Medical Policy

Policy Num:       08.001.034
Policy Name:     DYSPHAGIA THERAPY 

 Policy ID:          [08.001.034]  [Ac / L / M+ / P-]  [0.00.00]

Last Review:       October 24, 2024
Next Review:      October 20, 2025

Related Policies: None

DYSPHAGIA THERAPY

SUMMARY

Dysphagia, therapy to swallow, is a medical treatment indicated to improve or restore the functions of swallowing that have been altered by an illness or injury. The phases of swallowing include oral, pharynx, and/or esophagus (upper third).

Dysphagia is a swallowing disorder that can be due to various neurological, structural, and cognitive deficiencies. Dysphagia can be the result of head trauma, stroke, neuromuscular degenerative diseases, head and neck cancer, and encephalopathies. While dysphagia can affect any age group, it appears more frequently in the elderly.

Dysphagia is a swallowing disorder involving the oral cavity, pharynx, esophagus, or gastroesophageal junction. Consequences of dysphagia include malnutrition and dehydration, aspiration pneumonia, compromised general health, chronic lung disease, choking, and even death. Adults with dysphagia may also experience disinterest, reduced enjoyment, embarrassment, and/or isolation related to eating or drinking. Dysphagia may increase caregiver costs and burden and may require significant lifestyle alterations for the patient and the patient’s family.  Dysphagia intervention may concentrate on swallowing exercises, compensatory swallowing strategies (including posture considerations), bolus consistency modification, and caregiver/patient education.

OBJECTIVE

The objective of this policy is to establish the guidelines to evaluate and manage the patient with dysphagia

POLICY STATEMENTS

Therapy for the treatment of dysphagia is considered medically necessary and proceeds for payment when any of the following criteria are met:

• Weight loss or malnutrition due to inability to obtain adequate nutrition orally, or

• History of, or being at high risk of, recurring aspirations or suffocation, or

• The patient is unable to swallow and has a nasogastric tube or gastrostomy for feeding.

Dysphagia therapy does not apply for payment for all other indications, since its effectiveness for indications other than those mentioned above has not been established.

Esophageal dilation proceeds for payment for the treatment of symptomatic obstruction of the esophagus.

Esophageal dilation for the treatment of non-obstructive esophageal dysphagia is not applicable for payment, since its efficacy has not been established.

The placement of a stent may be considered for payment in cases of refractory stenosis (it can not be dilated to an adequate diameter), such as malignant esophageal strictures.

The following interventions, but not limited to these alone, do not proceed for payment for the treatment of dysphagia because their efficacy in these indications has not been established:

• Botulinum toxin

• Electrical stimulation

• Pharyngeal motor cortex stimulation

• Repetitive transcranial magnetic stimulation

POLICY GUIDELINES

An individual treatment plan is written and should include the following:

• Diagnosis; proposed treatment plan, interventions, and length of treatment; and
• Specific tests and measures that will be used to document progress; and
• Significant improvement is expected from the treatment; and
• A discharge plan for transition from one-on-one supervision to individual maintenance provided by the home caregiver.

The diagnosis of dysphagia or difficulty swallowing requires extensive evaluation by the doctor. Many problems can be identified and treated based on the results of this test only. In some cases, more extensive evaluations are required using a variety of studies such as ultrasound and modified barium swallow studies and an evaluation by a swallowing therapist.

The treatment of dysphagia/difficulty swallowing may include simple recommendations for things, such as the consistency of food or its placement in the mouth, or may require a treatment program aimed at achieving a functional improvement.

Patients who are motivated, are moderately alert, and have a certain degree of swallowing are appropriate candidates for dysphagia therapy. Elements of the therapy program may include thermal stimulation to increase the sensitivity of the reflex deglutition, exercises to improve motor-oral control, training in laryngeal adduction and compensatory swallowing techniques, and positioning and diet modifications. Design programs to ensure the safety of the patient's swallowing during oral feeding and maintain adequate nutrition.

Dysphagia can be caused by any condition that weakens or damages the nerves and muscles used to swallow. For example, people with diseases of the nervous system, such as cerebral palsy or Parkinson's disease, often have trouble swallowing. In addition, a stroke or a traumatic brain injury can affect the coordination of the muscles of swallowing or feeling of limit in the mouth and throat. An infection or irritation can cause narrowing of the esophagus. People born with abnormalities in the mechanism of swallowing may not be able to swallow normally. Babies born with a cleft palate are not able to suck adequately, which complicates breastfeeding, and can be taken from a regular bottle. In addition, cancers of the head, neck or esophagus can cause dysphagia. Sometimes, treatment for these cancers can cause dysphagia. Injuries to the head, neck, and chest can also create problems swallowing.

The physician must establish a preliminary diagnosis to address the symptoms associated with dysphagia. This preliminary diagnosis should address the possibility of treating the patient in terms of:

· Alert level

· Ability to cooperate

· Ability to retain new knowledge

· Cognitive state

· Medical stability

· Psychological stability

There must be a significant and recent change based on swallowing to consider medically necessary a dysphagia assessment. One or more of the following conditions must be present:

 · History of aspiration problems or defined risk of aspiration.

· Insufficient potency of the salivary glands and / or the presence of local structural lesions in the pharynx that produce significant difficulties in oropharyngeal swallowing.

· Incoordination, loss of sensibility, postural difficulties or other disorders that affect the neuromotor oropharyngeal skills necessary to close the oral cavity and / or bite, chew, suck, the shape and consolidation of the food bolus in the upper esophagus, while protecting the airway.

· Post-surgical reaction.

· Significant weight loss directly related to reduced oral intake as a consequence of dysphagia.

Significant weight loss:

 ·.loss of > 2% in a week

· >5% in a month

· > 10% in 6 months

· > 20% in a year

BENEFITS APPLICATION

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

BlueCard/National Account Issues

N/A

BACKGROUND

People with dysphagia have difficulty swallowing and may also experience pain while swallowing.  Some people may be completely unable to swallow or may have trouble swallowing liquids, foods, or saliva.

Dysphagia occurs when there is a problem with any part of the swallowing process.  Weak tongue or cheek muscles may make it hard to move food around in the mouth for chewing.  Food pieces that are too large for swallowing may enter the throat and block the passage of air.

Other problems include not being able to start the swallowing reflex (a stimulus that allows food and liquids to move safely through the pharynx) because of a stroke or other nervous system disorder.  People with these kinds of problems are unable to begin the muscle movements that allow food to move from the mouth to the stomach.  Another difficulty can occur when weak throat muscles cannot move all of the food toward the stomach.  Bits of food can fall or be pulled into the trachea, which may result in aspiration pneumonia.

Dysphagia may be caused by any condition that weakens or damages the muscles and nerves used for swallowing.  For example, people with nervous system diseases, such as cerebral palsy or Parkinson's disease, often have problems swallowing.  Additionally, cerebrovascular accident or traumatic brain injury may affect the coordination of the swallowing muscles or limit sensation in the mouth and throat.  An infection or irritation can cause narrowing of the esophagus.  People born with abnormalities of the swallowing mechanism may not be able to swallow normally.  Infants who are born with a cleft palate are unable to suck properly, which complicates breast-feeding and drinking from a regular baby bottle. In addition, cancers of the head, neck, or esophagus may cause dysphagia.  Sometimes the treatment for these types of cancers can cause dysphagia.  Injuries of the head, neck, and chest may also create swallowing problems.

Physicians and speech-language pathologists who test for and treat swallowing disorders use a variety of tests that allow them to look at the parts of the swallowing mechanism, including fiber optic laryngoscopy, videofluoroscopy, and ultrasound.

Once the cause of the dysphagia is found, surgery or medication may help.  If treating the cause of the dysphagia does not help, the patient may refer the patient to a speech-language pathologist who is trained in testing and treating swallowing disorders.  The speech-language pathologist will test the person's ability to eat and drink and may teach the person new ways to swallow.

Oral-motor therapy is directed at correcting abnormal oral muscle behaviors that interfere with feeding.  Oral-motor therapy may be focused upon inducing active suckle movements, coordinating tongue movements, or facilitating normal oral movement patterns such as lip closure.

Oral-motor therapy has also been used in developmentally delayed children to stop drooling, correct abnormal tongue thrust, and improve speech.  Speech management of the developmentally delayed child has included training to improve the functioning of oral and pharyngeal muscles.  This oral-motor training is usually introduced before the emergence of speech.  Most Aetna plans exclude treatment of developmental delay.  

Symptoms: The American Speech-Language-Hearing Association lists the following as signs and symptoms of feeding and swallowing disorders in very young children:

1. Arching or stiffening of the body during feeding
2. Irritability or lack of alertness during feeding
3. Refusing food or liquid
4. Failure to accept different textures of food (e.g., only pureed foods or crunchy cereals)
5. Long feeding times (e.g., more than 30 minutes)
6. Difficulty chewing
7. Difficulty breast feeding
8. Coughing or gagging during meals 
9. Excessive drooling or food/liquid coming out of the mouth or nose
10. Difficulty coordinating breathing with eating and drinking
11. Increased stuffiness during meals 
12. Gurgly, hoarse, or breathy voice quality
13. Frequent spitting up or vomiting
14. Recurring pneumonia or respiratory infections
15. Less than normal weight gain or grow

REGULATORY STATUS

Law 220-2012, as amended, is repealed.New Law 163 of August 13, 2024:Law for the protection, security, integration, well-being and comprehensive development of people with Autism Spectrum Disorders prevails.

RATIONALE

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American]; LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflective of and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g., women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Population reference No. 1

• Individuals with dysphagia due to neurological, structural or cognitive deficiencies may be medically necessary.

SUPPLEMENTAL INFORMATION

N/A

PRACTICE GUIDELINES AND POSITION STATEMENTS

N/A

MEDICARE NATIONAL COVERAGE

National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Speech-Language Pathology Services for the Treatment of Dysphagia (170.3) located at cms.gov.

REFERENCES

1. National Institutes of Health (NIH), National Institute on Deafness and Other Communication Disorders. Dysphagia. Health Information. NIH Document No. 99-4307. Bethesda, MD: NIH; October 1998. Available at: http://www.nidcd.nih.gov/health/voice/dysphagia.asp. Accessed May 13, 2002.

 2. Medicare LCD ;L29313

3. American Speech-Language Hearing Association (ASHA). Swallowing. Public Information. Rockville, MD: ASHA; 2002. Available at: http://www.asha.org/public/speech/swallowing/Swallowing-Disorders-in-Adults.htm. Accessed May 13, 2002.

4. Paik N. Dysphagia. eMedicine J. 2001;2(7). Available at: http://www.emedicine.com/pmr/topic194.htm. Accessed May 13, 2002.

5. Davies S. An interdisciplinary approach to the management of dysphagia. Prof Nurse. 2002;18(1):22-25.

6. Cook IJ, Kahrilas PJ. AGA technical review on management of oropharyngeal dysphagia. Gastroenterology. 1999;116(2):455-478

7. Aetna : Clinical Policy Bulletin :Dysphagia Therapy Number 0625

8. White, JV., Guenter, P., Jensen, G., Malone, Al, Schofield, M., the Academy Malnutrition Work Group, the A.S.P.E.N Malnutrition Task Force, & the A.S.P.E.N. Board of Director. Consensus Statement of The Academy of Nutrition and Dietetics / American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition), Journal of The Academy of Nutrition and Dietetics. 2012; 112(5): 730-738.

8. LCD L35070, Speech-Language Pathology (SLP) Services: Communication Disorders for services related to communication disorders. Revision Effective Date: 11/21/2019

9. National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Speech-Language Pathology Services for the Treatment of Dysphagia (170.3) located at cms.gov.

CODES

APPLICABLE MODIFIERS

As per Correct Coding Guidelines

POLICY HISTORY