Enteral Nutrition (Mandated and Expanded Benefit)
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Defines coverage, patient selection, and benefit administration for enteral nutrition (oral or tube-delivered enteral formulas and amino acid–based elemental formulas) for Blue Cross Blue Shield - Wyoming members, including state-mandated and expanded benefit conditions.
No material clinical or coverage changes in this revision.
Coverage Criteria for Enteral Nutrition
Covered indications
Covered when the following distinct condition groups are met:
Act 191 referenced
Act 158-2014 referenced
Expanded benefit; continuation threshold described
Basic milk or soy formulas are not eligible for coverage. Lactose intolerance, milk protein intolerance, or other milk allergies alone are not indications for coverage; an exception is hemorrhagic colitis secondary to these conditions, which may be eligible.
Enteral formula supplied solely because a member cannot take adequate calories by regular diet is not eligible for coverage unless the enteral formula is the sole source of nutrition and is one of the specified specialized formulas listed for the expanded benefit (hydrolyzed predigested or amino acid–based formulas, formulas for special metabolic needs, modular components, or defined specialized-content formulas).
Coding and Billing
| No codes listed |
Provider Requirements and Operational Rules
Coverage limited to listed indications and HCPCS codes
Coverage for enteral feeding solutions and the HCPCS codes listed in the policy header is limited to the indications and benefit categories described in the policy; benefits for enteral feeding solutions provided for state‑mandated conditions are exempt from contract deductibles.
Coverage continues until ≥50% oral caloric intake
If coverage is authorized under the expanded benefit, it continues until the member can take at least 50% of their daily caloric requirement from regular foods; no other step‑therapy sequence is specified.
- Coverage continuation threshold: eligible until >=50% daily calories obtained from regular foods
Document diagnosis and exact formula (and sole‑source status when required)
Provider orders must document the specific medical condition listed under Patient Selection and specify the enteral formula type; when the policy requires the formula to be the sole source of nutrition, the order must state that the enteral formula is the sole source.
- Document the exact patient selection indication (e.g., state‑mandated disorder or expanded‑benefit indication)
- Specify formula type (e.g., hydrolyzed, amino acid–based elemental, modular, or defined specialized formula)
- State explicitly when the formula is the sole source of nutrition
Risk of denial if not sole‑source or not a specified formula
Enteral formula supplied solely because a patient cannot take adequate calories by regular diet is not eligible for coverage unless the formula is the sole source of nutrition and is one of the specialized formulas listed in the expanded benefit.
- Basic milk or soy formulas are not eligible.
- Oral or tube‑administered enteral formula must be a hydrolyzed, amino acid–based, modular, or defined specialized formula (as listed) and the sole source to be eligible.
Background
Enteral feeding provides nutrition via specialized enteral or elemental formulas administered orally or through a feeding tube (nasogastric, gastrostomy, jejunostomy, etc.) for patients who cannot meet nutritional needs by regular diet but have adequate gastrointestinal absorption. Amino acid–based elemental medical formulas are 100% free–amino-acid formulas used in specified conditions (for example, food protein allergies, food protein–induced enterocolitis syndrome, eosinophilic disorders, and short bowel syndrome), and infant formulas may be considered eligible based on formula content and clinical indication.
Definitions
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