CurrentCignaPolicy A022

Enteral and oral nutritional formula coverage (Administrative Policy A022)

Administrative guidance on coverage, exclusions, and coding for enteral (tube) and oral nutritional formulas under Cigna benefit plans; applies to plan administration and claims adjudication where plan language permits or excludes these benefits.

Policy Summary

PayerCigna

PolicyEnteral and oral nutritional formula coverage (Administrative Policy A022)

Policy CodePolicy A022

Change TypeNo material change

Effective DateFeb 15, 2025

Next Review DateFeb 15, 2026

Key ActionVerify benefit availability and plan terms by referencing the member's applicable benefit plan document and any state mandates.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

many plans excludeCoverage exclusions

B4149–B4161, S9432–S9433HCPCS excluded

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Policy 0136See

Coverage Criteria and Exclusions

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When enteral nutritional formula is excluded from the member's benefit plan, the items below and related supplies/equipment are not covered or reimbursable:

ALL of the following

Examples include
- Standardized or specialized infant formula for conditions including: food allergies; multiple protein intolerances; lactose intolerances; gluten-free formula for gluten-sensitive enteropathy/celiac disease; milk allergies; sensitivities to intact protein; protein or fat maldigestion; intolerances to soy formulas or protein hydrolysates; prematurity; low birthweight.
- Baby food.
- Grocery items that can be blenderized and used with an enteral feeding system.
- High protein powders and mixes.
- Lactose-free products and products to aid in lactose digestion.
- Low carbohydrate diets; normal grocery items.
- Oral/enteral formula used to replace fluids and electrolytes.
- Oral vitamins and minerals.
- Weight-loss foods and formula and products to aid weight loss.

Refer to Medical Coverage Policy 0136 Nutritional Support for conditions of coverage available under the medical plan.

HCPCS exclusions

Specific HCPCS codes are listed as generally excluded from coverage regardless of indication or use.

The following HCPCS codes are generally excluded from coverage regardless of indication or use:

ALL of the following

Excluded HCPCS codes
- B4149 - Enteral formula, manufactured blenderized natural foods with intact nutrients.
- B4150 - Enteral formula, nutritionally complete with intact nutrients.
- B4152 - Enteral formula, nutritionally complete, calorically dense (>= 1.5 Kcal/ml) with intact nutrients.
- B4153 - Enteral formula, nutritionally complete, hydrolyzed proteins.
- B4158 - Enteral formula, pediatrics, nutritionally complete with intact nutrients.
- B4159 - Enteral formula, pediatrics, nutritionally complete soy based.
- B4160 - Enteral formula, pediatrics, calorically dense (>= 0.7 Kcal/ml).
- B4161 - Enteral formula, pediatrics, hydrolyzed/amino acids and peptide chain proteins.
- S9432 - Medical foods for noninborn errors of metabolism.
- S9433 - Medical food nutritionally complete, administered orally, providing 100% of nutritional intake.

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Coding and Billing

Generally excluded enteral/oral nutrition HCPCSHCPCSNot Covered

B4149	Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
B4150	Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
B4152	Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
B4153	Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
B4158	Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit.
B4159	Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit.
B4160	Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
B4161	Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
S9432	Medical foods for noninborn errors of metabolism.
S9433	Medical food nutritionally complete, administered orally, providing 100% of nutritional intake.

Coding updates note

Coding updates noteAMA and CMS code updates may occur more frequently than policy updates; the listed codes may not be all-inclusive.

Deleted or inactive codesDeleted codes and codes not effective at the time of service may not be eligible for reimbursement.

Check payer coding guidesVerify current coding via AMA and CMS resources and Cigna coding guides before claims submission.

Provider Actions and Verification

Documentation Required

Verify plan benefits and governing documents

Verify benefit availability and plan terms by referencing the member's applicable benefit plan document and any state mandates; coverage determinations require consideration of the terms of the applicable benefit plan document, any applicable laws/regulations, relevant collateral materials (including this Administrative Policy), and the specific facts of the situation.

Check the member’s specific benefit plan document to determine whether enteral and/or oral nutritional formula benefits are included or expressly excluded.
Confirm any state mandates that may alter coverage requirements for the member.
If the plan excludes enteral formula, note that related supplies and equipment used solely with enteral feeding are also not covered.

Definitions

Enteral nutrition

DefinitionProvision of nutritional requirements through a tube in the stomach or small intestine (tube feeding); nutrition delivered directly into the gastrointestinal tract.

ExampleEnteral nutrition typically refers to feeding via gastrostomy or nasogastric tubes.

ScopeUsed when oral intake is inadequate or not possible to meet nutritional needs.

Oral nutrition

DefinitionNutrition taken through the mouth.

ContextIncludes regular oral intake and oral consumption of specialized formulas when appropriate.

DistinctionDifferent from enteral nutrition which is delivered directly into the GI tract via a tube.

Enteral nutrition formula

DefinitionLiquid foods specially formulated for oral consumption or enteral feedings.

UseDesigned to meet nutritional requirements when ordinary food is insufficient or cannot be tolerated.

FormulationMay be nutritionally complete and intended for administration orally or via enteral feeding tubes.