CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Enteral / Parenteral Nutrition Therapy Coverage Criteria

This policy governs reimbursement and coverage criteria for enteral (tube) and parenteral (intravenous) nutrition therapy for BlueCHiP for Medicare and Commercial products, including which products and supplies are covered or not covered.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyEnteral / Parenteral Nutrition Therapy Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescribe enteral or parenteral formulas and, where applicable, ensure administration by a Home Infusion Therapy provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Preauth not requiredprior authorization requirement

Relizorb: Not covereddigestive enzyme cartridge coverage stance

Multiple B-codescovered supply and formula codes

Sole sourceenteral coverage condition

Coverage Criteria for Enteral and Parenteral Nutrition

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Covered Therapy

Covered when ALL of the following are met:

Enteral therapy — sole source: Enteral nutrition therapy as the sole source of nutrition delivered by means of a nasogastric, nasoenteric, gastrostomy, or jejunostomy tube is covered.

Sole source defined as the primary source of sufficient caloric/nutrient intake to achieve or maintain appropriate body weight.

Parenteral therapy — indication: Parenteral nutrition via peripheral or central venous routes is covered when the gastrointestinal tract is non‑functioning or adequate nutrient intake is not possible via oral or tube‑feeding routes.

Long‑term parenteral nutrition typically requires a tunneled central catheter; infusion pumps are generally used for administration.

Prescribing and administration: Enteral or parenteral formulas must be prescribed by a physician and, where applicable, administered by a Home Infusion Therapy provider.

Benefits and administrative requirements may vary by contract; refer to the member’s benefit booklet.

The following enteral products are not covered: enteral products used as supplements to the patient’s daily diet; enteral products that are administered orally and related supplies; baby food and other grocery items that can be pureed and delivered via the enteral system; and over‑the‑counter nutrition drinks (for example Boost, Ensure, Pediasure, Sustacal) unless they are provided via tube as the sole source of nutrition.

Specific HCPCS formula and additive codes are also listed as non‑covered when the formula is not administered via a feeding tube (for example B4102, B4103, B4104); see the coding section for the full list of non‑covered codes.

Use of in‑line digestive enzyme cartridges (Relizorb) is not covered for BlueCHiP for Medicare and is considered not medically necessary for Commercial products. The determination is based on insufficient evidence to demonstrate a meaningful improvement in net health outcomes.

The policy specifically identifies the in‑line enzyme cartridge HCPCS codes as non‑covered / not medically necessary (for example Q9994 previously and B4105 effective 1/1/2019); providers should expect claims for these cartridges to be denied under the applicable product line.

Coverage stance: Enteral and parenteral nutrition products and supplies are covered when they meet the policy’s medical necessity criteria (for example enteral feeding provided as the sole source of nutrition and parenteral nutrition when the GI tract is non‑functioning).

However, the use of in‑line digestive enzyme cartridges (Relizorb) is explicitly not covered for BlueCHiP for Medicare and considered not medically necessary for Commercial products due to insufficient evidence of benefit. Providers should follow the coding table and expect denial when billing the listed enzyme cartridge codes.

Coding — HCPCS and Clinical Parameters

Covered HCPCS CodesHCPCSCovered

B4034	Enteral supply kit; syringe, per day feeding
B4035	Enteral feeding supply kit; pump fed, per day
B4036	Enteral supply kit; gravity fed, per feeding day
B4081	Nasogastric tubing with stylet
B4082	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 (clear liquids), 500 ml = 1 unit
B4103	(formula code listed as non-covered when formula is not administered via a tube)

1–10 of 43

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Non-covered / Not Medically Necessary CodesHCPCSNot Covered

Q9994	In-line cartridge containing digestive enzyme(s) for enteral feeding, each (not covered for Medicare; deleted 12/31/2018)
B4105	In-line cartridge containing digestive enzyme(s) for enteral feeding, each (listed as not covered / not medically necessary)
B4102	Enteral formula codes listed as not covered when formula is not administered via a tube
B4103	Enteral formula code listed as non-covered when formula is not administered via a tube

inv-07: Adult caloric intake — typical adult calories per kg/day

Typical adult caloric intake20-35 calories per kilogram per day

PurposeSufficient to achieve or maintain appropriate body weight in most adults

ApplicationUse adult recommendation for patients >18 years when estimating energy needs

inv-08: Pediatric caloric ranges by age group

Infants 0–1 year90–120 calories per kilogram per day

Children 1–7 years75–90 calories per kilogram per day

Children 7–12 years60–75 calories per kilogram per day

Adolescents 12–18 years30–60 calories per kilogram per day

Provider Actions, Documentation, and Authorization

Prior Authorization

Preauthorization is not required.

Documentation Required

Provider Actions — general

For BlueCHiP for Medicare and Commercial products: enteral or parenteral formulas must be prescribed by a physician and administered by a Home Infusion Therapy provider when applicable. Peripheral vein access is covered. Providers should ensure prescriptions clearly indicate medical necessity, route of administration, and that a Home Infusion Therapy provider will administer therapy where required. For Commercial products, refer to the payer's Oral Nutrition mandate for coverage of oral nutrition products.

Physician prescription required for enteral/parenteral formulas when applicable
Administration by Home Infusion Therapy provider required when applicable
Peripheral vein access is covered

Documentation Required

Prescribing and administration documentation

A signed physician prescription/order is required for enteral or parenteral formulas. Documentation must support that the formula is for tube feeding (not oral supplement) and, when applicable, that a Home Infusion Therapy provider will administer the product. Include clinical rationale that the member cannot meet nutritional needs orally and that the enteral route is appropriate (eg, functional GI tract, inability to swallow, sole-source nutrition when indicated). Maintain records of feeding tube type and placement, duration of therapy, and prior treatments tried.

Signed physician prescription/order required
Documentation of tube feeding indication (not oral supplement)
Home Infusion Therapy provider documented when administering

Denial Risk

In-line enzyme cartridge denial risk

Digestive enzyme cartridges attached to enteral tubing (eg, Relizorb — Q9994, B4105) are NOT covered for BlueCHiP for Medicare and are considered not medically necessary for Commercial products. Claims for these cartridges may be denied. Do not bill Relizorb (Q9994, B4105) as a covered enteral supply for BlueCHiP for Medicare or Commercial members.

Relizorb — HCPCS Q9994
Relizorb — HCPCS B4105

Background

Enteral nutrition delivers liquid nutritional formula into the gastrointestinal tract through feeding tubes (for example nasogastric, nasoenteric, gastrostomy, or jejunostomy) for patients who have a functional GI tract but cannot maintain adequate oral intake. Parenteral nutrition delivers nutrients intravenously via peripheral or central venous catheters when the GI tract is non‑functioning or when adequate intake cannot be achieved by oral or tube feeding.

Formulas must be prescribed by a physician and, where applicable, administered by a Home Infusion Therapy provider. Enteral nutrition is covered when provided as the sole source of nutrition, and parenteral nutrition is covered when clinically indicated (for example non‑functioning GI tract or inability to tolerate enteral feeding).

Definitions and Typical Requirements

inv-14: Sole source — definition describing primary source of caloric/nutrient intake

DefinitionSole source = the primary source of sufficient caloric/nutrient intake to achieve or maintain appropriate body weight

Context of useApplies when enteral nutrition is the only route providing adequate nutrition (e.g., patients who cannot eat orally but have a functioning GI tract)

Delivery routes referencedNasogastric, nasoenteric, gastrostomy, or jejunostomy tubes

inv-15: Estimated energy needs — adult and pediatric typical caloric needs

Adult estimated energy needsApproximately 20–35 calories per kilogram per day for most adults

Pediatric summaryCaloric needs vary by age; use age-specific ranges (see pediatric block) when estimating requirements

Parenteral nutrition noteParenteral nutrition provides macronutrients and micronutrients when oral/tube feeding is not possible; infusion pump generally used