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Pediatric Oral Function Therapy
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Defines medical necessity criteria for initial and continued pediatric oral function therapy (feeding/swallowing therapy) for children and describes when services are covered by the Health Plan. Applies to pediatric members/enrollees receiving oral/feeding/swallowing treatment.
Criteria I. now specifies initial pediatric oral function therapy and includes required documentation of an individualized treatment plan.
Added Criteria II. regarding requirements for continuation of pediatric oral function therapy.
Expanded Criteria I.D. to explicitly include parenteral nutrition and gastrostomy feedings as options for nutritional support.
Medical Necessity — Pediatric Oral Function Therapy
Initial Therapy Criteria
Initial pediatric oral function therapy is medically necessary when ALL of the following are met:
I.A. Indications (one required)
- I.A.1: Anatomic or neurologic condition contributing to failure to meet developmental milestones of growth and development, including either: (a) reduction in weight or cessation of weight gain over the previous two months; or (b) crossing two or more major weight percentiles downward.
- I.A.2: Pediatric feeding disorder, swallowing impairment, or avoidant/restrictive food intake disorder (ARFID) causing a significant change in feeding behavior that compromises the child's nutritional status, demonstrated by either: (a) reduction in weight or cessation of weight gain over the previous two months; or (b) crossing two or more major weight percentiles downward.
- I.A.3: Under five years of age and failing to meet developmental milestones of growth and development, including either: (a) significant weight loss or cessation of weight gain over the previous two months; or (b) crossing two or more major weight percentiles downward.
- I.A.4: Under five years of age where growth and development milestones have been met only via nutritional support, and transition to nutritionally and calorically appropriate foods is warranted. Nutritional support includes: (a) high-calorie or nutritionally deficient foods; (b) parenteral nutrition; or (c) gastrostomy feedings.
- I.A.5: Demonstrates signs and symptoms of aspiration or penetration of liquids into the respiratory tract resulting in respiratory issues such as pneumonia or respiratory distress.
- I.A.6: Factor(s) affecting neuromuscular coordination (for example prematurity, low birth weight, hypotonia or hypertonia).
- I.A.7: Limited food intake due to a neurodevelopmental disability (e.g., autism) that can cause hypersensitivity to textures.
- I.A.8: Limited food intake due to hypersensitivity to textures secondary to limited food availability or exposure in early development.
- I.A.9: Complex medical conditions with concern for feeding difficulty (e.g., heart disease, pulmonary disease, allergies, gastroesophageal reflux disease, delayed gastric emptying).
See required conditions block for details.
Initial Therapy Required Conditions
AND All of the following must be met (I.B):
Providers must supply the individualized treatment plan with measurable goals when requesting initial therapy.
Continuation Therapy Criteria
Continuation of pediatric oral function therapy is medically necessary when ALL of the following are documented:
For continuation requests include updated plan and objective evidence of progress (examples: demonstration of targeted skills outside therapy sessions).
This policy is limited to pediatric members/enrollees. Criteria pertaining to adults were removed from this pediatric policy and adult coverage criteria are excluded from this document; any prior adult-specific language or requirements should not be applied to pediatric determinations.
The CPT codes listed in this policy are provided for informational and administrative purposes only. Inclusion or exclusion of any CPT codes does not guarantee coverage; coverage determinations are made by applying the clinical criteria in this policy together with the member's benefit terms. Providers should reference current professional coding guidance when submitting claims.
Procedure Codes
Documentation, Prior Auth, and Submission Requirements
Prior authorization and coding references
Prior authorization and coverage evaluations must follow the policy's clinical criteria and include the individualized treatment plan and supporting evidence of qualifying indications; referenced CPT codes for services are 92526, 92610, and 92700.
Provider submission requirements
Submit requests that explicitly reference the policy criteria and include required clinical documentation (individualized treatment plan, evidence of prior treatment of underlying conditions when present, and for continuation requests updated plan and progress).
- Ensure the request maps to one or more qualifying indications in I.A.
- For initial requests include documentation that adequate treatment for underlying medical conditions occurred if present.
- For continuation requests include an updated plan with evidence of ongoing progress (e.g., application of targeted skills).
Required documentation for authorization
Document an individualized treatment plan that contains achievable, measurable short- and long-term goals, an estimated length of treatment, evidence that contributing medical/nutritional issues were addressed or incorporated, and progress notes for continuation.
- Individualized plan with measurable short- and long-term goals and estimated treatment length (I.B.2).
- Evidence that adequate treatment for any contributing underlying medical conditions occurred if present (I.B.1).
- For continuation, updated plan plus documentation of ongoing progress (II.A.1–3).
Denial risks for incomplete requests
Requests that do not include an individualized treatment plan with measurable short- and long-term goals, or that lack documentation of adequate treatment of underlying medical conditions or evidence of ongoing progress for continuation, may be denied.
- Missing individualized treatment plan with measurable goals (I.B.2) risks denial.
- Lack of documentation that adequate treatment of contributing underlying medical conditions occurred (I.B.1) risks denial.
- Continuation requests without updated plan and evidence of progress (II.A.1–3) risk denial.
Key Terms
Clinical Context
Pediatric feeding disorders and dysphagia describe problems with oral intake that may include difficulty with feeding skills and/or swallowing. These conditions can involve medical, nutritional, feeding-skill, and psychosocial components and may stem from complex medical diseases, developmental or neuromuscular disorders, sensory processing issues, structural abnormalities, or behavioral factors. Clinical assessment typically evaluates oropharyngeal anatomy and function, respiratory status, posture, cranial nerve function, and vocal quality and is most often performed by speech-language pathologists or occupational therapists.
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