Diagnosis: Gastroesophageal reflux disease (GERD), oral aversion to textured solids, reactive airway disease, and autism with developmental and speech delays
Treatment: Special Feeding Routine Evaluation
The insurer denied the Special Feeding Routine Evaluation.
The denial is overturned.

The patient is a male child with medical history significant for gastroesophageal reflux disease (GERD), oral aversion to textured solids, reactive airway disease, and autism with developmental and speech delays. His diet is severely limited to liquids and purees. Although his weight is at the 50th percentile for age and gender, his diet does not provide well-balanced nutrition to meet his needs. He has failed treatment by a feeding therapist and is now being referred to a special day feeding program (with site modifications due to the pandemic).

Yes, the proposed treatment, Special Feeding Routine Evaluation (92205 x 1), is medically necessary.

Successful feeding of infants and children entails a complex interplay between neuromuscular function, behavior, and environment. Well-coordinated feeding supports weight gain, good health, and achievement of developmental milestones. Disrupting these interdependencies causes feeding disorders.

About 25 percent of all children and up to 80 percent of developmentally disabled children exhibit feeding disorders. Severe and persistent feeding disorders occur in up to ten percent of children, particularly those with chronic conditions. The etiology of feeding disorders is multifactorial, and includes medical, nutritional, behavioral, psychological, and environmental factors. If not dealt with appropriately, feeding disorders can lead to cognitive decline, malnutrition, growth retardation, increased susceptibility to illness, and even death.

A feeding disorder is an inability to consume adequate and appropriate nutrition by mouth. While feeding disorders may ultimately lead to eating disorders, they are not the same. Feeding disorder symptoms include inadequate fluid intake, food refusal, difficulty swallowing, inability to feed oneself, prolonged feeding time, choking or gagging with or without emesis, inappropriate mealtime behaviors, and selecting food by its type or texture.

This young male child has a severe feeding disorder, and in spite of his seemingly age-appropriate weight, he is not consuming adequate nutrition to support growth and development. He has tried and failed outpatient feeding therapy, with ongoing refusal to eat textures, relying solely on liquids and purees. The recommended program provides a multidisciplinary evaluation to identify all aspects contributing to his feeding disorder, as well as therapies to provide him with a much needed chance to achieve a well-balanced age-appropriate diet. The requested Special Feeding Program Routine Evaluation (99205x1) is thus medically necessary and appropriate for the requested duration.