CurrentHealth NetPolicy CP.MP.188

Pediatric Oral Function Therapy

Defines medical necessity criteria for initial and continuation pediatric oral function therapy (feeding/swallowing/oral function treatment) for members under the health plan, including required documentation and conditions qualifying for therapy. Also lists applicable CPT codes for evaluation and treatment.

Policy Summary

PayerHealth Net

PolicyPediatric Oral Function Therapy

Policy CodePolicy CP.MP.188

Change TypeRevised criteria and annual wording updates

Effective Date

Next Review Date

Key ActionSubmit documentation demonstrating initial therapy meets all criteria: one qualifying condition from I.A and both items in I.B (adequate prior treatment of underlying conditions and individualized treatment plan with measurable goals and estimated length).

SourceLink

POLICY UPDATE CHANGES

Updated Criteria I. to specify initial pediatric oral function therapy. Added Criteria I.B. regarding adequate treatment for any contributing underlying medical conditions and documentation of an individualized treatment plan with measurable goals and estimated length. Added Criteria II. regarding requirements for continuation of pediatric oral function therapy.

Multiple prior annual reviews made wording updates and additions (for example, replaced 'sensory issue' with 'neurodevelopmental disability', added complex medical conditions, and included parenteral nutrition and gastrostomy feedings).

2Main policy sections (Initial and Continuation)

3Referenced CPT codes

9Qualifying condition bullets in I.A

Coverage Summary

This policy (Policy Number: CP.MP.188; Subject: Pediatric Oral Function Therapy) defines medical necessity criteria for pediatric oral function therapy (feeding/swallowing/oral function treatment) for members under the health plan. Coverage stance: covered_with_criteria. The criteria are organized for both Initial and Continuation therapy and must be met for services to be considered medically necessary.

Thresholds and Quick Facts

Weight change over prior two monthsReduction in weight or cessation of weight gain over the previous two months

Weight percentile declineCrossing two or more major weight percentiles downward

Main policy sectionsInitial and Continuation

Referenced CPT codes92526, 92610, 92700

Qualifying condition bullets (I.A)Includes 9 condition bullets (anatomic/neurologic conditions, PFD/ARFID, age <5 with growth failure, dependence on nutrition support, aspiration signs, neuromuscular factors, neurodevelopmental disability, hypersensitivity from limited exposure, complex medical conditions)

Date of last review2026-04-26

Medical Necessity Criteria

Initial pediatric oral function therapy - Medically necessary criteria

Initial pediatric oral function therapy is medically necessary when meeting ALL of the following:

ALL of the following

One of the following
- ALL of the following
  - Reduction in weight or cessation of weight gain over the previous two months
  - Crossing two or more major weight percentiles downward
- ALL of the following
  - Reduction in weight or cessation of weight gain over the previous two months

Provider Actions & Prior Authorization

Prior Authorization

Medical necessity documentation required for initial therapy

Submit documentation demonstrating that initial therapy meets all required criteria: at least one qualifying condition from Criteria I.A (e.g., anatomic/neurologic condition with weight reduction or crossing weight percentiles, pediatric feeding disorder/ARFID with weight change, under-five failure to meet milestones with weight changes, dependence on nutritional support such as parenteral nutrition or gastrostomy feedings, signs of aspiration, neuromuscular coordination factors, limited intake due to neurodevelopmental disability or hypersensitivity, or complex medical conditions affecting feeding) AND both items in Criteria I.B: (1) adequate treatment of any contributing underlying medical conditions has occurred without resolution of the feeding problem, and (2) documentation of an individualized treatment plan with achievable and measurable short- and long-term goals and estimated length of treatment.

92526
92610
92700

Coding

Referenced CPT codes for evaluation and treatmentCPTCovered

92526	Treatment of swallowing dysfunction and/or oral function for feeding
92610	Evaluation of oral and pharyngeal swallowing function
92700	Unlisted otorhinolaryngological service or procedure

Background

Oral function therapy aims to identify the child's optimal feeding methods, maximize safety, prevent medical complications, and help the child achieve age-appropriate feeding skills through a customized plan developed with the family.

Pediatric feeding disorders (PFD) are defined as impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. PFD and related conditions (including ARFID) may present as avoidance or restriction of food, limited variety or quantity, disruptive mealtime behaviors, failure to master self-feeding, use of inappropriate feeding devices, or suboptimal growth and nutrition.

Assessment of feeding and swallowing is commonly performed by speech-language pathologists or occupational therapists and includes examination of the face and oropharynx, respiratory pattern, posture/position, cranial nerve and reflexes, and vocal quality. Common causes include complex medical conditions, developmental disability, neuromuscular coordination factors, structural abnormalities, sensory or socio-emotional factors, and medication or neurologic disorders.

Evidence and guideline references cited in the policy include Pediatrics 2019 (Houtrow & Murphy), the ASHA Pediatric Feeding and Swallowing practice portal, and the Pediatric Feeding Disorder consensus definition (Goday et al., 2019).

Definitions

Pediatric Feeding Disorder (PFD)Impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.

Revision History

04/25revised

Updated Criteria I. to specify initial pediatric oral function therapy and added Criteria I.B. regarding adequate treatment for contributing conditions and documentation of an individualized treatment plan; added Criteria II. for continuation requirements. Background updated to align with updated criteria; reviewed codes and descriptions. Reviewed by internal specialist.

05/20-04/26 (multiple prior annual reviews)revisedLatest

Multiple prior annual reviews updated wording (e.g., replaced 'sensory issue' with 'neurodevelopmental disability', added complex medical conditions, included parenteral nutrition and gastrostomy feedings); background and references updated with no impact to clinical criteria. Coding and descriptions reviewed across revisions.

Policy Summary

PayerHealth Net

PolicyPediatric Oral Function Therapy

Policy CodePolicy CP.MP.188

Change TypeRevised criteria and annual wording updates

Effective Date

Next Review Date

SourceLink

On This Page

Crossing two or more major weight percentiles downward

ALL of the following

Significant weight loss or cessation of weight gain over the previous two months
Crossing two or more major weight percentiles downward

ALL of the following

Nutritional support consisting of high-calorie foods or nutritionally deficient foods
Parenteral nutrition
Gastrostomy feedings

Demonstrates signs and symptoms of aspiration or penetration of liquids into the respiratory tract, resulting in respiratory issues such as pneumonia and respiratory distress

Factor affecting neuromuscular coordination such as prematurity, low birth weight, hypotonia or hypertonia

Limited food intake due to a neurodevelopmental disability, such as autism, that can cause hypersensitivity to textures

Limited food intake due to hypersensitivity to textures secondary to limited food availability or exposure in early development

Complex medical conditions with concern for feeding difficulty (e.g., heart disease, pulmonary disease, allergies, gastroesophageal reflux disease, delayed gastric emptying)

And all of the following

Adequate treatment for any contributing underlying medical conditions, if present, has occurred without resolution of the feeding problem
Documentation of an individualized treatment plan with achievable and measurable short and long term goals of therapy and estimated length of treatment

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Continuation pediatric oral function therapy - Medically necessary criteria

Continuation of pediatric oral function therapy is medically necessary when meeting ALL of the following:

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Prior Authorization

Documentation required for continuation of therapy

Provide documentation for continuation requests showing that ongoing treatment is needed to achieve goals; an updated treatment plan that includes measurable and achievable goals with an estimated length of necessary continued treatment; and evidence the member is demonstrating ongoing progress since initial therapy (for example, applying targeted skills in the home and/or community environment).

92526

Documentation Required

Individualized treatment plan requirements

Individualized treatment plan must include achievable and measurable short- and long-term goals of therapy and an estimated length of treatment. The plan should also document prior interventions for any contributing underlying medical conditions (if present) and the outcomes of those interventions.

ARFIDAvoidant/Restrictive Food Intake Disorder — eating/feeding disturbance characterized by lack of interest in food, sensory-based avoidance, or aversion to consequences of eating leading to persistent failure to meet nutritional/energy needs.