1. Aetna considers both fiberoptic endoscopy and videofluoroscopy medically necessary for evaluation of swallowing function.

   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:

   1. A more conservative examination than videofluoroscopy is required because of concerns about aspiration of barium, food, and/or liquid; or
   2. Need to assess fatigue or swallowing status over a meal; or
   3. Repeat examination to assess change; to assess effectiveness or need for maneuvers; or
   4. Severe dysphagia with very weak or possibly absent swallow reflex and/or very limited ability to tolerate any aspiration (e.g., brainstem stroke, member tube-fed for prolonged period, very poor pulmonary status, or, poor immunologic status); or
   5. Therapeutic examination that requires time to try out several maneuvers, several consistencies, etc. (e.g., want to try real foods; want parent to hold baby in several positions; or want to try biofeedback); or
   6. To visualize the larynx directly for signs of trauma or neurological damage and assess laryngeal competence post-intubation or post-surgery (especially with coronary artery bypass grafting, carotid endarterectomy, or any surgery where the recurrent laryngeal nerve was vulnerable); or
   7. When positioning for fluoroscopy is problematic (e.g., member bedridden, weak, has contractures, in pain, has decubitus ulcers, quadriplegic, wearing neck halo, obese, or, on ventilator); or
   8. When there is a suspicion that laryngeal competence may be compromised in a member with a tracheostomy; or
   9. When transportation to fluoroscopy is problematic (e.g., medically fragile/unstable member in an intensive care unit, cardiac or other monitoring in place, on ventilator, or, nursing/medical care must be with member); or
   10. When transportation to the hospital is problematic (e.g., nursing home issues, including cost of transportation, resources needed to accompany member, strain on member, or, member fearful of leaving familiar surroundings, etc.).
        

2. 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.