CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Enteral / Parenteral Nutrition Therapy

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 Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Enteral / Parenteral Nutrition Therapy

Policy CodePolicy N/A

Change TypeClarified (no material change)

Effective DateNov 1, 2019

Next Review Date

Key ActionEnsure enteral or parenteral formulas are prescribed by a physician and administered by a Home Infusion Therapy provider with documentation supporting sole-source nutrition when applicable.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 03/03/2021; no explicit material clinical policy statement changes indicated.

Multiple

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Coverage Summary & Criteria

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

Parenteral nutrition coverage: Parenteral nutrition therapy as the sole source of nutrition delivered through a catheter through a central or peripheral vein is covered.
Enteral nutrition coverage: Enteral nutrition therapy as the sole source of nutrition delivered by means of a nasogastric (NG), nasoenteric (NE) tube, gastrostomy (G) tube, or jejunostomy (J) tube is covered.
Prescription and administration requirement: Enteral or parenteral formulas must be prescribed by a physician for use and administered by a Home Infusion Therapy provider.

Non-Covered / Not Medically Necessary Items

The following are not covered or are not medically necessary

ANY of the following

Enteral products as supplements: Enteral products used as supplements to the patient's daily diet (not sole source).
Orally administered enteral products: Enteral products that are administered orally and related supplies.
Baby food/grocery items: Baby food and other grocery items/products that can be pureed in a blender and used with the enteral system.
OTC oral products: Over-the-counter products (e.g., Boost, Ensure, Pediasure, Sustacal) unless provided by tube as sole source of nutrition.

Non-Covered Formulas (Not Administered via Feeding Tube)

Formulas not covered because not administered via a feeding tube

ANY of the following

B4102: Enteral formula, for adults, used to replace fluids and electrolytes (e.g., clear liquids), 500 mL = 1 unit.
B4103: Enteral formula, for pediatrics, used to replace fluids and electrolytes (clear liquids), 500 mL = 1 unit.
B4104: Additive for enteral formula (e.g., fiber) (not administered via feeding tube).

HCPCS Codes — Covered and Not Covered

Covered Supply and Device Codes (Medicare Advantage and Commercial)HCPCSCovered

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)

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Not Covered / Not Medically Necessary CodesHCPCSNot Covered

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

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).

Actions — Documentation, Billing, and Authorization

Documentation Required

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.

support sole-source nutrition documentation when applicable
Scope: Medicare Advantage & Commercial

Billing Rule

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 and Evidence

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.

Key facts

Relizorb FDA statusRelizorb is an FDA-approved (510(k)) digestive enzyme cartridge but large-scale human outcome studies are lacking per policy

Definition: Sole sourceThe primary source of sufficient caloric/nutrient intake to achieve or maintain appropriate body weight.

Policy effective date2019-11-01

Revision History

2019-11-01effective

Policy effective date 11/01/2019 as stated in the document header.

2021-03-03clarifiedLatest

Policy last updated 03/03/2021; document states prior authorization is not required and reiterates noncoverage of in-line digestive enzyme cartridges.