Criteria
Intensity of Service: Essential program elements to meet minimum standards of a Feeding Disorder Program
Must have all the following to qualify for Feeding Disorder IOP/PHP Program:
- IOP is a short-term structured treatment for psychiatric illness provided by a multidisciplinary health care treatment team. The treatment is more intensive than outpatient treatment but less intensive than partial hospital programming. Treatment will include a minimum duration of 3 hours per treatment day and will not exceed 19 hours per week.
- Continuous structured treatment of psychiatric illness by a multidisciplinary health care treatment team. PHP is typically held during daytime hours and provides 20 or more hours per week to treat multidimensional instability not requiring 24-hour care.
- Clinical assessment at least 1 time per day.
- Individual or group or family modalities must be provided.
- Psychiatric or medication evaluation at least 1 time per week and more frequent as clinically indicated.
- Treatment is individualized, not determined by a programmatic time frame and will include documentation of clear, objective and observable discharge criteria. A treatment plan includes targets of behavior modification for inappropriate feeding patterns, which will include supervised feedings and meals. Progress and barriers in gaining and utilizing skills is documented.
- Multidisciplinary assessment with an individualized treatment plan which addresses psychological, social, medical and cognitive needs. This should include coordination of care with individual’s outpatient providers.
- Feeding Disorder Programs are staffed by a multidisciplinary treatment team under the leadership of qualified physicians and psychologists who conduct and document a multidimensional assessment prior to admission.
- The behavioral program is overseen by a Board-Certified Behavior Analyst.
- A nutritional assessment completed by a registered dietitian within the last six (6) weeks obtains information needed to rule out or confirm a nutrition-related problem.
- Family assessment by a licensed behavioral health provider to assess family's willingness to comply with programming. Family therapy when appropriate.
- Prompt and robust family or support system involvement is expected at every level of treatment plan development, unless doing so is clinically contraindicated. Clinical rationale for exclusion of family participation must be present in documentation.
- Coordination of care with other clinicians is expected and documented, including with any outpatient psychiatrist, therapist, occupational therapist, speech therapist, physical therapist, or the individual's PCP who are providing care to the individual.
- Goals are clear, achievable and time-limited with a focus on reduction of the symptoms that led to admission.
- Discharge planning is initiated on the day of admission.
Exclusion Criteria for feeding disorder PHP/IOP programs:
- Any of the following:
- Individual has unstable medical problems (e.g., uncontrolled reflux disease) which contraindicate treatment.
- The results of a modified barium study suggest that the individual is not safe for oral feeding.
- The individual is diagnosed with an eating disorder (e.g., anorexia, bulimia).
- Individual's condition would be medically appropriate to receive services in a less intensive setting (e.g., home or outpatient therapy).
- Proposed treatment is to prevent or slow deterioration in function or prevent re-occurrences.
- Proposed treatment is primarily to improve or maintain general physical condition.
- Long-term rehabilitative services when significant therapeutic improvement is not expected within two months.
Intensive Outpatient Program
Admission Criteria:
All of the following must be met:
- Must meet all Intensity of Service Criteria 1-15.
- This service intensity is required in order to meet the essential health needs of the individual; and there is a reasonable expectation of reduction in behaviors/symptoms with treatment at this level of care.
- The individual has a documented primary diagnosis found in the Feeding and Eating Disorder section of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders which is the primary focus of active treatment each program day or has a diagnosis of Globus hystericus that has resulted in a documented micronutrient deficiency (e.g., scurvy) identified in labs or office visit, completed within the last six (6) weeks.
- Consistent in type, frequency and duration of treatment with evidenced-based guidelines as determined by medical research.
- The individual is cognitively and emotionally capable of actively engaging in the treatment program. Cognitive and emotional symptoms are addressed throughout the program stay.
- The individual and/or guardian is expressing willingness to participate in treatment.
- The requested services do not duplicate other provided services.
- All of the following must be met:
A. A medical evaluation has been completed and includes assessment for neurological, metabolic and gastrointestinal disease, AND an evaluation performed to identify any structural or functional abnormalities (e.g., videofluorographic swallowing study).
B. Individual has a significant feeding disorder associated with a medical condition (e.g., failure to thrive, prematurity, neurological conditions, developmental disability, malabsorption or gastroesophageal reflux, gastrostomy tube, scurvy, globas hystericus).
C. Adequate treatment for any contributing underlying medical conditions, if present, has occurred without resolution of the feeding problem.
D. Individual has been unresponsive to initial outpatient treatment efforts by single discipline(e.g., occupational therapist, speech language therapist) over a 2-month period or deemed medically unstable to be treated in an outpatient program.
E. Meaningful improvement is expected from the therapy. Documentation of current goals and expected improvements or barriers to improvement is clearly documented and readily apparent at all times.
F. The therapy is individualized, and there is documentation outlining quantifiable and attainable short and long-term treatment goals.
G. The treatment plan includes active participation/involvement of a parent or guardian.
H. The treatment includes a transition from one-to-one supervision to outpatient therapy on discharge.
9. One of the following must be met:
A. Consumes less than 20% of nutritional needs by mouth.
B. Consumes less than 70% of nutritional needs with solid food by mouth and has high to moderate levels of inappropriate behavior during meals which interferes with the child obtaining sufficient calories, volume of fluids, and/or varieties of food to sustain the individual's growth and/or nutrition.
C. Weight for age is below the 5th percentile due to malnutrition.
D. Weight is < 80% of ideal weight for height-age.
E. Weight crosses more than two major percentiles downward, for example, going from the 90th percentile to the 25th (crossing the 75th and 50th).
F. Weight for height falls below the 10th percentile due to malnutrition.
G. Have been hospitalized in the last week to a pediatric hospital due to Globus symptom
H. Has a neurodevelopmental diagnosis and meets normal growth curve however demonstrates micronutrient deficiencies or unstable lab values (e.g. elevated lipids, elevated triglycerides, low iron, Vitamin D or C….)
10. The individual has documented symptoms and/or behaviors which create a significant functional impairment in at least two (2) of the following areas:
A. Primary support
B. Social/ interpersonal
C. Occupational / educational two
D. Health/medical complications.
Partial Hospital Program
Admission Criteria
Must meet Admission Criteria 1-10 above.
- If Partial Hospital Feeding Disorder Program is requested, must additionally meet A. or B. below:
A. Individual has a G-tube with no increase in the percentage of calories obtained via oral feeding for 3 consecutive months with the expectation to wean from G-tube to oral feeding or
B. Individual has a complex chronic medical history or chronic and enduring poor nutritional intake that would lead to secondary health outcomes, or declining nutritional status that warrants more frequent individual and family participation than outpatient treatment, or has complex medical complexity that is precluding the individual and family's ability to make therapeutic gains in an outpatient setting.
Continued Stay Criteria for Feeding Disorders IOP/PHP:
- Must continue to meet Intensity of Service Criteria 1-15 and Admission Criteria 1-10.
- There is adherence with all aspects of the treatment plan, unless clinically precluded.
- One or more of the following criteria must be met:
A. The treatment provided is leading to measurable clinical improvements in acute symptoms and a progression towards discharge from the present level of care, but the individual is not sufficiently stabilized so that he/she can be safely and effectively treated at a less restrictive level of care, or
B. If the treatment plan implemented is not leading to measurable clinical improvements in acute symptoms and a progression towards discharge from the present level of care, there must be evidence of active, timely ongoing reevaluation and modification to the treatment plan to address the current needs, act on specific barriers to achieving improvement, and to stabilize symptoms necessitating the admission, or
C. The individual has developed new symptoms and/or behaviors that require this intensity of service for safe and effective treatment.
4. All of the following must be met:
A. The individual and family are involved to the best of their ability in the treatment and discharge planning process.
B. Continued stay is not primarily for the purpose of providing a safe and structured environment.
C. Continued stay is not primarily due to a lack of external supports.
D. There is evidence of coordination of care with appropriate community resources, schools, day cares and health care services.
Discharge Criteria:
All of the following:
- Individual has met 80% of goals set at admission (e.g., weight gain, percentage of decrease in feeding supplementation, parent fidelity with protocol, etc.).
- Parents have completed training on home transition and feeding protocol.
Benefit Denial determination:
Must meet any of the following:
- The individual has completed treatment goals as outlined in the master treatment plan or has reached maximum benefit from the treatment. Treatment plan goals and objectives have been met and/or a safe, continuing care program can be arranged and deployed.
- There is significant documented reduction in the intensity, duration and frequency of the symptoms/behaviors that resulted in the admission so that the individual's current behaviors and symptoms meet criteria for another level of care.
- The child, family and/or caregivers are competent, but non-participatory in treatment or in following program expectations and regulations.
- The individual is not making progress toward treatment goals and there is no reasonable expectation of progress in the treatment program.
- The individual no longer meets criteria for this level of care, but discharge disposition and/or planning has not yet been completed and/or placement is pending.
Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.
Procedure Codes
| T1025 |
T1025 with Modifier 22 |
