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ModifiedAmerihealth Caritas Vip CarePolicy MA08.003h

Enteral Nutritional Therapy

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This policy governs Medicare Advantage coverage of enteral nutrition, formulas, administration equipment, and supplies when oral nutrition is inadequate because of qualifying gastrointestinal or swallowing-related conditions. It also defines documentation, ordering, delivery, dispensing, reimbursement, and noncoverage requirements.

Policy Summary

PayerAmerihealth Caritas Vip Care

PolicyEnteral Nutritional Therapy

Policy CodePolicy MA08.003h

Change TypeModified

Effective DateSeptember 16, 2024

Last ReviewSep 18, 2026

Next Review DateN/A

Key ActionDocument why syringe or gravity administration is inadequate or why a pump is required before billing B9002 or B4035.

SourceLink

POLICY UPDATE CHANGES

HCPCS code B4105 was revised from experimental/investigational to medically necessary.

HCPCS code S9435 was revised from medically necessary to not covered.

HCPCS code S9432 was added as not covered.

The policy clarified that no more than a 31-day supply may be dispensed at one time, while refill requirements do not apply to daily all-inclusive supply allowance codes B4034, B4035, B4036, and B4148.

HCPCS code B4148 and the elastomeric control-fed supply method were added as medically necessary.

The policy was reissued under the annual review process.

14Medically necessary supply and equipment codes

14Medically necessary formula codes

8Not covered codes

31 daysMaximum supply dispensing period

2/dayMaximum enzyme cartridges

<100 mL/hrPump-use rate example

Enteral Nutrition Coverage Criteria

Initial enteral nutrition coverage

Covered when all of the following are met:

Enteral nutrition medical necessity

Qualifying indication
- Impaired food passage or ingestion: Permanent full or partial nonfunctional disease or impairment of structures that normally permit food to reach the small bowel, including obstruction due to head and neck cancer or reconstructive surgery, central nervous system disease interfering with neuromuscular ingestion mechanisms such that oral feeding is insufficient, or a motility disorder such as severe post-stroke dysphagia.Permanent or long and indefinite duration as defined in the policy
- Small-bowel disease: Disease of the small bowel impairing digestion and absorption of an oral diet, including inflammatory bowel disease, small-bowel surgical resection, cystic fibrosis, chronic pancreatitis, or advanced liver disease.

Policy Summary

PayerAmerihealth Caritas Vip Care

PolicyEnteral Nutritional Therapy

Policy CodePolicy MA08.003h

Change TypeModified

Effective DateSeptember 16, 2024

Last ReviewSep 18, 2026

Next Review DateN/A

Key ActionDocument why syringe or gravity administration is inadequate or why a pump is required before billing B9002 or B4035.

SourceLink

On This Page

Oral nutrition is inadequate: Adequate nutrition is not possible through dietary adjustment and/or oral supplements.

Coverage is possible for partial impairments, such as dysphagia permitting only small amounts of food or Crohn's disease requiring prolonged infusion to overcome malabsorption.

Special enteral formula coverage

Special formulas are covered only when individual-specific medical necessity is supported and documented:

Special enteral formula: The individual meets enteral nutrition coverage criteria, and the medical necessity for the special formula is supported for that individual and documented in the medical record.Codes B4149, B4153-B4155, B4157, B4161, and B4162

Without supporting documentation, the special formula is not medically necessary and is not covered.

Enteral pump coverage

A pump is covered when its use is medically necessary and documented:

Enteral pump coverage: The individual meets enteral nutrition coverage criteria, and the medical record documents why syringe or gravity administration is inadequate or why pump administration is required.HCPCS B9002

Examples include reflux or aspiration with gravity feeding, severe diarrhea, dumping syndrome, an administration rate below 100 mL/hr, blood glucose fluctuations, circulatory overload, or use of a gastrostomy/jejunostomy tube for feeding.

In-line digestive enzyme cartridge coverage

Covered when all of the following are met:

In-line digestive enzyme cartridge coverage: The individual meets the coverage criteria for enteral nutrition and has a diagnosis of exocrine pancreatic insufficiency (EPI).No more than 2 B4105 cartridges per day

More than two cartridges per day is not medically necessary and is not covered. In-line digestive enzyme cartridges are separately reimbursable from enteral feeding supply kits.

Enteral nutrition is not covered for individuals with a functioning gastrointestinal tract when the need is attributable to anorexia, nausea associated with a mood disorder, end-stage disease, or similar reasons. It is also not covered for temporary impairments or when enteral products or supplies are administered orally.

Nutritional supplements used as the mainstay of a daily nutritional plan or between meals to increase protein-caloric intake are not covered. These products are not eligible for reimbursement consideration under this policy.

Food thickeners, baby food, regular grocery products that can be blenderized for enteral use, electrolyte-containing fluids, and self-blenderized formulas are not covered. This includes food thickener code B4100 and electrolyte-containing fluid codes B4102 and B4103.

All other uses of enteral nutrition, administration supplies, and equipment are considered experimental/investigational and are not covered unless the indication is supported as an accepted off-label use under the Company policy addressing off-label coverage for prescription drugs and biologics.

The following products are not covered: food thickener administered orally; adult or pediatric enteral formulas used to replace fluids and electrolytes; oral nutritionally complete medical food; modified solid food supplements; and medical foods for inborn or non-inborn errors of metabolism. The applicable codes include B4100, B4102, B4103, S9432, S9433, S9434, and S9435.

Enteral formula additives, including B4104, are included in the allowance for the enteral formula and are not separately reimbursable when billed with the formula. Catheter or tube anchoring device A5200 is included in the reimbursement for the specified enteral feeding supply kits and is not separately reimbursable when billed with B4034, B4035, B4036, or B4148.

Special enteral formulas are not medically necessary and are not covered when individual-specific medical necessity is not supported and documented in the medical record. This requirement applies to B4149, B4153-B4155, B4157, B4161, and B4162.

A pump or pump supply allowance is not medically necessary and is not covered without documentation supporting pump use. Feeding supply kits must correspond to the prescribed administration route and method; more than one kit type delivered on the same date or provided on an ongoing basis is not covered. The applicable administration methods include syringe, pump, gravity, and elastomeric-control-fed delivery.

More than two in-line digestive enzyme cartridges per day is not medically necessary and is not covered. B4105 is covered only when the individual meets enteral nutrition coverage criteria and has a diagnosis of exocrine pancreatic insufficiency.

Equipment and Supply Medical Necessity

Enteral equipment and supply coverage

Enteral equipment and supplies are covered when all of the following are met:

Equipment and supply coverage: The individual meets enteral nutrition medical necessity criteria, and the equipment or supply is appropriate for the prescribed route and method of administration.

Enteral nutrition may be administered by syringe, gravity, or pump. Feeding supply kits must correspond to the route and method of administration, including syringe, pump, gravity, or elastomeric-control-fed administration.

Covered, Noncovered, and Billing Codes

Generally appropriate enteral formulasHCPCSCovered

B4150	Semisynthetic intact protein/protein isolates enteral formula
B4152	Semisynthetic intact protein/protein isolates enteral formula

Special enteral formulasHCPCSCovered

B4149	Special enteral nutrition formula
B4153-B4155	Special enteral nutrition formulas
B4157	Special enteral nutrition formula
B4161	Special enteral nutrition formula
B4162	Special enteral nutrition formula

Equipment and suppliesHCPCSCovered

B9002	Enteral nutrition pump
B4034-B4036	Enteral feeding supply kits and allowances corresponding to administration method
B4148	Enteral feeding supply kit or allowance corresponding to administration method
B4081-B4083	Nasogastric tubes
B4087-B4088	Gastrostomy/jejunostomy tubes
B4035	Pump supply allowance

In-line digestive enzyme cartridgesHCPCSCovered

B4105

In-line digestive enzyme cartridges

Not separately reimbursableHCPCSNot Covered

B4104	Enteral formula additives
A5200	Catheter/tube anchoring device
B4034-B4036	Enteral feeding supply kits
B4148	Enteral feeding supply kit
B9998	Enteral supplies, not otherwise classified

Not covered productsHCPCSNot Covered

B4100	Food thickeners
B4102	Electrolyte-containing fluids
B4103	Electrolyte-containing fluids

CPT Procedure Code Number(s)CPT

N/A

ICD-10 Procedure Code Number(s)ICD-10

N/A

ICD-10 Diagnosis Code Number(s)ICD-10

No codes listed

Medically Necessary — Enteral SuppliesHCPCSCovered

B4034	Enteral Feeding Supply Kit; Syringe fed, per day, includes, but not limited to feeding/flushing syringe, administration set tubing, dressings, tape.
B4035	Enteral Feeding Supply Kit; Pump fed, per day, includes, but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
B4036	Enteral Feeding Supply Kit; gravity fed, per day, includes, but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
B4081	Nasogastric tubing with stylet
B4082	Nasogastric tubing without stylet
B4083	Stomach tube Levine type
B4087	Gastrostomy/jejunostomy tube, standard, any material, any type, each
B4088	Gastrostomy/jejunostomy tube, low-profile, any material, any type, each
B4105	In-line cartridge containing digestive enzyme(s) for enteral feeding, each
B4148	Enteral feeding supply kit; elastomeric control fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

1–10 of 13

1/2

Medically Necessary — FormulaHCPCSCovered

B4149	Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4150	Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4152	Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4153	Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4154	Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4155	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit
B4157	Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4158	Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit.
B4159	Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit.
B4160	Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.

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1/2

Not CoveredHCPCSNot Covered

B4100	Food thickener, administered orally, per ounce
B4102	Enteral formula, for adults, used to replace fluids and electrolytes (eg, clear liquids), 500 ml= 1 unit
B4103	Enteral formula for pediatrics, used to replace fluids and electrolytes (eg, clear liquids), 500 ml= 1 unit
S9432	Medical foods for non-inborn errors of metabolism
S9433	Medical food nutritionally complete, administered orally, providing 100% of nutritional intake
S9434	Modified solid food supplements for inborn errors of metabolism
S9435	Medical foods for inborn errors of metabolism

Not Separately Reimbursable — Enteral Formula AdditiveHCPCSNot Covered

B4104

Additive for enteral formula (eg, fiber)

Not Separately Reimbursable With Enteral Feeding Supply KitsHCPCSNot Covered

A5200

Percutaneous catheter/tube anchoring device, adhesive skin attachment

Revenue Code Number(s)Revenue

N/A

Added as not coveredHCPCSNot Covered

S9432

Medical foods for non-inborn errors of metabolism

Deleted from policyHCPCS

B9000

Enteral nutrition infusion pump - without alarm

HCPCS narrative revisedHCPCS

B9002

Enteral nutrition infusion pump, any type

Medically Necessary if criteria are metHCPCSCovered

S9435

Medical foods for inborn errors of metabolism

Non-covered, per Medicare rulesHCPCSNot Covered

S9433	Medical food nutritionally complete, administered orally, providing 100% of nutritional intake
S9434	Modified solid food supplements for inborn errors of metabolism

Coding and billing correctionHCPCS

B5034	Changed to B4034
B4034	Replacement code for B5034

Nasogastric Tube Replacement Quantity Limit

Replacement itemNasogastric tubes (HCPCS B4081-B4083)

Covered quantity limitNo more than 3 tubes per applicable 3-month period

Excess quantityMore than 3 tubes in the applicable 3-month period is not medically necessary and is not covered

Gastrostomy/Jejunostomy Tube Replacement Quantity Limit

Replacement itemGastrostomy/jejunostomy tubes (HCPCS B4087-B4088)

Covered quantity limitNo more than 1 tube every 3 months

Excess quantityMore than 1 tube every 3 months is not medically necessary and is not covered

In-line Digestive Enzyme Cartridge Quantity Limit

SupplyIn-line digestive enzyme cartridge (HCPCS B4105)

Covered quantity limitNo more than 2 cartridges per day

Excess quantityMore than 2 cartridges per day is not medically necessary and is not covered

Consumable Supply Dispensing Limit

Applies toConsumable accessories and supplies

Maximum dispensing quantityNo more than a 1-month supply, with a maximum of 31 days, may be dispensed at one time

Daily allowance codesB4034, B4035, B4036, and B4148 are daily, all-inclusive allowances; refill requirements do not apply

Adult Calorically Dense Enteral Formula Threshold

Formula typeAdult nutritionally complete, calorically dense enteral formula

Caloric thresholdEqual to or greater than 1.5 kcal/mL

Example codeB4152

Pediatric Calorically Dense Enteral Formula Threshold

Formula typePediatric nutritionally complete, calorically dense enteral formula

Caloric thresholdEqual to or greater than 0.7 kcal/mL

Example codeB4160

Enteral Formula Billing Unit Conversion

Billing unit1 unit

Calories per unit100 calories

Applicable productsEnteral formulas billed under the listed formula codes, including B4152 and B4160

Provider and Supplier Billing Responsibilities

Documentation Required

Maintain Medical Necessity Records

Maintain medical records that support the medical necessity of all care and services billed. Records must be sufficient for Company review or audit, regardless of provider participation status.

Documentation Required

Maintain a Valid Provider Order

Before submitting a claim, maintain a timely, appropriate, and complete order for each item billed. The order must be signed and dated by the treating professional provider; a retrospective order obtained during or after an audit does not satisfy this requirement.

Documentation Required

Document Delivery or Member Receipt

Maintain contemporaneously prepared documentation confirming delivery or the member’s receipt of supplies and equipment. Make delivery documentation available to the Company upon request.

Commercial carrier delivery: retain a copy of the delivery confirmation.
DME supplier/provider delivery: retain a delivery confirmation signed by the member or caregiver.

Documentation Required

Document Utilization, Replenishment, and Refills

Monitor the quantity of accessories and supplies the member actually uses and retain dated documentation of replenishment contacts. Time replenishment and delivery so supplies are not sent too early.

Do not contact the member about replenishment earlier than approximately 30 days before the delivery or shipping date.
Do not deliver supplies earlier than approximately 10 days before the member is expected to exhaust the on-hand supply.
Missing documentation may result in reimbursement of overpayments after an audit or record request.

Billing Rule

Report the Supporting Diagnosis Code

Report the most appropriate ICD-10 diagnosis code supporting medical necessity, as specified by the policy.

Billing Rule

Limit Supply Dispensing to 31 Days

Limit the quantity of supplies dispensed at one time to no more than a 1-month supply, with a maximum of 31 days.

Supply allowance codes B4034, B4035, B4036, and B4148 are daily, all-inclusive allowances; refill requirements do not apply to these codes.

Documentation Required

Document Special Formula Necessity

Support and document the medical necessity of special enteral formulas for each individual. If the medical necessity is not documented in the medical record, the formula is not medically necessary and is not covered.

Applicable special formula codes include B4149, B4153-B4155, B4157, B4161, and B4162.

Documentation Required

Support Pump Necessity

When ordering an enteral pump (B9002), document why syringe or gravity administration is inadequate. Without documented medical necessity, the pump is not medically necessary and is not covered.

Examples include reflux or aspiration, severe diarrhea, dumping syndrome, an administration rate below 100 mL/hr, blood glucose fluctuations, circulatory overload, or use of a gastrostomy/jejunostomy tube for feeding.

Documentation Required

Support the Pump Supply Allowance

Support and document the medical necessity of the enteral pump before billing the pump supply allowance (B4035). If pump necessity is not documented, B4035 is denied as not medically necessary and is not covered.

Billing Rule

Match the Kit to the Administration Method

Match each feeding supply kit to the member’s actual administration route and method. A kit that does not correspond to the method of administration is not medically necessary and is not covered.

Applicable kit codes include B4034-B4036 and B4148.
Methods include syringe, pump, gravity, and elastomeric control-fed administration.

Billing Rule

Observe Tube Quantity Limits

Use enteral feeding supply kits according to the applicable quantity limits. More than three nasogastric tubes or more than one gastrostomy/jejunostomy tube every 3 months is not medically necessary and is not covered.

Nasogastric tubes: B4081-B4083; maximum three.
Gastrostomy/jejunostomy tubes: B4087-B4088; maximum one every 3 months.

Billing Rule

Apply Enzyme Cartridge Criteria

Bill in-line digestive enzyme cartridges (B4105) only when the individual meets enteral nutrition coverage criteria and has exocrine pancreatic insufficiency (EPI).

Do not bill more than two B4105 cartridges per day.
B4105 is separately reimbursable from enteral feeding supply kits B4034-B4036 and B4148.

Denial Risk

Do Not Separately Bill Included Components

Do not separately bill components included in an all-inclusive enteral feeding supply kit. Separate billing for kit components is not appropriate.

B4104 additives are included in the enteral formula allowance.
A5200 catheter/tube anchoring devices are included in kits B4034-B4036 and B4148.
Do not use a specific HCPCS code or B9998 for components already included in the kits.

Denial Risk

Avoid Excluded Products and Routes

Do not bill excluded products or administration routes. Enteral nutrition products and supplies administered orally are not covered, and enteral nutrition is not covered for functioning gastrointestinal tracts when needed for anorexia, nausea associated with mood disorder, end-stage disease, or other listed indications, or for temporary impairments.

Nutritional supplements used as a daily nutritional plan or between meals are not covered.
Food thickeners, baby food, regular grocery products suitable for blending, electrolyte-containing fluids, and self-blenderized formulas are not covered.
Oral administration and other excluded uses are not eligible for reimbursement consideration.

Billing Rule

Code Listing Does Not Guarantee Reimbursement

Treat code listings as informational only; inclusion of a code in the policy does not guarantee reimbursement. Verify eligibility, benefits, limitations, exclusions, precertification or referral requirements, provider contracts, and other Company policies.

Coding updates and future applicable coding changes may apply in accordance with nationally accepted coding guidelines.

Denial Risk

Identify Bundled or Nonseparately Reimbursable Items

Identify items that are bundled or not separately reimbursable before submitting claims. Enteral formula additives and catheter/tube anchoring devices are included in related allowances and must not be separately reimbursed when billed with them.

B4104 is included in the enteral formula allowance.
A5200 is not separately reimbursable when reported with B4034, B4035, B4036, or B4148.
B4034-B4036 and B4148 are all-inclusive; do not separately bill their components or use B9998 for those components.

Denial Risk

Identify Not Covered Products and Medical Foods

Do not submit claims for products and medical foods identified as not covered, because they are not eligible for reimbursement consideration.

B4100 food thickener; B4102 and B4103 electrolyte-containing enteral formulas.
S9432 medical foods for non-inborn errors of metabolism; S9433 orally administered complete medical food; S9434 modified solid food supplements for inborn errors of metabolism; S9435 medical foods for inborn errors of metabolism.

Policy Background

Enteral nutrition provides nutrients through a tube into the stomach or small intestine for individuals who cannot be adequately sustained through oral feeding because of chronic illness or trauma. Administration may use a nasogastric, gastrostomy, or jejunostomy tube and may be delivered by syringe, gravity, or pump. Coverage focuses on conditions that prevent sufficient nutrient intake or impair digestion and absorption when dietary adjustment and oral supplements are inadequate.

Definitions

Permanent Impairment

DefinitionPermanent impairment is a permanence that does not require a determination that there is no possibility the condition may improve in the future

Physician judgmentThe attending physician's judgment must be substantiated in the medical record

Duration standardThe condition must be of long and indefinite duration for the permanence test to be met

Enteral Nutrition

DefinitionProvision of nutritional requirements through a tube into the stomach or small intestine

Tube routesMay be provided through nasogastric, jejunostomy, or gastrostomy tubes

Home administrationCan be provided safely and effectively at home by trained nonprofessional individuals

Replacement and Dispensing Limits

Nasogastric Tube Replacement Limit

Tube typeNasogastric tubes, including HCPCS B4081-B4083

Replacement limitNo more than 3 tubes per 3 months

Coverage consequenceQuantities above the limit are considered not medically necessary and are not covered

Gastrostomy/Jejunostomy Tube Replacement Limit

Tube typeGastrostomy/jejunostomy tubes, including HCPCS B4087-B4088

Replacement limitNo more than 1 tube every 3 months

Coverage consequenceQuantities above the limit are considered not medically necessary and are not covered

Consumable Enteral Supply Dispensing Limit

Supply typeConsumable enteral accessories and supplies

Dispensing limitMaximum 31-day supply per dispensing

Delivery timingSupplies should not be delivered earlier than approximately 10 days before the member would exhaust the on-hand supply

Required Documentation

Documentation Required

Document pump and pump-allowance necessity

For B9002 and B4035, document why syringe or gravity administration is inadequate or why pump administration is required. Supporting examples include reflux or aspiration, severe diarrhea, dumping syndrome, an administration rate below 100 mL/hr, blood glucose fluctuations, circulatory overload, or gastrostomy/jejunostomy tube feeding.

B9002: enteral nutrition infusion pump, any type
B4035: pump-fed supply allowance

Documentation Required

Document route-specific kit necessity

Document that the feeding supply kit corresponds to the prescribed route and method of administration, such as syringe, pump, gravity, or elastomeric control fed.

Documentation Required

Maintain required DME records

Maintain medical necessity records, a timely, complete, signed, and dated professional provider order before claim submission, and contemporaneous delivery confirmation or member/caregiver receipt. A retrospective order created during or after an audit does not satisfy the order requirement.

Documentation Required

Document utilization and refills

Monitor actual supply use, document replenishment contact timing, and dispense no more than a 31-day supply at one time. Missing required documentation may result in repayment of overpayments.

Replenishment contact: no earlier than approximately 30 days before delivery or shipping
Delivery: no earlier than approximately 10 days before the member exhausts on-hand supplies

Billing Rule

Report the appropriate diagnosis code

Report the most appropriate diagnosis code supporting medical necessity as listed in the policy.

Billing Rule

Limit each dispensing to 31 days

Limit supplies dispensed at one time to a maximum 31-day supply. Supply allowance codes B4034, B4035, B4036, and B4148 are daily, all-inclusive allowances and are not subject to refill requirements.

Excluded Products and Services

Not covered under this policy are enteral nutrition products or supplies administered orally; food thickeners, baby food, regular grocery products suitable for blenderization, electrolyte-containing fluids, and self-blenderized formulas; nutritional supplements used as a primary or supplemental daily nutrition plan; and oral medical foods or modified solid food supplements. Adult and pediatric formulas used to replace fluids and electrolytes and medical foods for inborn or non-inborn errors of metabolism are also excluded. Components included in all-inclusive enteral feeding supply kits, including applicable additives and anchoring devices, are not separately reimbursable.