Notification

Pediatric Intensive Day Feeding Program


Notification Issue Date: 12/28/2018

This version of the policy will become effective 01/28/2019.

The following new policy has been developed to Communicate the Company’s coverage criteria for pediatric intensive day feeding program.



Medical Policy Bulletin


Title:Pediatric Intensive Day Feeding Program

Policy #:10.00.03

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

MEDICALLY NECESSARY

Treatment of a feeding disorder in an outpatient pediatric intensive day feeding program is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The individual has a medical condition, developmental condition, and/or psychosocial impairment (e.g., malnutrition, gastrointestinal disorders, gastrostomy tube, neurologic conditions, developmental disability, behavioral health problems) that is interfering with feeding and adequate treatment addressing any contributing underlying condition has occurred without resolution of the feeding disorder.
  • Traditional outpatient feeding services (e.g., early intervention including speech and occupational therapies in the home or center-based therapy provided one to two times per week) has occurred without resolution of the feeding disorder.
  • The individual's growth pattern demonstrates either of the following:
    • Failure to meet expected weight gain due to inadequate oral intake, as demonstrated by failure to adequately track the growth chart for weight gain or a body mass index (BMI) falling below the 10th percentile (e.g., World Health Organization growth charts).
    • Meeting expected weight gain/BMI on growth charts (e.g. World Health Organization growth charts), but only via nutritional support consisting of high-calorie foods, formula, other supplements, tube feedings, or nutritionally deficient foods, so that they are nutritionally at high risk and meeting criteria of malnutrition. Transition to nutritionally and calorically appropriate food is warranted.
  • Provider will coordinate and oversee the pediatric intensive day feeding program consisting of an inter-disciplinary team (e.g., behavioral therapist, occupational therapist, physician, registered dietitian and speech language pathologist/therapist).
  • The individual must require intensive therapy services such as occupational therapy, speech therapy, and nutrition services, and may also require other medical services.
  • The individual is able to participate in a full program of therapies.
  • The individual has an adult primary caregiver who is able to provide assistance in integrating the pediatric intensive day feeding program into the home and community settings.
  • There is documentation of a diagnosis-specific individualized treatment plan with an estimated length of treatment.

Continued coverage of the pediatric intensive day feeding program beyond the original determined length of treatment is considered medically necessary and, therefore, covered when any of the following criteria are met:
  • New clinical findings or a change in the individual's condition that interferes with feeding.
  • The individual has demonstrated continued improvement but has not met the established treatment goals in the treatment plan.

This medical policy does not apply to individuals with anorexia nervosa or bulimia, which are characterized by marked disturbances in eating behavior.

NOT MEDICALLY NECESSARY

If the above criteria are not met, treatment of a feeding disorder in an pediatric intensive day feeding program is considered not medically necessary and, therefore, not covered because the available published peer reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

Traditional outpatient feeding services provided in an outpatient setting (e.g., early intervention including speech and occupational therapies in the home or center-based therapy provided one to two times per week), must occur first. If these feeding services are available and have not been used, the pediatric intensive day feeding program is not medically necessary and, therefore, not covered in lieu of traditional outpatient feeding services.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

For individuals transitioning from another level of care (e.g., acute inpatient) and being referred to a pediatric intensive day feeding program, a list of short- and long-term goals should be provided to the day rehabilitation program.

The medical record must include the plan of care that has been written and developed by the eligible health care provider. The plan of care must be established prior to the initiation of therapy and signed by the provider.

The plan of care includes the following information:
  • The individual's significant history
  • The individual's diagnoses that require therapy
  • Any related professional provider's orders
  • The goals for therapy, which should be specific and measurable, and the expected potential for achievement, which should include the type, amount, duration, and frequency of therapy services
  • Any contraindications to a course of therapy
  • The individual's and the adult caregiver's awareness and understanding of the diagnoses, prognoses, and goals of therapy
  • When appropriate, a summary of past therapies and the results that were achieved

Daily treatment notes include the following information:
  • Date of treatment
  • Specific treatment provided
  • Response to treatment
  • Skilled ongoing reassessment of the individual’s progress towards established goals
  • Objective, measurable, and specific documentation of progress towards goals using consistent and comparable methods
  • Changes to plan of care or objective reasoning for why the individual has not progressed towards goals
  • Name and credentials of the treating clinician

Guidelines

The criteria listed in this policy should be evaluated by giving deference to the individual's current medical condition (e.g., age, developmental status, injury, and/or impairment) and the requirements and goals of the pediatric intensive day feeding program (e.g., a pediatric intensive day feeding program structured for a pediatric individual with a traumatic brain injury).

Continued coverage is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment, or terminating services. Re-evaluation for continued coverage requires the same professional skills as evaluation. It is not a routine, recurring service.

INTENSITIES OF TREATMENT FOR PEDIATRIC FEEDING DISORDERS

Pediatric individuals receive varying types and intensities of treatment depending on their needs, from acute inpatient therapy services to traditional individual outpatient therapy sessions.

Acute inpatient therapy services are intensive rehabilitative therapies and associated medical services (e.g., case management), with 24 hours of medical and nursing supervision. Services are generally performed in a rehabilitation unit within a hospital or in a free-standing rehabilitation hospital.

Intensive day feeding services, consisting of therapies such as occupational therapy, speech therapy, nutrition services, are provided when the individual requires the intensity of acute inpatient rehabilitation but does not require the medical and nursing supervision provided in acute inpatient rehabilitation 24 hours a day.

Traditional outpatient therapy services are moderately intensive multi-disciplinary services (e.g., occupational therapy, speech therapy) performed in an outpatient facility.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, a pediatric intensive day feeding program is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as not medically necessary or a benefit contract exclusion are not eligible for coverage or reimbursement by the Company.

For most of the Company's products, day rehabilitation services have visit limitations. Individual member benefits must be verified.

Description

PEDIATRIC INTENSIVE DAY FEEDING PROGRAM

Treatment of a feeding disorder in a pediatric intensive day feeding program involves multiple therapeutic meals per day overseen by a multidisciplinary professional team (e.g., behavioral therapist, occupational therapist, physician, registered dietitian and speech language pathologist/therapist). The program typically consists of four to seven hours of daily rehabilitative therapies, may be five days per week and typically includes a combination of one-to-one and group therapy. A component of a program for pediatric intensive day feeding may include other medical services such as psychological therapy, nursing, and case management. Pediatric intensive day feeding programs are offered in an outpatient setting, and the individual returns home each evening and for the entire weekend. Pediatric intensive day feeding programs are provided when the individual requires the intensity of acute inpatient rehabilitation but does not require the medical and nursing supervision provided in acute inpatient rehabilitation 24 hours a day.

FEEDING DISORDERS

In accordance with the World Health Organization, International Classification of Functioning, Disability, and Health's framework, pediatric feeding disorder may be defined as impaired oral intake that is not age-appropriate, and is associated with a medical, nutritional, feeding skill, and/or psychosocial dysfunction. A child with a feeding disorder does not consume enough food or liquid (or a broad enough variety of food) to gain weight and grow normally. General feeding difficulties are relatively common among most children. For example, a child may be a picky eater and consume a limited number of foods, but the foods eaten span all the food groups and provide a well-balanced diet. A child with a feeding disorder, on the other hand, may only eat a few foods, completely avoiding entire food groups, textures or liquids necessary for proper development. As a result, children diagnosed with feeding disorders are at greater risk for compromised physical and cognitive development. Children with feeding disorders may also develop more slowly and experience behavioral problems and faltering growth.

Feeding disorders typically develop for several reasons, including medical conditions (food allergies), anatomical or structural abnormalities (e.g., cleft palate), and reinforcement of inappropriate behavior. In most cases, no single factor accounts for a child's feeding difficulties. Rather, several factors interact to produce them.

While a wide spectrum of complex factors can contribute to feeding disorders in infants and children, certain medical and psychological conditions may accompany them.
  • Gastroesophageal reflux disease
  • Gastrointestinal motility disorders
  • Palate defects
  • Malnutrition
  • Prematurity
  • Oral Motor Dysfunction (dysfunctional swallow, dysphagia, oral motor dysphagia)
  • Esophagitis
  • Gastritis
  • Duodenitis
  • Food allergies
  • Delayed exposure to a variety of foods
  • Behavior management
  • Autism Spectrum Disorders
  • Prolonged nothing by mouth (NPO) status in infancy
  • Short Gut Syndrome

References


Addison LR, Piazza CC, Patel MR, et al. A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. J Appl Behav Anal. 2012;45(3):455-471.

American Speech-Language Hearing Association. Feeding and swallowing disorders (dysphagia) in children. Available at: https://www.asha.org/public/speech/swallowing/Feeding-and-Swallowing-Disorders-in-Children/. Accessed October 19, 2018.

Block RW, Krebs NF; American Academy of Pediatrics Committee on Child Abuse and Neglect; American Academy of Pediatrics Committee on Nutrition. Failure to thrive as a manifestation of child neglect. Pediatrics. 2005;116(5):1234-1237.

Borowitz KC, Borowitz SM. Feeding problems in infants and children: assessment and etiology. Pediatr Clin North Am. 2018;65(1):59-72.

Centers for Disease Control and Prevention. National Center for Health Statistics. Growth charts. [CDC Web site]. 09/09/2010. Available at: https://www.cdc.gov/growthcharts/who_charts.htm. Accessed October 19, 2018.

Cooper LJ, Wacker DP, McComas JJ, et al. Use of component analyses to identify active variables in treatment packages for children with feeding disorders. J Appl Behav Anal. 1995;28(2):139-53.

Dawson JE, Piazza CC, Sevin BM, et al. Use of the high-probability instructional sequence and escape extinction in a child with food refusal. J Appl Behav Anal. 2003;36(1):105-8.

Dempster R, Burdo-Hartman W, Halpin E, et al. Estimated cost-effectiveness of intensive interdisciplinary behavioral treatment for increasing oral intake in children with feeding difficulties. Journal of Pediatric Psychology. 2016;41(8):857-866.

Food and Agriculture Organization of the United Nations (FAO), World Health Organization (WHO) and United Nations University (UNU): Human Energy Requirements. Chapter 3: Energy requirements of infants from birth to 12 months. [FAO Website]. Available at: www.fao.org/docrep/007/y5686e/y5686e05.htm Accessed October 19, 2018.

Food and Agriculture Organization of the United Nations (FAO), World Health Organization (WHO) and United Nations University (UNU): Human Energy Requirements. Chapter 4: Energy requirements of children and adolescents. [FAO Website]. Available at: www.fao.org/docrep/007/y5686e/y5686e06.htm#bm06. Accessed October 19, 2018.

Goday P, Huh SY, Silverman A, et al. Pediatric feeding disorder: consensus definition and conceptual framework. J Pediatr Gastroenterol Nutr. 2018 Oct 24. [Epub ahead of print]

Kerzner B, Milano K, MacLean WC, et al. A practical approach to classifying and managing feeding difficulties. Pediatrics.2015;135 (2):344-353.

Krugman ST, Dubowitz H. Failure to thrive. Am Fam Physician. 2003;68(5):879-884.

Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr.2013;37(4):460-481.

Motil KJ, Duryea TK. Poor weight gain in children younger than two years: Management. [UpToDate Web site].10/01/2018. Available at: https://www.uptodate.com/contents/poor-weight-gain-in-children-younger-than-two-years-management [via subscription only]. Accessed October 19, 2018.

National Institute of Health and Care Excellence (NICE). Faltering growth: recognition and management of faltering growth in children. [NICE Web site]. September 2017. Available at:
https://www.nice.org.uk/guidance/ng75. Accessed October 19, 2018.

Peterson KM, Piazza CC, Volkert VM. A comparison of a modified sequential oral sensory approach to an applied behavior-analytic approach in the treatment of food selectivity in children with autism spectrum disorder. J Appl Behav Anal. 2016;49(3):485-511.

Piazza CC, Patel MR, Gulotta CS, et al. On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. J Appl Behav Anal. 2003;36(3):309-24.

Rybak A. Organic and nonorganic feeding disorders. Ann Nutr Metab. 2015;66(suppl 5):16-22.

Sharp WG, Volkert VM, Scahill L, et al. A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: How standard is the standard of care?J Pediatr. 2017;181:116-124.

Silverman AH. Behavioral management of feeding disorders of childhood. Ann Nutr Metab.2015;66 Suppl 5:33-42.

Twachtman-Reilly J, Amaral SC, Zebrowski PP. Addressing feeding disorders in children on the autism spectrum in school-based settings: physiological and behavioral issues. Lang Speech Hear Serv Sch. 2008;39(2):261-72.

Williams C, VanDahm K, Stevens LM, et al. Improved outcomes with an outpatient multidisciplinary intensive feeding therapy program compared with weekly feeding therapy to reduce enteral tube feeding dependence in medically complex young children. Curr Gastroenterol Rep. 2017;19(7):33.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy.


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)



0931 Medical rehabilitation day program half day

0932 Medical rehabilitation day program full day

Coding and Billing Requirements


Cross References


Policy History

10.00.03
01/28/2019This version of the policy will become effective 01/28/2019.

The following new policy has been developed to Communicate the Company’s coverage criteria for pediatric intensive day feeding program.

Version Effective Date: 01/28/2019
Version Issued Date: 01/28/2019
Version Reissued Date: N/A

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.