Aetna considers speech therapy for treatment of dysphagia, regardless of the presence of a communication disability, medically necessary for members who meet the criteria set forth below.  Note: Some plans limit coverage of medically necessary speech therapy services.  Members should check their benefit plan descriptions for any applicable benefit plan limitations and exclusions on coverage for speech therapy services. 

1. Aetna considers therapy for the management of dysphagia medically necessary in members who meet any of the following criteria: 
   
   
   1. Member exhibits weight loss or malnutrition because he/she has dysphagia and is unable to obtain adequate nutrition orally; or
   2. Member is unable to swallow and has a nasogastric or gastrotomy tube for nutrition; or
   3. Member has a history of, or is at high risk for, recurrent aspirations or choking.
      
      
2. Aetna considers dysphagia therapy experimental and investigational for all other indications.
   
   
3. Aetna considers electrical stimulation for the treatment of dysphagia experimental and investigational because its effectiveness for this indication has not been established.
   
   
4. Aetna considers esophageal dilation medically necessary for the treatment of symptomatic obstruction of the esophagus. 

   Aetna considers esophageal dilation for the treatment of non-obstructive esophageal dysphagia experimental and investigational because its effectiveness has not been established.

See also CPB 243 - Speech Therapy.

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, video fluoroscopy, 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.  Please check benefit plan descriptions for details.

Electrical stimulation (ES) has been examined for the treatment of dysphagia. However, there is currently insufficient evidence to support the effectiveness of ES in treating this condition. Park et al (1997) reported a pilot study of oral ES on swallow function in post-stroke patients. They found that oral ES resulted in an improvement in swallow function in 2 of the 4 patients. The authors concluded that these early results are promising, but further research is needed. In a controlled study, Freed et al (2001) compared the effectiveness of transcutaneous ES to thermal-tactile stimulation (TS) in patients with dysphagia caused by stroke. The investigators concluded that transcutaneous ES appears to be a safe and effective treatment for dysphagia due to stroke and results in better swallow function than conventional TS treatment. However, there were no follow-up data in this study. Grill et al (2001) reviewed emerging clinical applications of ES, and concluded that functional ES has great potential for increasing life support as well as for quality of life in chronic ailments, particularly obstructive sleep apnea and dysphagia.

In a non-concurrent cohort study, Blumenfeld et al (2006) assessed the effectiveness of ES in treating persons with dysphagia and aspiration. The charts of 40 consecutive subjects undergoing ES and 40 consecutive persons undergoing traditional dysphagia therapy (TDT) were reviewed. Pre- and post-therapy treatment success was compared utilizing a previously described swallow severity scale. A linear regression analysis was employed to adjust for potential confounding variables. The swallow severity scale improved from 0.50 to 1.48 in the TDT group (p < 0.05) and from 0.28 to 3.23 in the ES group (p < 0.001). After adjusting for potential confounding factors, persons receiving ES did significantly better in regard to improvement in their swallowing function than persons receiving TDT (p = 0.003). The authors concluded that the findings of this non-concurrent cohort study suggested that dysphagia therapy with transcutaneous ES is superior to traditional dysphagia therapy alone in individuals in a long-term acute care facility. They also stated that confirmation of these findings with a prospective, placebo-controlled, randomized clinical trial is needed before a definitive determination regarding the effectiveness of ES dysphagia therapy can be made.

Kiger et al (2006) compared the outcomes using transcutaneous neuromuscular ES (VitalStim therapy) to outcomes using traditional swallowing therapy for deglutition disorders. A total of 22 patients had an initial and a follow-up video-fluoroscopic swallowing study or fiberoptic endoscopic evaluation of swallowing and were divided into an experimental group that received VitalStim treatments and a control group that received traditional swallowing therapy. Outcomes were analyzed for changes in oral and pharyngeal phase dysphagia severity, dietary consistency restrictions, and progression from non-oral to oral intake. Results of chi-square analysis showed no statistically significant difference in outcomes between the experimental and control groups.

Shaw and colleagues (2007) carried out a retrospective analysis of 18 patients with dysphagia who received VitalStim therapy. All subjects underwent pre-therapy evaluation by speech-language pathologists, including modified barium swallow and/or functional endoscopic evaluation of swallowing and clinical evaluation of swallowing that included assessment of laryngeal elevation, diet tolerance, and swallowing delay, and were then assigned an overall dysphagia severity score. After therapy, all patients underwent the same assessments. Twelve of the 18 subjects also underwent a functional swallowing telephone survey months (range of 1 to 21 months) after their therapy to evaluate if the improvement was worthwhile and sustained. Eleven of the 18 patients (61 %) demonstrated some improvement in their swallowing. Six of the 18 patients (33 %) were improved enough to no longer require a feeding tube. However, of the 5 patients categorized as having "severe dysphagia" before therapy, only 2 showed any improvement, and these patients still required a feeding tube for adequate nutrition. Telephone surveys did confirm that those who improved with their therapy seemed to maintain their progress and that most patients were satisfied with their therapy. The authors concluded that VitalStim therapy seems to help those with mild-to-moderate dysphagia. However, the patients with the most severe dysphagia did not gain independence from their feeding tubes.

In a meta-analysis, Carnaby-Mann and Crary (2007) evaluated the effect of transcutaneous neuromuscular electrical stimulation (NMES) on swallowing rehabilitation. The authors concluded that this preliminary meta-analysis revealed a small but significant summary effect size for transcutaneous NMES for swallowing. Because of the small number of studies and low methodological grading for these studies, caution should be taken in interpreting this finding. These results support the need for more rigorous research in this area. This is in agreement with the observation of Steel et al (2007) who noted that although ES approaches to the restoration and rehabilitation of swallowing is an exciting area of research which holds promise for future clinically relevant technology and/or therapy, implementation of ES in clinical swallowing rehabilitation settings still remains pre-mature.

Guidelines on the use of esophageal dilation (Riley & Attwood, 2004) stated that esophageal dilation is indicated in the treatment of symptomatic obstruction of the esophagus. The guidelines explained that obstruction may develop as a consequence of a wide range of anatomical and functional esophageal disorders. Reflux-induced strictures, malignant strictures, and achalasia are the most frequent indications but patients with anastomotic, sclerotherapy, radiation, medication, and corrosive induced strictures, and those with rings and webs frequently require dilatation. The guidelines stated that patients with diffuse esophageal spasm and other motility disorders may occasionally require dilatation of the lower oesophageal sphincter when conservative measures fail.

There is inadequate evidence of the clinical utility of esophageal dilation in dysphagia not associated with obstruction.  In a randomized controlled  trial (n = 96), Lavu et al (2004) examined the impact of esophageal dilation with a large-diameter dilator on dysphagia and quality of life in such patients.  These investigators found that most patients with esophageal dysphagia have a non-obstructing esophageal lumen.  Their findings did not support the practice of empiric esophageal dilation for patients with non-obstructive esophageal dysphagia.  Improvement in both treatment and control groups suggests that it occurred due to proton pump inhibitor therapy, lending credence to the hypothesis that esophageal hypersensitivity to acid contributes to symptoms in most patients with non-obstructive esophageal dysphagia, which is the predominant category of dysphagia.