These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Prior authorization is required for more than 20 visits per therapy per calendar year.
- Oral Function / Feeding Therapy visits count towards Speech Therapy (ST) limits unless the Occupational Therapy modifier ‘GO’ is used when billing.
- Oral Function / Feeding Therapy visits billed with the ‘GO’ modifier count towards Occupational Therapy (OT) limits.
- Occupational Therapy (OT) visits count towards Physical Therapy (PT) limits unless modifier ‘GO’ is used when billing.
Speech therapy and/or occupational therapy to address feeding and oral function are covered subject to the indications listed below, and per your plan documents.
Indications that are covered
HealthPartners covers feeding / oral motor function / swallowing therapy as medically necessary for children when the evaluation (which is covered) has confirmed the presence of a feeding/oral function problem (which may be associated with reduction or cessation of weight gain); and at least one of the following:
- Muscle tone abnormalities that significantly interfering with feeding or swallowing;
- Oro-facial defects, such as cleft palate, that interfere with feeding or swallowing
- Delayed or abnormal oral motor development or patterns (e.g., a tonic bite reflex, tongue thrust)
- Hypersensitive responses to touch, including consistencies and textures, and/or temperature in and around the mouth
- Inability to properly coordinate feeding, swallowing, and breathing due to prematurity, chronic medical conditions or central nervous system damage
- Related medical conditions such as gastroesophageal reflux (GER), pharyngeal dysphagia, aspiration or prior tube-feeding that may affect willingness to eat
- Definite differences/ dysfunction (scores equivalent to 2.0 deviations or greater from the norm) are documented in standardized sensory testing in the area of oral sensory processing, or oral sensory sensitivity
Annual evaluations from providers are required for ongoing treatment and should contain specific documentation regarding progress toward goals. Re-evaluations are required to document measurable functional progress and the continued medical necessity for therapy.
HealthPartners covers neuromuscular electrical stimulation (NMES), such as VitalStim®, when it is administered as an adjunct to covered feeding / oral motor function therapy. It is not separately reimbursable.
Indications that are not covered
- Neuromuscular electrical stimulation for feeding/eating disorders, such as VitalStim®, is not covered as a stand-alone therapy or for home use.
- Therapies for children with selective eating disorders that manifest as them being “picky eaters”, who are able to eat and swallow normally, and do not have any of the covered indications listed above.
- Swallowing/feeding therapy for specific food aversions.
- Group therapy, except when used in the context of a child diagnosed with autism.
- Therapy when functional improvement is not expected or progress has plateaued.
- Therapy to improve or enhance job, school or recreational performance.
Failure to thrive refers to slowed rate of growth, usually describes weight loss, decreased rate of weight gain and/or decreased linear growth; also called undernutrition, delayed growth, growth faltering, and failure to grow.
Feeding disorder refers to a condition in which a patient is unable or refuses to eat, or has difficulty eating, which may increase the chance of failing to grow normally. Examples of feeding disorders in children include, but are not limited to, adipsia (the absence of thirst or the desire to drink); dysphagia (difficulty in swallowing); choking, gagging, or vomiting when eating. Feeding disorders generally present as a food refusal or lower amount of food intake than that appropriate for age due to behavioral issues [selective diet, anticipatory gagging] or underlying organic conditions [dysphagia, aspiration]. This situation concerns mostly infants and children below 6 years of age; however, feeding problems can appear also later on in life. Feeding disorders commonly encountered in a pediatric setting include food refusal, inadequate intake, over-selectivity, and texture-related problems (Linscheid, 2006).
Feeding/oral function therapy is speech or occupational therapy for oral motor or sensory feeding problems as described above. This is generally provided by speech pathologists or occupational therapists, but may include other practitioners.
Food aversions refer to a dislike of a specific food.
Neuromuscular electrical stimulation (NMES), such as VitalStim®, is an approach to dysphagia management involving application of an electrical current to peripheral tissue targets. Such stimulation aims to improve function by strengthening the swallowing musculature or by stimulating the sensory pathways relevant to swallowing, or both. VitaslStim® is a specific treatment protocol that superimposes NMES upon volitional swallows.
Oral aversions refer to intolerance to certain textures or temperatures.
Selective Eating Behaviors: refers to willingness to consume foods from all food groups and all food consistencies, but restricted in variety of foods excepted within those groups.
Swallowing Disorders, also called dysphagia, are defined as any difficulty or abnormality of swallowing.
If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
Covered when criteria are met:
Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
Oral function therapy – treatment of swallowing dysfunction and/or oral function for feeding
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
Evaluation of oral and pharyngeal swallowing function
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Covered only as an adjunct to feeding / oral function therapy
Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
Application of a modality to one or more areas; electrical stimulation (unattended)
Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.
- American Speech-Language-Hearing Association (n.d.). Cleft Lip and Palate (Practice Portal). Retrieved November 16, 2018, from www.asha.org/Practice-Portal/Clinical-Topics/Cleft-Lip-and-Palate/.
- American Speech-Language-Hearing Association (n.d). Pediatric Dysphagia. (Practice Portal). Retrieved November 16, 2018, from www.asha.org/Practice-Portal/Clinical-Topics/Pediatric-Dysphagia.
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- Latif, L. A., Brizee, L. S., Casey, S., Cumbie, E., Feucht, S., Glass, R., … Katsh, N. (2010). Washington State Department of Health. Nutrition interventions for children with special health care needs. 3rd ed. Olympia, WA: Washington State Department of Health. Retrieved from: http://here.doh.wa.gov/materials/nutrition-interventions/15_CSHCN-NI_E10L.pdf.
- National Institute for Health and Care Excellence. (2017). Cerebral palsy in under 25s: assessment and management. NICE guideline (NG62).
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