Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Feeding difficulties and laryngomalacia.
Treatment: Ongoing speech therapy.
The insurer denied the Ongoing speech therapy.
The denial is overturned. 

The patient is a male child with feeding difficulties and laryngomalacia. He has history of pocketing food, without a typical chewing pattern. Testing with the Goldman Fristoe 2 Test of Articulation was conducted to fully evaluate his speech and oral functioning revealing multiple abnormalities in positioning of lingual musculature for multiple sounds, dissociation of lingual/labial/mandibular structures, tongue posture, swallowing, and ability to elevate and protrude lingual musculature. In addition to issues with articulation, he has dysphagia with hypersensitivity to textures and temperatures and tastes. He has improved significantly since beginning feeding therapy, but still has a restrictive eating pattern that does not provide a broad enough range of nutrition. However, while he has shown significant improvements, his progress has been slow with slow acquisition of carryover. Continued feeding therapy has been recommended. 

Yes, the proposed treatment, ongoing speech therapy, 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 (e.g. anorexia nervosa, bulimia), 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. Feeding involves a very complex interplay of anatomical structures, neuromuscular control, physiological processes including digestion, social interactions and behaviors, and coordination with other bodily functions such as breathing. Disruption of any of these may lead to feeding dysfunction. Causes of feeding dysfunction include: anatomical abnormalities such as cleft lip or palate, micrognathia, or esophageal anomalies; neuromuscular abnormalities such as cerebral palsy, muscular dystrophy or hypotonia; physiologic disruption caused by infections, congenital heart disease, chronic lung disease, digestive problems or other chronic medical conditions; inadequate interaction with caregivers due to parental depression or environmental disruption; or history of invasive procedures such as nasogastric tube or intubation.

Feeding disorders may even appear in children who are developing typically and show up as food refusal, extreme food preference, disruptive feeding behaviors or prolonged feeding times. Although environmental or behavioral factors are frequently to blame, feeding disruption may also represent the initial manifestation of a medical condition such as gastroesophageal reflux or food allergy. Unfortunately, maladaptive feeding behaviors often remain long after the medical issues have been resolved.

This young male child has had significant feeding difficulties with history of weight loss. He has made good progress with feeding therapy but continues to have restrictive eating patterns that are negatively impacting his nutrition. In addition, he has a number of challenges in articulation identified during formal testing that negatively impact his ability to eat functionally and communicate functionally. Ongoing speech and feeding therapy is therefore medically necessary and appropriate for this child.