Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Failure to thrive

Treatment: Feeding therapy (92526 x 1)

The insurer denied coverage for feeding therapy (92526 x 1)

The denial is overturned

 
Patient is a toddler with a past medical history of failure to thrive, non- immunoglobulin  E (IgE) mediated cow's milk intolerance, food refusal, autism spectrum disorder, gastroesophageal reflux, constipation, and feeding difficulties starting in infancy. He currently is a picky eater with limited food choices and textures. He can self-feed preferred foods but requires coaching/prompting. To address these needs, he was admitted to the Intensive Feeding Day Program. His care ended 3-4 days earlier than expected since his mother was hospitalized, and his father became the main caretaker.

The patient showed progress with both the short and long-term goals established by multidisciplinary feeding team with most goals attained by the discharge date. An additional 3 follow-up sessions were recommended to ensure continued progress at home. 

The insurer has denied coverage for additional Feeding Therapy visits citing Centene Clinical Policy: Pediatric Oral Function Therapy CP.MP.188 criteria. The treating team is appealing.
The questions for review are the appropriateness of the denial and whether feeding therapy is medically indicated in this patient.

This patient has a behavioral feeding disorder characterized by food refusal, feeding interrupts, gagging, texture preferences, and inadequate calorie intake.  In addition, he has had food sensitivities in the past potentially limiting his dietary options. He appears under-nourished at this point.  His assessment submitted for review suggests that his intervention within the program uses behavioral modification and oral motor sensory integration therapy. The detailed documentation shows that the patient had achieved many of the short and long-term goals of the feeding specialty team. In addition, he had gained weight progressively as documented on the above dates. The average weight gain during therapy was 0.2  kilogram Kg/week. The average weight gain since ending the program was 0.054 Kg/week.

It would be expected that with a structured feeding program he would expand the variety of foods that he will accept and be able to take adequate intake to achieve his needs. In fact, he had progressed sufficiently during his time receiving therapy.

This child's documented rate of weight gain has certainly suffered since completing the feeding program. His recent diagnosis of autism spectrum disorder is perhaps playing a part in his marginal nutritional progress. The request for additional feeding therapy visits to reach the goals outlined by the feeding team is warranted and reasonable. Therefore, additional feeding therapy is 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, the Centene Medical Necessity Policy for Pediatric Oral Function Therapy and the review of poor weight gain in children from UpToDate.

Overturn denial of an additional feeding therapy visits.

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 (92526 x 1) is substantiated.