CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Oral Nutrition Mandate

Defines coverage criteria for non-prescription oral nutritional formulas, low-protein food products, and special medical formulas for home use for commercial products under Rhode Island mandate; describes prior authorization/reimbursement process and exclusions (donor breast milk, enteral tube feeding).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Oral Nutrition Mandate

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2014

Next Review Date

Key ActionObtain physician order and complete the recommended prior authorization for Commercial products via the online tool; after approval, submit itemized receipts with the reimbursement form within one year for member reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes to this policy at this time.

5Examples of covered malabsorption indications listed

5Inherited metabolic disorders listed

3HCPCS codes listed

Coverage Summary

This policy implements Rhode Island General Law 27-20-56 and defines coverage for non-prescription oral nutritional formulas, low-protein food products, and special medical formulas for home use when ordered by a physician and medically necessary to treat listed causes of malabsorption. The policy applies to Commercial products only. Effective date: 2014-12-01; Policy last reviewed: 2023-02-01.

Medical Necessity Criteria

Coverage for Low Protein Food Products

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- Ordered by a physician
- Individual has an inherited disease of amino acids and organic acids
- Examples include
  - Phenylketonuria (PKU)
  - Tyrosinemia
  - Homocystinuria
  - Maple Syrup Urine Disease
  - Propionic Aciduria and Methylmalonic Aciduria

Coverage for Oral Nutritional Formulas / Special Medical Formulas

Covered when ALL of the following are met:

ALL of the following

Ordered by a physician
Malabsorption caused by one of the following
- Crohn's Disease
- Ulcerative Colitis
- Gastroesophageal Reflux
- Chronic Intestinal Pseudo Obstruction

Non-Coverage / Contractual Exclusions

Non-Coverage / Contractual Exclusion

Non-covered when ALL of the following apply:

ALL of the following

Commercial product and criteria above are NOT met
Donor breast milk therapy (explicit exclusion)
Enteral nutrition as sole source via feeding tube is not addressed by this policy (see related policy)

Related policy guidance exists for enteral tube feeding (Enteral/Parenteral Nutrition Therapy). This policy does not address enteral nutrition as the sole source of nutrition delivered through a feeding tube, and donor breast milk is explicitly not covered under this policy.

Provider Actions & Billing

Prior Authorization

Prior authorization recommended for Commercial Products

Prior authorization is recommended for Commercial Products only. Participating providers obtain authorization via the online tool; a preauthorization form is provided for non‑participating providers.

Billing Rule

Member reimbursement after preauthorization

Following preauthorization approval, the member may be reimbursed by submitting itemized receipts highlighting the special foods purchased together with the reimbursement form. Receipts and the reimbursement form must be submitted within one year from the date of purchase to the BCBSRI Claims Department at the address provided.

Submit itemized receipt(s) highlighting or circling the special foods purchased
Submit completed Oral Enteral Food Products Reimbursement Form
Submit both within one year from date of purchase to: Attention: Claims Department, Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI 02903-2699

Documentation Required

Physician order required

A physician prescription/order is required for coverage of non‑prescription enteral formulas for home use, low protein food products, and special medical formulas as specified by the Rhode Island mandate.

Definitions & Background

Rhode Island General Law 27-20-56 mandates coverage for non-prescription enteral formulas for home use when a physician has issued a written order and the products are medically necessary to treat malabsorption caused by Crohn's Disease, Ulcerative Colitis, Gastroesophageal Reflux, Chronic Intestinal Pseudo-Obstruction, and inherited diseases of amino acids and organic acids. The mandate and this policy apply to Commercial products only. The policy explicitly excludes donor breast milk and does not address enteral tube feeding as the sole source of nutrition (see related Enteral/Parenteral Nutrition policy).

Term	Definition
Non-prescription nutritional formulas for home use
Nutritional liquids (e.g., Ensure, Boost) delivered orally for home use.
Low protein food products
Food products modified to be low in protein for individuals with PKU and other inherited diseases of amino acids and organic acids.
Special medical formulas
Formulas (e.g., Neocate) labeled for infants and children with inborn errors of metabolism, usually prescription and obtained from a pharmacy.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Oral Nutrition Mandate

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2014

Next Review Date

SourceLink

On This Page

S9433	Medical food nutritionally complete, administered orally, providing 100% of nutritional intake
S9435	Medical foods for inborn errors of metabolism
S9434	Modified solid food supplements for inborn errors of metabolism

OpenPayer

Medical Coverage Policy Oral Nutrition Mandate

Coverage Summary

Medical Necessity Criteria

Non-Coverage / Contractual Exclusions

Coding

Provider Actions & Billing

Definitions & Background

Revision History