Subject:
Pediatric Intensive Feeding Programs
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Intensive Feeding Programs (IFP) – Defined as a multidisciplinary approach to the assessment and management of complex swallowing and feeding disorders. These disorders are generally seen in younger children, unlike anorexia and bulimia which are commonly seen in adolescents and adults. However, some individuals up to the age of eighteen may require the services of an intensive feeding program.
A comprehensive interdisciplinary team will usually include a behavioral health therapist, speech and language pathologist/therapist, registered dietitian, occupational therapist, clinical coordinator and supervising physician. Programs may be conducted in an outpatient or inpatient setting lasting 4-8 weeks.
Outpatient IFP – This setting is usually the appropriate for most individuals who require intensive feeding therapy.
Inpatient IFP – This setting is usually reserved for infants and children 3 years of age and under with a diagnosis of failure to thrive (FTT), severe developmental or physical disabilities or following a surgical procedure. The individual must have failed outpatient IFP or is unable to participate in an outpatient program because of a medical contraindication.
Feeding Disorders - This term refers to a condition in which a child is unable or refuses to eat and/or drink sufficient quantities of food to support normal growth for the individual age. This avoidant or restrictive food intake can result in significant organic, nutritional or emotional sequelae.
Signs or symptoms of potential organic problems include dysphagia (difficulty swallowing), odynophagia (painful swallowing), choking, coughing or wheezing. Additional issues, although less urgent, may include growth failure, diarrhea and vomiting.
Behavioral issues, including but not limited to developmental disabilities and autism spectrum disorder, are another major factor in treatment of feeding disorders.
Feeding Problems and Difficulties – Connote some feeding issues in individuals who are maintaining normal nutrition, growth and development. These problems are generally self-limiting and do not require intensive feeding programs. They may range from the “Picky Eater”, who avoid certain colors, textures and food presentations to the feeding style of caregivers.
Coverage of Intensive Feeding Programs – Access to any IFP will be determined by some or all of the following: contractual benefit design, applicable regulatory mandates, reimbursement policy; and prior authorization requirements, as well as, meeting medical necessity criteria.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. Outpatient Pediatric Intensive Feeding Programs (OPIFP) is medically necessary when ALL of the following criteria are met:
a. The individual has received a comprehensive history, physical and behavioral evaluation.
b. Any underlying medical or physical conditions have been treated for at least 6-12 months without resolution of the feeding problem.
c. A feeding disorder has been diagnosed in association with organic, nutritional or emotional problems (e.g. failure to thrive, prematurity, neurologic conditions and developmental disabilities, persistent notable medical conditions – electrolyte, cardiac).
[INFORMATIONAL: The American Academy of Pediatrics is moving away from the pejorative term, “Failure to Thrive”, recommending the use of “Pediatric Undernutrition”, as noted in its Bright Futures in Practice-Guidelines.]
d. Documentation of specific interventions attempted by the interdisciplinary team that have not resulted in improvement in an outpatient clinic settings.
e. The proposed program will be provided by an interdisciplinary team that includes the following: a behavioral health therapist, speech and language pathologist/therapist, occupational therapist, registered dietitian, clinical coordinator and supervising physician.
f. An individualized treatment plan is provided that defines short term and long term objectives with measurable metrics and which reflect meaningful improvement.
g. The treatment plan must include engagement of the child’s parent or guardian.
h. Documentation of the anticipated length of the program, codes used in billing for services and all costs associated with the program.
i. Children under three years of age who had physical defects that prevented normal enteral nutrition (e.g. cleft palate, tracheo-esophageal fistula) that has been surgically corrected but the child still refuses to eat.
II. Inpatient Pediatric Intensive Feeding Program is medically necessary when all of the follow criteria are met:
a. All criteria in I.a-h or I.i have been met.
b. There is detailed documentation of failure or contraindication of an Outpatient Pediatric Intensive Feeding Programs (OPIFP).
III. Pediatric Intensive Feeding Programs are not considered medically necessary when any of the following apply:
a. The individual can eat and swallow with normal functioning.
b. The individual is considered a “Picky Eater” or “Selective Eater” but continues to meet normal growth, development and nutrition milestones for his/her age group.
c. It is determined that a significant part of the feeding problem is caregiver feeding style.
IV. A repeat course of intensive feeding is not considered medically necessary unless significant progress was demonstrated in the initial program or extraordinary clinical concerns are documented.
V. Duplicate therapy; (e.g., concurrent speech, occupational, nutritional behavioral), to that provided in an intensive feeding program is not considered medically necessary.
VI. Intensive Feeding Program for the purpose of maintaining an individual’s level of functioning is not considered medically necessary. It is expected that by the completion of a program the individual and caregivers are capable of sustaining the approaches to feeding developed during the intensive sessions.
Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE-SNP Coverage:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Pediatric Intensive Feeding Programs
Intensive Feeding Programs, Pediatric
References:
1. Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev. 2008; 14(2): 118-127.
2. Babbitt RL, Hoch TA, Coe DA, et al. Behavioral assessment and treatment of pediatric feeding disorders. J. Dev Behav Pediatr. 1994; 15(4): 278-291.
3. Bell HR, Alper BS. Assessment and intervention for dysphagia in infants and children: Beyond the neonatal intensive care unit. Semin Speech Lang. 2007; 28(3): 213-222.
4. Berlinks, Lobato DJ, Pinkos B, Cerezo CS, Leleikons. Patterns of medical and development comorbities among children presending with feeding problems. J. Dev Behav Pediatr. 2011; 32: 41-47.
5. Critch J, Day As, et al. Use of Enteral Nutrition for the control of Intestinal Inflammation in Pediatric Crohn Disease. JPGN. 2012; 54(3): 298-305.
6. El-Matary W, Otley A, et al. Enteral feeding therapy for maintaining remission in Crohn’s Disease: A system in review. J. Parental and Enteral Nutrition. 2010; 20(10): 1-12.
7. Gisel E. Interventions and outcomes for children with dysphagia. Dev. Disabil Res Rev. 2008; 14(2): 165-173.
8. Kerzner B, Milanok, et al. A practical approach to classifying and managing feed difficulties. Pediatrics, 2015, Feb; 135(2): 344-353.
9. Lebetter JR, Gast DL. Feeding problems in children with autism spectrum disorders: a review. Focus Austism Other Dev Disabil. 2006; 21(3): 153-166.
10. Miller CK, Burklow KA, Santorok, Et al. An interdisciplinary team approach to the management of pediatric feeding and swallowing disorders. Children Healthcare. 2001; 30: 201-218.
11. Sigall-Boneh R, Pfeffer-Gik T, Segal I, et al. Partial Enteral Nutrition with a Crohn’s Disease exclusion diet is effective for induction of remission in children and young adults with Crohn’s Disease. Inflammatory Bowel Disease. 2014; 20: 1352-1360.
12. Schwarz SM, Corredor J, Fisher-Medina J, et al. Diagnosis and treatment of feeding disorders in children with developmental disabilities. Pediatrics 2001; 108(3): 671-676.
13. Silverman AH. Interdisciplinary Care for feeding problems in children. Nutrition in Clinical Practice. 2010; 25: 160-165.
14. Twachman – Reilly J. Amara/S. Zebrowski PP. Addressing feeding disorders in children on the autism spectrum in school based settings. Physiological and behavioral issues. Language, Speech and Hearing services in schools. 2008; 39: 261-272.
15. Water RS. The multidisciplinary approach to management of swallowing disorders in the pediatric patient. In: Tuchman DN, Walter RS, eds. Disorders of Feeding and Swallowing in Children: Pathophysiology, Diagnosis and Treatment. San Diego, CA; Singular Publishing;1994: 251-257.
16. Yamamoto T, Nakahigashi, Et al. Enteral nutrition for the maintenance of remission in Crohn’s disease: a systemic review. Eur J Gastroenterology Hepatology. 2010; 22: 108.
17. Motil KJ, Duryea TK. Poor weight gain in children younger than two years in resource-rich countries: Etiology and evaluation. In: UpToDate, Drutz, JE, Jensen C, Torchia MM. (Eds), UpToDate, Waltham, MA. (Accessed on July 2, 2020.)
18. Motil KJ, Duryea TK. Poor weight gain in children younger than two years in resource-rich countries: Management. In: UpToDate, Drutz, JE, Jensen C, Augustyn M, Torchia MM. (Eds), UpToDate, Waltham, MA. (Accessed on July 2, 2020.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
92526
92610
92611
92612
92613
92616
92617
92700
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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