CurrentCignaPolicy 0422

Pediatric intensive multidisciplinary feeding programs

Defines medical necessity criteria, exclusions, settings (outpatient day vs inpatient) and coding guidance for pediatric intensive multidisciplinary feeding programs. Applies to Cigna-administered health benefit plans and does not address home or telehealth services.

Policy Summary

PayerCigna

PolicyPediatric intensive multidisciplinary feeding programs

Policy CodePolicy 0422

Change TypeAnnual review — no policy statement changes

Effective DateDec 15, 2024

Next Review DateDec 15, 2025

Key ActionProviders must document a two month trial of conventional outpatient treatment (unless contraindicated) demonstrating failure before outpatient intensive program coverage will be considered.

POLICY UPDATE CHANGES

Annual review on 12/15/2024 indicates No changes to policy statement.

2Levels of care addressed (outpatient day, inpatient)

2Required documented outpatient trial duration (months)

5Not medically necessary scenarios listed

10Representative CPT/UB code groups listed

Coverage Summary

Pediatric intensive multidisciplinary feeding programs are interdisciplinary and combine medical, behavioral, nutrition and therapy disciplines and may be delivered either as inpatient (round-the-clock care) or outpatient day programs. The policy scope summarizes criteria for when these programs are considered medically necessary, documents required prior treatments and exclusions, and provides coding guidance for Cigna-administered plans.

Medical Necessity Criteria

Outpatient Pediatric Intensive Multidisciplinary Feeding Program - Medically Necessary

Treatment of feeding disorder in an outpatient pediatric intensive multidisciplinary feeding program is considered medically necessary when ALL of the following criteria are met:

Outpatient pediatric intensive multidisciplinary feeding program criteria

Significant feeding disorder associated with medical condition: Individual has a significant feeding disorder associated with a medical condition (e.g., failure to thrive, prematurity, neurologic conditions, developmental disability, gastrointestinal disorders, gastrostomy tube).
Adequate treatment of underlying conditions: Adequate treatment for any contributing underlying medical conditions, if present, has occurred without resolution of the feeding problem.
Documentation required that adequate treatment for contributing underlying medical conditions has occurred without resolution.
Prior conventional outpatient treatment trial: Conventional outpatient treatment has not succeeded.Two month documented trial
A two month trial of conventional treatment must be documented.
Parent/guardian participation: The treatment plan includes active participation/involvement of a parent or guardian.
Treatment plan must document parent/guardian involvement.
Transition plan to outpatient therapy: The treatment includes a transition from one-to-one supervision to outpatient therapy on discharge.

Inpatient Pediatric Intensive Multidisciplinary Feeding Program - Medically Necessary

Treatment of feeding disorder in an inpatient pediatric intensive multidisciplinary feeding program is considered medically necessary when ALL of the following criteria are met:

Inpatient pediatric intensive multidisciplinary feeding program criteria

Meets outpatient criteria: Individual meets criteria for an outpatient pediatric intensive multidisciplinary feeding program (see outpatient criteria).
References outpatient criteria for specifics.
Failure or contraindication to outpatient program: There is documented failure or contraindication for an outpatient intensive multidisciplinary feeding program.
Medically stable and able to participate: Individual is stable medically and is capable of participating in an inpatient multidisciplinary intensive feeding program.
Regular documentation supporting significant progress toward treatment is required to determine ongoing medical necessity.

Not Medically Necessary / Exclusions

A pediatric intensive multidisciplinary feeding program is considered not medically necessary for any of the following:

Not medically necessary / exclusions

Maintenance or preventive treatment provided to prevent recurrence or to maintain the patient's current status.
Services intended to maintain current status may be denied as not medically necessary.
General physical condition improvement: Treatment intended to improve or maintain general physical condition.
Home feeding program alternative: When a home feeding program can be utilized to continue therapy.
Duplicative therapy: Therapy that duplicates services already being provided as part of an authorized therapy program through another therapy discipline.

Coding

Considered Medically Necessary when used to report pediatric intensive feeding programsCPTCovered

92526	Treatment of swallowing dysfunction and/or oral function for feeding.
99199	Unlisted special service, procedure or report.

Hospital UB Revenue / Room & Board and Ancillary CodesmixedCovered

0113	Room & Board-Private (One Bed)-Pediatric.
0123	Room & Board-Semiprivate (Two Beds)-Pediatric.
0133	Room & Board-Three and Four Beds-Pediatric.
0143	Room & Board-Deluxe Private-Pediatric.
0153	Room & Board-Ward-Pediatric.
0430-0439	Occupational Therapy.
0440-0449	Speech Therapy-Language Pathology.
0515	Clinic-Pediatric Clinic.
0931	Medical Rehabilitation Day Program-Half Day.
0932	Medical Rehabilitation Day Program-Full Day.

Codes Not Medically Necessary for food aversion treatmentCPTNot Covered

92526

Treatment of swallowing dysfunction and/or oral function for feeding (Not Medically Necessary when used to report pediatric intensive feeding programs for the treatment of swallowing/feeding therapy for food aversions).

Provider Actions & Billing Impact

Documentation Required

Document prior outpatient treatment trial

Document a trial of conventional outpatient treatment prior to consideration of outpatient intensive program. The policy requires a two month trial of conventional outpatient treatment must be documented unless contraindicated.

Documentation Required

Document underlying medical treatment attempts

Document that adequate treatment for any contributing underlying medical conditions has occurred without resolution of the feeding problem before an intensive program is considered.

Documentation Required

Parent/guardian participation documented in treatment plan

Include evidence in the treatment plan that a parent or guardian actively participates or is involved in treatment as a required component of medical necessity for outpatient pediatric intensive multidisciplinary feeding programs.

Denial Risk

Denial risk for maintenance or duplicative therapy

Claims may be denied as not medically necessary for maintenance or preventive treatment to maintain current status, treatments intended to improve or maintain general physical condition, therapy duplicative of authorized programs from another discipline, when a home feeding program can be used, or for swallowing/feeding therapy for food aversions in patients who are meeting normal growth and developmental milestones.

Maintenance or preventive care to prevent recurrence or maintain status
Treatment to improve/maintain general physical condition
Duplicative therapy already provided by another authorized therapy discipline
Swallowing/feeding therapy for food aversions meeting normal growth and development (CPT 92526 noted as not medically necessary in this use case)

Billing Rule

Use appropriate codes as of date of service

Use the most appropriate CPT/UB and other codes effective on the date of service when submitting claims. Services billed with codes not listed as covered under this policy will be denied.

Background, Definitions & Evidence

Pediatric intensive feeding programs are interdisciplinary, combining medical, behavioral, nutrition and therapy approaches and may be provided either inpatient or as outpatient day programs. Programs aim to improve oral intake and may include tube weaning and other nutrition-focused goals.

Outpatient therapy is preferred and is considered the most medically appropriate setting unless the individual independently meets coverage criteria for a different level of care (for example, inpatient care for severe feeding difficulties requiring around-the-clock medical supervision).

Definitions

Evidence

Determination Type	Note
NCD	No National Determination found
LCD	No Local Determination found

OpenPayer

Pediatric intensive multidisciplinary feeding programs

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions & Billing Impact

Background, Definitions & Evidence

Medicare Determinations

Revision History