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.

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

1. Assistance with oral feeding, nutritional and supplemental (e.g., infant formula, Ensure, etc.) by mouth is not covered.
2. Prophylactic parenteral nutrition is not covered (e.g., AIDs, dialysis, and cancer chemotherapy).
3. Intraperitoneal parenteral nutrition is considered investigational at this time and not covered due to lack of objective evidence of safety and efficacy.
4. 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.
5. 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.
6. 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.

Addendum:

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