Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 09/18/1995	Title: Enteral/Parenteral Nutrition Therapy
Revision Date: 01/01/2021	Document: BI137:00
CPT Code(s): B4034-B4036, B4081-4083, B4087, B4088, B4100, B4102-B4104, B4105, B4149, B4150, B4152-4155, B4157-4164, B4168, B4172, B4176, B4178, B4180, B4185, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9000, B9004, B9006, B9998, B9999, S9341-S9343, S9364-S9368
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above Revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. Enteral or parenteral nutrition must be prior authorized. In the case of single gene inborn errors of metabolism (such as phenylketonuria “PKU”), the nutritional source for oral or enteral feedings is covered as medically necessary.
Medical Statement
Enteral Nutrition: Enteral nutrition requires preauthorization. The patient must have permanent (or long term - reasonably expected to persist for >90 days as a general rule, but not necessarily a lifetime) loss of function of the alimentary tract of such severity that the individual cannot ingest sufficient nutrients by mouth to maintain weight and strength. The underlying GI problem may have either an anatomical or a functional basis. (e.g., cancer, neuropathy). In the case of single gene inborn errors of metabolism (such as phenylketonuria “PKU”), the nutritional source for oral or enteral feedings is covered as medically necessary. Durable Medical Equipment and disposable medical supplies used to deliver enteral nutrition are covered. Parenteral Nutrition Maintenance of weight and strength commensurate with the patients overall health status must require intravenous nutrition and must not be possible utilizing all of the following approaches: 1. modification of the nutrient composition of the enteral diet (e.g. lactose free, gluten free, low in long chain triglycerides, substitution with medium chain triglycerides, provision of protein as peptides or amino acids, etc.), AND 2. pharmacologic treatment of the etiology of the malabsorption (e.g. pancreatic enzymes or bile salts, broad spectrum antibiotics for bacterial overgrowth, prokinetic medication for reduced motility, etc.); AND 3. Enteral nutrition. Codes Used In This BI: B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 B4100 B4102 B4103 B4104 B4105 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9000 B9002 B9004 B9006 B9998 B9999 S9341 S9342 S9343 S9364 S9365 S9366 S9367 S9368
Limits
Assistance with oral feeding, nutritional and supplemental (e.g., infant formula, Ensure, etc.) by mouth is not covered. Prophylactic parenteral nutrition is not covered (e.g., AIDs, dialysis, and cancer chemotherapy). Intraperitoneal parenteral nutrition is considered investigational at this time and not covered due to lack of objective evidence of safety and efficacy. Infusion pumps are covered when parenteral nutrition is covered. Only one pump (stationary or portable) will be covered at any one time. Additional pumps will be denied as not medically necessary. Special parenteral formulas are rarely medically necessary. If the medical necessity for these formulas is not substantiated, payment will be made for the medically appropriate formula. The ordering physician must document the medical necessity for protein orders outside of the range of 0.8-1.5 gm/kg/day, dextrose concentration less than 10%, or lipid use greater than 15 units of a 20% solution or 30 units of a 10% solution per month.
Reference
Addendum: 1. Effective 07/01/2017: Coverage spelled out for nutritional products for single gene, inborn errors of metabolism.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.

Coverage Policies

Important! Please note:

Enteral or parenteral nutrition must be prior authorized.

In the case of single gene inborn errors of metabolism (such as phenylketonuria “PKU”), the nutritional source for oral or enteral feedings is covered as medically necessary.

Addendum:

1. Effective 07/01/2017: Coverage spelled out for nutritional products for single gene, inborn errors of metabolism.