Fiberoptic endoscopic evaluation of swallowing (FEES) is the preferred test over videofluoroscopy in the evaluation of a swallowing disorder in any of the following conditions:
Aetna considers the sensory testing component (also known as “endoscopic air pulse stimulation”) of fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) medically necessary for the evaluation of members with persistent dysphagia who meet criteria for FEES above.
Oropharyngeal dysphagia is usually either a primary abnormality related to structural aberrations of the oropharynx or a secondary manifestation of neuromuscular disease. Causes for dysfunctional swallowing are protean. Both diagnosis and therapy of oropharyngeal dysphagia are based on functional assessment. Following the performance of a clinical examination, instrumental work-up includes evaluating specific aspects of swallowing function, judging the consequences of the swallowing dysfunction, and assessing factors that may be contributing to swallowing dysfunction.
Videofluoroscopy has long been viewed as the "gold standard" for evaluation of a swallowing disorder for the comprehensive information it provides. However, it is not very efficient and accessible in certain clinical and practical situations. Fiberoptic endoscopic evaluation of swallowing (FEES) has been shown to be safe and effective for assisting in swallowing evaluation, and in therapy as a visual display to help patients learn various swallowing maneuvers.
In FEES, a flexible fiberoptic endoscope is introduced transnasally to the patient's hypopharynx where the clinician can clearly view laryngeal and pharyngeal structures. The patient is then led through various tasks to evaluate the sensory and motor status of the pharyngeal and laryngeal mechanism. Food and liquid boluses are then given to the patient so that the integrity of the pharyngeal swallow can be determined. Information obtained from this examination includes ability to protect the airway, the ability to sustain airway protection for a period of several seconds, the ability to initiate a prompt swallow without spillage of material into the hypopharynx, timing and direction of movement of the bolus through the hypopharynx, ability to clear the bolus during the swallow, presence of pooling and residue of material in the hypopharynx, timing of bolus flow and airway protection, sensitivity of the pharyngeal/laryngeal structures and the effect of anatomy on the swallow.
Appropriate postural changes and swallowing maneuvers are attempted to detect problems and enable the examiner to make recommendations regarding optimal interventions to improve the safety and efficiency of the swallow, the advisability of oral feeding, and use of appropriate behavioral strategies that facilitate safe and efficient swallowing. The most critical finding is aspiration, and the literature demonstrates that FEES is able to detect this finding with good sensitivity.
Fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) is an alternative to modified barium swallow evaluation of patients at risk for aspiration. The procedure entails the passage of a specially equipped flexible endoscope into the oropharynx. The special equipment includes a sensory stimulator that allows quantification of stimuli, a television monitor, a video printer, and a videocassette recorder. Sensory evaluation is performed by administering pulses of air at sequentially increased pressures to elicit the laryngeal adductor reflex. Motor evaluation is carried out by delivering various food items with different consistencies while factors such as oral transit time, inhibition of swallowing, laryngeal elevation, spillage, residue, condition of swallow, laryngeal closure, reflux, aspiration, and ability to clear residue, are monitored.
A randomized controlled clinical outcome study of FEESST by Aviv et al (2000) found no significant difference in rates of pneumonia in dysphagic patients evaluated with modified barium swallow and dysphagic patients evaluated with FEESST. The use of laryngopharyngeal sensory testing is controversial. The Veterans Health Administration, Department of Defense (2003) clinical practice guideline for the management of stroke rehabilitation in the primary care setting concluded that “[t]here is insufficient evidence to recommend for or against fiber-optic endoscopic examination of swallowing with sensory testing (FEESST) for the assessment of dysphagia”. The evidence review stated that the overall quality of evidence supporting FEESST is “poor”. An evidence-based guideline on dysphagia from the Scottish Intercollegiate Guidelines Network (SIGN, 2004) concluded that "[l]aryngopharyngeal testing has also been described but insufficient evidence was identified to recommend it". Current clinical guidelines on stroke from the Royal College of Physicians (2004) recommend FEES or some other instrumental investigation to allow visualization of the pharynx in persons who have persistent dysphagia. Although FEESST is listed in an appendix to these guidelines, the guidelines make no recommendation for its use.
Bockler (2015) noted that although FEES has been established as a valid procedure in instrumental evaluation of swallowing even in young children, the significance of the endoscopic method on infants has not yet been fully clarified. These researchers evaluated FEES in infants by focusing on its feasibility and limits. A total of 27 infants from a neuropediatric hospital presented for FEES were included in this analysis. Compared with Langmore standard FEES was carried out in a modified algorithm. In 24 of the 27 infants information about swallowing pathology could be obtained. Silent aspiration of saliva (Penetration Aspiration Scale (PAS) level 8) or silent deep penetration of test diets to the level of the glottis (PAS level 5) presented in 10 children and overt deep penetration of test diets in 3 children. In no case a sufficient insight into the subglottis or trachea could be obtained. Therefore a differentiation of silent deep penetration and aspiration of test diets was impossible. As a consequence of the FEES results, probe and diet management was changed in 7 children. The authors concluded that FEES in a modified algorithm turned out to be a feasible tool for the diagnostics of swallowing disorders in approximately 89 % of the infants. The procedure was limited in terms of providing direct evidence on aspiration in cases of deep penetrations of test diets.
Reynolds et al (2016) stated that the standard procedure to assess an infant in the neonatal intensive care unit (NICU) who is suspected of aspirating on oral feedings is a video-fluoroscopic swallowing study (VFSS). The VFSS has been used for more than 30 years to assess dysphagia and is considered the gold standard. However, there are challenges to the VFSS, including radiation exposure, transport to radiology, usage of barium, limited positioning options, and cost. An alternative approach is FEES, which uses a flexible endoscope passed trans-nasally into the pharynx to assess anatomy, movement/sensation of structures, swallow function, and response to therapeutic interventions. Fiberoptic endoscopic evaluation of swallowing has been established as a valid tool for evaluating dysphagia and utilized as an alternative or supplement to the VFSS in both adults and children. These investigators provided an overview of the current challenges in the NICU with assessing aspiration and introduced a multi-disciplinary FEES program for bottle and breast-feeding. They performed a review of the literature of dysphagia, VFSS, and FEES in the adult, pediatric, infant, and neonatal populations. Clinical competency standards were researched and then implemented through an internal process of validation. Finally, a best practice protocol was designed as it relates to FEES in the NICU. Fiberoptic endoscopic evaluation of swallowing is a safe alternative to the VFSS. It can be utilized at the infant's bedside in a NICU for the diagnosis and treatment of swallowing disorders by allowing the clinician the ability to replicate a more accurate feeding experience, therefore, determining a safe feeding plan. These investigators noted that competency and training are essential to establishing a multi-disciplinary FEES program in the NICU. The authors concluded that further research is needed to compare the effectiveness and validity of FEES versus VFSS for infants in the NICU. Furthermore, they stated that evaluation of the effectiveness of FEES during breast-feeding is needed.
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes covered if selection criteria are met:|
|74230||Swallowing function, with cineradiography/videoradiography|
|92610||Evaluation of oral and pharyngeal swallowing function|
|92611||Motion fluoroscopic evaluation of swallowing function by cine or video recording|
|92612||Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording|
|92613||physician interpretation and report only|
|92614||Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording|
|92615||physician interpretation and report only|
|92616||Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording|
|92617||physician interpretation and report only|
|Other CPT codes related to the CPB:|
|92526||Treatment of swallowing dysfunction and/or oral function for feeding|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|G45.0 - G45.9||Transient cerebral ischemic attack|
|I65.01 - I67.9||Occlusion and stenosis precerebral arteries, occlusion of cerebral arteries and acute, but ill-defined cerebrovascular diseases|
|Sequela of cerebrovascular disease, dysphagia|
|J38.7||Other diseases of larynx|
|J69.0||Pneumonitis due to inhalation of food and vomit|
|K21.0 - K21.9||Gastro-esophageal reflux disease|
|K22.0||Achalasia of cardia|
|K22.4||Dyskinesia of esophagus|
|K22.8||Other specified diseases of esophagus|
|K23||Disorders of esophagus in diseases classified elsewhere|
|Q31.0 - Q32.4||Congenital malformations of larynx, trachea, and bronchus|
|R13.10 - R13.19||Dysphagia|