Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Failure to Thrive 

Treatment: Feeding Therapy (Speech Therapy)

The insurer denied coverage for Feeding Therapy (Speech Therapy).

The denial is overturned.

The patient is a child who was born at 39-weeks gestation with a history of failure to thrive, multiple food allergies, gastroesophageal reflux, constipation, eczema, asthma and feeding difficulties starting in infancy. The patient currently is a picky eater with limited food choices and textures. The patient can self-feed but requires coaching and takes nearly 2 hours per feed. Gastroenterology assessment in the past has included:

-	Modified barium swallow - behavioral oral motor dysfunction but no laryngeal penetration or aspiration.

-	Upper endoscopy - esophageal biopsy with 7 eosinophils likely related to gastroesophageal reflux treated with acid suppression in the past. 

The patient was able to sustain weight gain tolerating purees and Elecare Jr. but lost weight across percentiles when Elecare was no longer covered by insurance. The patient has tried and failed a course of Peractin to stimulate appetite. The patient has a paraprofessional assigned during school to assist with eating behaviors. The patient was evaluated. The team recommend adding Orgain Kids liquid supplements and enrollment in their inpatient daycare feeding program. At a visit with the patient's gastroenterologist it was noted that the patient increased weight on the Orgain Kids three times per day to 25.5 kilograms (45th percentile for age). The patient was approved for 20 speech/feeding visits. These visits occurred in multiple sessions throughout the day between Monday and Friday, 8AM - 3PM.

Although showing progress with both the short and long-term goals established by multidisciplinary feeding team, an additional 20 speech/feeding visits were requested. Additional feeding visits occurred.

This patient has a behavioral feeding disorder characterized by food refusal, feeding interrupts, gagging, texture preferences, and inadequate calorie intake.  In addition, the patient has food allergies and dietary restrictions limiting their dietary options. The patient appears well-nourished at this point and seems developmentally on target.  The assessment submitted for review suggests that intervention within the program uses behavioral modification and oral motor sensory integration therapy. The detailed documentation shows that the patient has achieved many of the short and long-term goals of the feeding specialty team. In addition, the patient has gained weight progressively as documented on the above dates. 
This patient's failure to thrive is certainly related to many of the above factors. It would be expected that with a structured feeding program the patient would expand the variety of foods that they will accept and be able to take adequate intake to achieve their needs. In fact, the patient has progressed sufficiently using the original 20 visits initially approved by the insurer in contrast to the statements made in the denial. The request for additional visits to reach the goals outlined by the feeding team as well as the need for some visits (3 weekly visits) to facilitate the transition of the techniques utilized in the inpatient daycare setting to the patient's home is warranted and reasonable. Therefore, the additional 20 speech/feeding visits are both medically necessary and in the best interest of the patient. This decision was rendered after review of the detailed therapy notes, the gastroenterology office visit notes and the review of poor weight gain in children from UpToDate cited above.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Feeding Therapy (Speech Therapy) is substantiated.