Pediatric intensive feeding programs are interdisciplinary programs to provide treatment for individuals with persistent disturbances of eating or eating-related behaviors that results in the altered consumption or absorption of oral intake of food that significantly impairs physical health or psychosocial functioning. Programs combine coordinated medical and behavioral techniques on an intensive basis. Multidisciplinary services may include but are not limited to; gastroenterology, behavioral psychology, registered dietician, occupational therapy, speech therapy, social work.
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:
Exclusion Criteria for feeding disorder PHP/IOP programs:
1. Any of the following:
Intensive Outpatient Program
All of the following must be met:
1. Must meet all Intensity of Service Criteria 1-15.
2. 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.
3. 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).
4. The treatment is not primarily social, custodial, interpersonal, or respite care.
5. Rendered in the least intensive setting that is appropriate for the delivery of necessary care.
6. Consistent in type, frequency and duration of treatment with evidenced-based guidelines as determined by medical research.
7. The individual is cognitively and emotionally capable of actively engaging in the treatment program.
8. The individual and/or guardian is expressing willingness to participate in treatment.
9. The requested services do not duplicate other provided services.
10. 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 [TM2] (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.
11. 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….)
12. The individual has documented symptoms and/or behaviors which create a significant functional impairment in at least two of the following areas:
A. Primary support
B. Social/ interpersonal
C. Occupational / educational two
D. Health/medical complicaitons.
Partial Hospital Program
Must meet Admission Criteria 1-12 above.
1. 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
B. Individual has a complex chronic medical history which has precluded individual and family participation in an outpatient treatment trial, 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:
1. Must continue to meet Intensity of Service Criteria 1-15 and Admission Criteria 1-12.
2. There is adherence with all aspects of the treatment plan, unless clinically precluded.
3. 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.
All of the following:
Benefit Denial determination:
Must meet any of the following:
Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.
T1025 with Modifier 22
Internal Medical Policy Committee 1-22-2020 Annual Review
Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.