Pediatric Swallowing Treatment Coverage Issues and Advocacy Bottom Line
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Bottom Line  |   October 01, 2009
Pediatric Swallowing Treatment Coverage
Author Notes
  • Janet McCarty, MEd, CCC-SLP, private health plans advisor, can be reached at jmccarty@asha.org.
    Janet McCarty, MEd, CCC-SLP, private health plans advisor, can be reached at jmccarty@asha.org.×
  • Amy Hasselkus, MA, CCC-SLP, associate director of health care services, can be reached at ahasselkus@asha.org.
    Amy Hasselkus, MA, CCC-SLP, associate director of health care services, can be reached at ahasselkus@asha.org.×
Article Information
Swallowing, Dysphagia & Feeding Disorders / Bottom Line
Bottom Line   |   October 01, 2009
Pediatric Swallowing Treatment Coverage
The ASHA Leader, October 2009, Vol. 14, 3-8. doi:10.1044/leader.BML.14132009.3
The ASHA Leader, October 2009, Vol. 14, 3-8. doi:10.1044/leader.BML.14132009.3
Health insurers review claims for pediatric swallowing services very closely, and may deny coverage for young children for a number of reasons. Some plans require that a documented disease be the causative factor, and that the swallowing problem result in weight loss, malnutrition, or a failure to gain weight; that a nasogastric or gastronomy tube is causing the inability to swallow; or that the child has a history or high risk of choking or recurrent aspirations. Other plans will not cover food-texture sensitivity/aversion problems. One state Medicaid program requires a standardized test to qualify children for swallow/feeding problems.
The most effective information to use in combating denials is research on outcomes and evidence-based practice that supports pediatric dysphagia treatment. ASHA has prepared information that clinicians can use to support the need for their services and to promote improved pediatric outcomes.
Outcome Data
The results of two ASHA systematic reviews—the effects of oral-motor exercises on dysphagia in children and the effects of oral-motor exercises on dysphagia in neonates—will be available in December 2009. Systematic reviews are formal assessments of the body of scientific evidence related to a clinical question and describe the extent to which various diagnostic or treatment approaches are supported by the evidence. They do not make specific recommendations for clinical practice, but are an important resource for incorporating evidence into clinical decision-making.
In addition, an ASHA treatment efficacy report on pediatric feeding and swallowing disorders is available on the ASHA Web site (search “pediatric dysphagia” on the ASHA Web site). This report can be used as an educational tool as well as a document supporting payment. The document defines pediatric swallowing disorders and their causes, discusses how a swallowing problem compromises nutrition and hydration in infants, and explains how swallowing difficulties can cause food and liquid to enter a child’s airway, resulting in pulmonary problems and lack of weight gain. It also provides information on efficacy studies that demonstrate how swallowing treatment reduces aspiration and improves nutrition and highlights the role of the speech-language pathologist.
Responding to Denials
Clinicians’ advocacy plays a prominent role in eventually obtaining payment for denied services.
If a health plan will cover dysphagia treatment only if the problem is related to a documented disease, and the child has no specific related disease, clinicians should document that lack of oral-motor function and muscular development indicates a physiological condition that is the identifying factor or cause for the swallow problem.
Other health plans deny dysphagia treatment for children who have sensitivity to food textures. The inability to manage age-appropriate food textures is defined as oral stage dysphagia (ICD-9 code 787.21) and is supported by several ASHA documents:
  • Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders describes SLPs as providers of clinical feeding and swallowing evaluations who make recommendations about management of these disorders and provide treatment.

  • Preferred Practice Patterns on Swallowing and Feeding Assessment–Children indicate that SLPs diagnose swallowing and/or feeding disorders and provide clinical descriptions of the characteristics of the disorder, including related functions that affect it (e.g., airway, neurologic, respiratory, gastrointestinal, behavioral, nutritional, craniofacial). They assess infants and children who have swallowing and/or feeding impairments affecting their body structure/function. Assessments include evaluation of behavioral factors, including acceptance of “range and texture of food/liquids as tolerated and developmentally appropriate.” Treatment is provided to support adequate hydration and nutrition, minimize the risk of pulmonary complications, and facilitate coordinated movements of the oral/pharyngeal mechanism and respiratory system, and includes “techniques for modifying behavioral and sensory issues that interfere with feeding and swallowing.”

  • Guidelines for Speech-Language Pathologists Providing Swallowing and Feeding in Schools describes swallowing and feeding as including the “introduction, preparation, transfer, and transport of food and liquid from the mouth through the esophagus into the stomach.” Characteristics of feeding and swallowing problems include choking, oral sensorimotor impairments, maladaptive behaviors, refusal to eat, and acceptance of a restricted variety of foods and liquids. A patient’s oral-motor deficit compromises the nutritional intake necessary for normal growth and development and meets the definition of a swallowing and feeding disorder; the SLP is the qualified and licensed provider to treat this disorder.

According to SLP Dianne Lazer, founder of the Better Speech and Feeding Center in Cherry Hill, N.J., other treatment is often denied for children who eat mostly processed grains and juice, foods that help them gain weight but are nutrient-deficient. These patients tend to refuse to eat more nutritious solid foods such as meats, vegetables, fruits, and whole grains. However, because the child is gaining weight and can chew “meltable” foods (e.g., graham crackers, breads), these claims are being denied. These children get limited practice developing chewing and swallowing skills for more advanced textures (meats, vegetables, and whole grains); as a result, the child’s oral-motor pattern is immature and should be considered a physiological condition or cause that impairs the child’s ability to swallow.
Lazer suggests that clinicians appeal these cases by documenting the oral-motor issues and the nutrient deficiencies of the child’s food, which put a child at risk for malnutrition and related growth and development problems. A nutritionist can recommend ways to improve the child’s diet and an SLP can provide swallowing treatment to help the child develop oral motor skills. Many health plans cover only the nutritionist’s services; SLPs should appeal these decisions and document their role in working with these patients.
Data Collection
ASHA continually seeks outcome data from clinicians to support the efficacy of treatments. This effective and powerful information helps meet the challenges from payers, legislators, administrators, and consumers to prove the value and benefits of speech-language treatment.
Aggregated local and national data answer critical questions related to treatment outcomes; the more data ASHA receives from members who work with the pediatric dysphagia population, the more likely ASHA will have sufficient information to publish data for that treatment category. ASHA members providing pediatric swallowing services may want to consider registering as NOMS (National Outcomes Measurement System) users. NOMS users contribute their data to ASHA, and can track trends in their own treatment outcomes and benchmark those trends to national data.
To become involved in ASHA’s NOMS data collection efforts, visit the ASHA Web site or contact Jaumeiko Brown at 301-296-8750 or jbrown2@asha.org.
Advocacy Overturns Treatment Denial

A Rhode Island speech-language pathologist spearheaded a successful effort to overturn an insurance carrier’s denial of pediatric swallowing treatment. The denial by Blue Cross and Blue Shield of Rhode Island (BCBSRI) was overturned by an external claim review organization. The organization’s final and legally binding decision establishes a critical precedent for families and clinicians whose pediatric swallowing treatment claims have come under exhaustive review.

This case involves a 4-year-old female denied coverage for oral-motor feeding treatment by BCBSRI, which insures more than 60,000 subscribers. BCBSRI claimed that “oral-motor feeding therapy is not medically necessary for treatment of the member’s condition.” BCBSRI noted “lack of disease causation” for the child’s loss of oral musculature and dysphagia.

Advocacy

The child’s SLP, Jennifer Price Hoskins, clinical director of a private practice that specializes in speech, language, and feeding treatment, gathered evidence to appeal the BCBSRI denial. Medical records indicated a history of “dysphagia”; a speech-language evaluation found reduced strength and mobility in the child’s jaws, lips, and tongue. The report stated that the child’s feeding disorder was secondary to physiological dysfunction of the oral mechanism that required oral-motor feeding treatment.

In response to Hoskins’ request, ASHA wrote a letter of support noting that the patient’s lack of oral-motor function and muscular development indicate a physiologic condition impairing the child’s ability to swallow that is, indeed, the identifying factor for her swallow problems. ASHA further noted that the child refuses specific foods and textures because she cannot manage those foods due to her reduced oral-motor skills. ASHA also provided supporting documentation on oral stage dysphagia, the inability to manage age-appropriate food textures.

Hoskins provided extensive details and support and the child’s mother wrote a letter stating that the oral-motor treatment helped her daughter chew, swallow, and ingest more nutritious foods.

Overturned Denial

The external claim review to determine whether oral-motor feeding treatment was medically necessary for treatment of the child’s condition was conducted by a pediatrician, who determined the service denial should be overturned based on four factors:

  • Presence of feeding disorder secondary to physiological dysfunction of the oral mechanism.

  • Improvement with treatment.

  • Maintenance of weight while receiving this treatment and ability to tolerate fluids and certain oral foods.

  • Tolerance for foods initially refused and steady progress with treatment.

The reviewing physician also noted that “early prevention is the key in preventing further feeding and eating disorders during adolescence and adulthood,” and stated that current literature stresses early intervention. The physician indicated that the child “does have an oral-motor swallowing dysfunction which has physiological or idiopathic causes,” and, therefore, “coverage and continuation of speech therapy for strengthening the child’s oral-motor musculature is medically necessary for treatment of her feeding disorder.”

—Janet McCarty

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October 2009
Volume 14, Issue 13