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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologyCareSource Georgia Nutritional Supports Coverage |…
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    CurrentCareSource GeorgiaPolicy Nutritional Supports-MP-MM-1330

    Nutritional Supports

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    Defines medical necessity, coverage criteria, and exclusions for oral and enteral nutrition products, donor human milk, and related supplies for Marketplace members in the listed states; affects providers requesting nutritional supports for members.

    Policy Summary
    PayerCareSource Georgia
    PolicyNutritional Supports
    Policy CodePolicy Nutritional Supports-MP-MM-1330
    Change TypeNo material change
    Effective DateSep 1, 2025
    Last ReviewSep 1, 2025
    Next Review DateSep 1, 2025
    Key ActionDocument medical necessity and provider education; submit prior authorization with supporting clinical documentation for approvals up to 12 months.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2025-09-01

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    policy effective date
    12 monthsmaximum approval duration
    Ages 2+RELiZORB patient age
    3 tiersmalnutrition tiers
    5 statesapplicable Marketplaces

    Coverage Criteria for Nutritional Supports

    Total oral nutrition (medical food) — Initial criteria

    Total oral nutrition is considered medically necessary when ALL of the following are met:

    Total oral nutrition criteria: 1) The product is a medical food for oral feeding; 2) the product is used under medical supervision; 3) the member has the ability to swallow without increased risk of aspiration; 4) the product is the member's primary source of nutrition; 5) the product is labeled and used for nutritional management of a member's specific medical condition without which serious morbidities may develop OR is used to promote normal development or function for the member; 6) the product is used under the supervision of a physician, physician's assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authorized to prescribe dietary treatments; 7) the member has one of the following medical conditions: a) a condition caused by an inborn error of metabolism (examples: phenylketonuria, homocystinuria, methylmalonic acidemia, galactosemia), OR b) a condition that interferes with nutrient absorption and digestion (examples include current diagnosis of non-IgE-mediated cow's milk allergy as defined by abnormal stools, poor weight gain trajectory for age, or early-onset severe atopic dermatitis).

    Total enteral nutrition via tube — Initial criteria

    Total enteral nutrition via tube feeding is medically necessary when the member has a functioning, accessible gastrointestinal tract, and ALL the following:

    Total enteral via tube criteria: 1) Enteral nutrition comprises the majority of the member's diet; 2) the product is used under the supervision of a physician, physician's assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authorized to prescribe dietary treatments; 3) there is documentation that the member cannot ingest nutrients orally due to a medical condition which either (a) interferes with swallowing (eg, dysphagia from neurological condition, severe chronic anorexia nervosa, serious oral aversion in children), (b) places the member at risk for aspiration if given orally, or (c) is associated with anatomic abnormality of the proximal GI tract (eg, esophageal tumor causing obstruction); 4) approval duration can be up to 12 months for all enteral nutrition products.

    Supplemental oral or enteral nutrition — Initial criteria

    Supplemental oral or enteral nutrition is considered medically necessary when ALL the following apply:

    Supplemental nutrition criteria: 1) The product is being used to supplement the member's primary source of nutrition (minority of intake); 2) the product is used as part of a defined and limited plan of care (eg, transitioning from total enteral nutrition to standard diet for age, member undergoing cancer treatment); 3) documentation of a medical basis for the member's inability to maintain appropriate body weight and nutritional status (initial and ongoing) with normal or therapeutic oral/enteral nutrition (eg, moderate to severe malnutrition unresponsive to standard interventions); 4) documentation of ongoing evidence of the member's positive response to the product and risk of decline without it (eg, improvement from moderate/severe malnutrition to mild/normal with risk of reversal if stopped); 5) the product must be used under the supervision of a physician, physician's assistant, or nurse practitioner, or ordered by a registered dietician upon referral; 6) the primary reason is not for convenience of the member or caregiver.

    Donor human milk — criteria

    CareSource considers donor human milk medically necessary when ALL the following criteria are met:

    Donor human milk criteria: 1) Provider must be in good standing with the Human Milk Banking Association of North America; 2) documentation supports medical necessity; 3) documentation supports that the provider has attested to educating the member in the donation process and about human milk; 4) documentation supports that the provider discussed the risks and benefits with the member.

    Enteral nutrition exceptions

    Automatic approvals / no further review:

    Automatic medical necessity: Enteral nutrition requests for members with inborn errors of metabolism and/or low-profile gastrostomy/jejunostomy/gastrojejunostomy tubes (eg, Mic-Key, button) meet medical necessity criteria and do not require further review.

    Coverage criteria (not in excerpt)

    No detailed criteria in this portion of the document.

    No explicit nodes: This document segment does not contain the full medical necessity criteria logic for all coverage scenarios; full criteria are located in other parts of the policy not included in this excerpt.

    See full policy for initial, continuation, and additional exception criteria.

    CareSource does not consider nutritional formulas and dietary supplements that are readily available for purchase over the counter to be medically necessary unless they are administered through a pre-existing feeding tube. Requests for these products when used for convenience, preference, or as meal replacements/snack alternatives are not covered. Approval durations for supplemental enteral nutrition products delivered via tube may be granted for up to 12 months when criteria for tube-administered enteral nutrition are met.

    This excerpt does not list additional explicit exclusions beyond those identified elsewhere in the policy document. Refer to the full policy for the complete exclusions list and state‑specific provisions.

    RELiZORB is explicitly listed in the policy as not considered medically necessary due to insufficient published evidence.

    Within this excerpt there are no additional explicit statements identifying other products or services as not medically necessary. Consult the full policy for the complete not‑medically‑necessary list.

    Coding and Clinical Thresholds

    No codes listed in this segmentmixed
    No codes listed
    Malnutrition z-score thresholds
    Mild malnutritionZ-score = -1 to -1.9 or z-score decrease of 1 over time
    Moderate malnutritionZ-score = -2 to -2.9 or z-score decrease of 2 over time
    Severe malnutritionZ-score = -3 or less or z-score decrease of 3 over time

    Provider Actions, Authorization, and Documentation

    Prior Authorization

    Authorization and approval duration — approvals up to 12 months

    Prior authorization/approval is implied for oral, supplemental, and enteral nutrition products with approval durations up to 12 months; approvals for these products can be issued for up to 12 months.

    • Approval duration can be up to 12 months for all oral nutrition products (chunk 10).
    • Approval duration can be up to 12 months for all enteral nutrition products (chunk 12).
    • Approval duration can be up to 12 months for all supplemental enteral nutrition products (chunk 14).
    Note

    Prior authorization specifics not provided

    This document segment does not list explicit prior authorization code lists or detailed prior authorization rules.

    Background

    Enteral nutrition provides targeted nutritional support for individuals whose gastrointestinal tract function, anatomy, or digestion/absorption is impaired. It may be delivered orally or via tubes (orogastric, nasogastric, gastrostomy, jejunostomy) and can serve as total enteral nutrition when it supplies the majority of daily calories, or as supplemental nutrition when used to augment oral intake. Indications include GI diseases and structural defects that interfere with nutrient transport, swallowing, or fat absorption (for example, inborn errors of metabolism, proximal anatomic obstruction, gastroparesis, or exocrine pancreatic insufficiency). Donor human milk and prescription adjuncts such as enzyme cartridges (e.g., RELiZORB) are described in the policy with specific coverage stances and documentation requirements.

    Definitions

    Enteral Nutrition — route and examples
    DefinitionNutritional support given via the gastrointestinal (GI) tract, either directly or through oral feeding or through tubes
    Routes (examples)Orogastric, nasogastric, gastrostomy (including low-profile/buttons), jejunostomy
    Delivery modesOral feeding or tube feeding for conditions impairing transport, digestion, or absorption
    Total Enteral Nutrition (TEN)
    DefinitionThe majority of daily calories are supplied by enteral nutrition products
    Context of useUsed when enteral nutrition comprises the primary source of nutrition (total enteral nutrition)

    Revision History

    2022-08-17issued

    Policy originally issued.

    2023-08-02revised

    Annual review with updated references and added malnutrition definition; approved at committee.

    2024-07-17revised

    Review updated references and changed title from 'Supplements' to 'Supports'; approved at committee.

    Policy Summary
    PayerCareSource Georgia
    PolicyNutritional Supports
    Policy CodePolicy Nutritional Supports-MP-MM-1330
    Change TypeNo material change
    Effective DateSep 1, 2025
    Last ReviewSep 1, 2025
    Next Review DateSep 1, 2025
    Key ActionDocument medical necessity and provider education; submit prior authorization with supporting clinical documentation for approvals up to 12 months.
    SourceLink
    On This Page
    Coverage Criteria for Nutritional SupportsCoding and Clinical ThresholdsProvider Actions, Authorization, and DocumentationBackgroundDefinitionsRevision History
    Step Therapy

    Exhaust other coverage (e.g., WIC) before submission

    All available avenues of coverage must be exhausted before supplemental nutrition coverage will be considered; for example, members eligible for WIC must apply for an eligibility evaluation first.

    • Members eligible for county WIC must apply for an eligibility evaluation before supplemental nutrition coverage is considered (chunk 11).
    • This requirement applies to supplemental oral nutrition prior to consideration (chunk 10).
    Step Therapy

    Step therapy — none specified

    No step therapy requirements or mandated step-wise treatment sequence are described in this text segment.

    Documentation Required

    Required documentation to support medical necessity and donor milk discussion

    Documentation must support medical necessity and, when donor human milk is requested, show the provider is in good standing with the Human Milk Banking Association of North America and that the provider educated the member and discussed risks and benefits.

    • Documentation must support medical necessity (chunk 14).
    • For donor human milk, provider must be in good standing with the Human Milk Banking Association of North America (chunk 14).
    • Documentation must support that the provider attested to educating the member about the donation process and that risks and benefits were discussed (chunk 14).
    Documentation Required

    Documentation references — ASPEN, ESPEN, CDC, FDA cited

    Providers may cite guideline and regulatory sources to support clinical documentation; references in the policy include ASPEN, ESPEN, CDC, and FDA documents related to clinical nutrition and donor human milk.

    • ESPEN guidelines and other clinical nutrition references are listed (chunk 22).
    • CDC and WHO growth chart and malnutrition resources are cited (chunk 23).
    • FDA guidance on donor human milk and RELiZORB are included in references (chunk 24).
    Denial Risk

    Denial risk — OTC formulas and supplements not covered (unless tube-administered)

    Requests for nutritional formulas and dietary supplements that can be purchased over the counter are not considered medically necessary and may be denied unless they are administered through a pre-existing feeding tube.

    • OTC nutritional formulas and dietary supplements are excluded unless administered through a pre-existing feeding tube (chunk 14).
    • Relizorb is specifically noted as not considered medically necessary due to insufficient published evidence (chunk 14).
    Note

    No further provider action specified in this segment

    No additional provider action item is specified in this document segment.

    Approval implication
    TEN requests for certain conditions may be auto-approved per policy exceptions
    Medical Food — definition
    DefinitionA specially formulated and processed product for oral or tube feeding labeled for the dietary management of a specific medical disorder
    FDA criteria (policy summary)Product must be for oral or tube feeding, labeled for dietary management of a specific disorder, and used under physician supervision
    IncludesSpecially formulated infant formulas when used as major treatment modality
    RELiZORB® — device indication and age
    Device indicationAn FDA‑approved digestive enzyme cartridge to treat exocrine pancreatic insufficiency
    Approved agesPediatric patients ages 2 years and older and adult patients
    Intended useUsed with enteral feeding to hydrolyze fats in enteral formulas to aid absorption
    Donor Human Milk — definition
    DefinitionBreast milk expressed by a mother and processed by a human milk bank (collected, pasteurized, tested, stored) for use by a recipient who is not the donor mother's own infant
    ProcessingHuman milk banks recruit donors, collect, pasteurize, test for bacterial contamination, store, and distribute donor milk
    Provider requirementProvider must be in good standing with Human Milk Banking Association of North America when ordering donor milk (per documentation requirements)
    Malnutrition — definition and review history
    Policy statusMalnutrition definition was added during annual review and is reflected in the policy review history
    Definition usedMalnutrition defined as deficiencies/excesses/imbalances measured by z-scores using WHO and CDC growth charts
    Severity tiers (added)Mild, Moderate, Severe malnutrition tiers defined by z-score cutoffs (-1 to -1.9; -2 to -2.9; ≤-3)
    2025-06-04revisedLatest

    Annual review with updated references and clarification of criteria for inborn errors of metabolism; approved at committee.