary feeding services are one response to these challenges."
Intensive programs also typically involve multiple feeding sessions per day and a treatment team approach in which multiple providers (e.g., psychology, speech, occupational therapy, nutrition) deliver services concurrently (Sharp et al. 2017). This high frequency of feeding sessions can result in rapid improvement in behavior (e.g., volume, variety, mealtime problem behavior) and offer greater monitoring of the child across multiple providers."
Finally, Sharp, William G., et al. published a meta-analysis concluding the following: "Our findings corroborate conclusions from previous single-subject1 and qualitative reviews indicating positive outcomes associated with day treatment and inpatient programs. All identified studies reported improvement in consumption following intervention. On average, dependence on enteral feeds was eliminated in 71% of children at discharge. When documented, these benefits appear to persist, with 80% of patients tube-free at follow-up. Treatment also promoted increased oral intake, improved mealtime behaviors, and reduced parenting stress if reported. "
Therefore, the requested service is medically appropriate and consistent with the generally accepted practices. Due to the current pandemic, a telehealth setting is considered safer and more appropriate to conduct the therapy sessions. Therefore, the requested service is medically necessary.