92700
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation that adequate treatment for any contributing underlying medical conditions (if present) has been provided without resolution of the feeding problem.
- Individualized treatment plan with achievable and measurable short- and long-term goals and an estimated length of treatment.
- Documentation supporting continuation of therapy per the policy's continuation criteria (specific continuation elements referenced in policy).
- Documentation that ongoing treatment is required to achieve the member's treatment goals.
Key Coverage Criteria
- Anatomic or neurologic condition contributing to failure to meet developmental milestones of growth and development, plus 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.
- Pediatric feeding disorder, swallowing impairment, or avoidant/restrictive food intake disorder (ARFID) causing a significant change in feeding behavior that compromises nutritional status, plus 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.
- Child under five years of age failing to meet developmental milestones of growth and development, plus 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.
- Child under five years old who has met growth and developmental milestones but requires transition to nutritionally and calorically appropriate foods because current feeding method warrants it.
- Child receiving nutritional support in the form of high-calorie or nutritionally deficient foods who requires transition to appropriate oral nutrition.
- Child receiving parenteral nutrition who requires transition to appropriate oral nutrition.
8 Active Policies
AMBETTER-CP.MP.188 — Pediatric Oral Function Therapy
ANTHEM-MED.00002 — MED.00002 Selected Sleep Testing Services
BCBSIL-MED201.047 — Vestibular Function Testing
BCBSMT-MED201.047 — Vestibular Function Testing
BCBSNM-MED201.047 — Vestibular Function Testing
Related Codes
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