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Defines coverage and reimbursement for enteral (tube) and parenteral (IV) nutrition therapies, supplies, and formulas for Medicare Advantage and Commercial products, including covered codes, exclusions, and billing guidance. Also states prior authorization and noncoverage of in-line digestive enzyme cartridges.
Policy last updated 03/03/2021; no explicit material clinical policy statement changes indicated.
This policy, titled Enteral and Parenteral Nutrition Therapy, defines coverage and reimbursement for enteral (tube) and parenteral (IV) nutrition therapies, supplies, and formulas for Medicare Advantage and Commercial products. Effective date: 2019-11-01; policy last updated 2021-03-03. Payer: Blue Cross Blue Shield - Rhode Island. Coverage stance is mixed: many enteral and parenteral supplies and formulas are covered when criteria are met, while certain items (notably in-line digestive enzyme cartridges) are specifically not covered.
Coverage Criteria - General
Coverage statements for Medicare Advantage Plans and Commercial Products
ALL of the following
Non-Covered / Not Medically Necessary Items
The following are not covered or are not medically necessary
ANY of the following
Non-Covered Formulas (Not Administered via Feeding Tube)
Formulas not covered because not administered via a feeding tube
ANY of the following
| B4034 | Enteral feeding supply kit; syringe, per day |
| B4035 | Enteral supply kit; pump fed, per feeding day |
| B4036 | Enteral feeding supply kit; gravity fed, per day |
| B4081 | Nasogastric with stylet tubing |
| B4083 | Nasogastric without stylet tubing |
| 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 |
| B4102 | Enteral formula, for adults, used to replace fluids and electrolytes (listed later as non-covered when not tube-administered) |
| B4103 | Enteral formula, for pediatrics, used to replace fluids and electrolytes (listed later as non-covered when not tube-administered) |
| B4105 | In-line cartridge containing digestive enzyme(s) for enteral feeding; each (Effective 1/1/2019) - not covered for Medicare Advantage Plans and not medically necessary for Commercial Products |
| Q9994 | In-line cartridge containing digestive enzyme(s) for enteral feeding; each (Effective 07/01/2018 and deleted as of 12/31/2018) - not covered |
Physician Prescription and Home Infusion Administration
Enteral or parenteral formulas must be prescribed by a physician for use and administered by a Home Infusion Therapy provider. Documentation should support sole‑source nutrition when applicable. Applies to Medicare Advantage and Commercial products.
Coding for Enteral and Parenteral Products
Report applicable HCPCS codes for enteral and parenteral formulas and supplies as listed in the policy and follow the stated unit definitions when submitting claims. Unit examples in the policy include caloric-based units for enteral formulas and volume-based units for parenteral solutions.
Background: Enteral (tube) feeding delivers liquid nutritional formula into the gastrointestinal tract via nasogastric, nasoenteric, gastrostomy, or jejunostomy tubes and is used when the GI tract is functional but oral intake is inadequate; it can serve as the sole source of nutrition or short- or long-term support. Parenteral nutrition delivers macronutrients and micronutrients intravenously through central or peripheral catheters when the GI tract is non-functioning and may be used as sole source nutrition. Caloric guidance: most adults require approximately 20–35 kcal/kg/day; pediatric needs vary by age (e.g., infants 0–1 year ~90–120 kcal/kg/day, older children/adolescents lower per-kg needs as detailed in the policy). Relizorb is an FDA-cleared in-line digestive enzyme cartridge designed to hydrolyze fats in enteral formula, but the policy states that large-scale human outcome studies are lacking and there is insufficient evidence that it produces meaningful improvements in net health outcomes; consequently in-line enzyme cartridges are considered not covered/not medically necessary.
Policy effective date 11/01/2019 as stated in the document header.
Policy last updated 03/03/2021; document states prior authorization is not required and reiterates noncoverage of in-line digestive enzyme cartridges.
Considered not covered for Medicare Advantage Plans and not medically necessary for Commercial products; insufficient evidence of clinical benefit.
Follow the policy's unit definitions for billing: for enteral formulas report 100 calories = 1 unit, and for parenteral solutions report 500 mL = 1 unit (as specified for the various HCPCS codes).
Not Covered: In-line Digestive Enzyme Cartridges
In-line digestive enzyme cartridges (e.g., Relizorb) are considered not covered for Medicare Advantage Plans and not medically necessary for Commercial products due to insufficient evidence of meaningful improvement in net health outcomes.
Prior authorization is not required.