CurrentColorado Rocky Mountain Health PlansPolicy CS136OH.F

Enteral Nutrition (Oral and Tube Feeding) (for Ohio Only)

Defines coverage guidance for enteral nutrition products (oral and tube feeding) for members in Ohio, referencing Ohio Administrative Code requirements for medical necessity. Applies to requests for enteral formulas, medical foods, and related supplies for Colorado Rocky Mountain Health Plans members covered under Ohio rules.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEnteral Nutrition (Oral and Tube Feeding) (for Ohio Only)

Policy CodePolicy CS136OH.F

Change TypeNo material changes

Effective DateJun 1, 2026

Next Review Date

Key ActionObtain and document medical necessity per Ohio Administrative Code Rule 5160-10-26 before requesting coverage for enteral nutrition products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

B4100–B4162, S9432–S9435Listed HCPCS/National codes referenced

Ohio-onlyGeographic applicability

OAC 5160-10-26Primary coverage criteria source

2026-06-01Policy effective date

Coverage Criteria

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Medical necessity per Ohio Administrative Code

Covered when service meets Ohio Administrative Code medical necessity criteria

OAC-based medical necessity: Coverage is determined by meeting the criteria in Ohio Administrative Code Rule 5160-10-26 for DMEPOS: nutrition products; requests for unproven services or those with coverage/quantity limits will be evaluated under OAC 5160-1-01.

Providers must follow OAC rules for specific clinical criteria and documentation.

The list of procedure and diagnosis codes included in this policy is provided for reference only and does not imply coverage. Listing a code here does not establish that the corresponding service is a covered benefit; benefit coverage is determined by applicable federal, state, and contractual requirements and laws. Some services identified by the codes may be non-covered or subject to limitations under federal, state, or contract rules.

The inclusion of a code in this policy does not guarantee payment or create any right to reimbursement. Services associated with listed codes must meet the applicable medical necessity criteria (see Ohio Administrative Code Rule 5160-10-26 where applicable) and all other plan requirements; services that fail to meet those criteria are not covered.

Coding and HCPCS / S-Codes

Enteral nutrition HCPCS codes (part 1)HCPCS

B4100	Food thickener, administered orally, per oz.
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 (e.g., clear liquids), 500 ml = 1 unit.
B4104	Additive for enteral formula (e.g., fiber).
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.

Enteral nutrition HCPCS codes (part 2)HCPCS

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.
B4154	Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
B4155	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit.
B4157	Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, 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.

Enteral nutrition HCPCS and S-codes (pediatrics and medical foods)HCPCS

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.
B4162	Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, 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.
S9434	Modified solid food supplements for inborn errors of metabolism.
S9435	Medical foods for inborn errors of metabolism.

Caloric density — adult and pediatric thresholds

Adult calorically dense threshold>= 1.5 kcal/ml (HCPCS B4152)

Pediatric calorically dense threshold>= 0.7 kcal/ml (HCPCS B4160)

Unit reporting100 calories = 1 unit for B4152 and B4160 (per HCPCS descriptions)

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Requirement

Prior authorization and utilization management are governed by Ohio Administrative Code (OAC) Rule 5160-10-26. Providers must obtain any required prior authorization per the OAC and plan-specific procedures before furnishing services.

State-rule-based prior authorization per OAC 5160-10-26
Follow Colorado Rocky Mountain Health Plans prior auth submission processes where applicable

Step Therapy

Step Therapy per OAC

Step therapy requirements and sequencing decisions are based on OAC guidance and the plan's utilization management protocols. Providers should follow the OAC-prescribed step therapy pathways and submit documentation showing prior steps were tried and failed or were contraindicated.

Document trials of required prior therapies and dates
If a step is contraindicated, include clinical rationale and supporting documentation

Denial Risk

Denial Risks Tied to OAC Evaluation

Requests will be evaluated against OAC criteria and plan limits. Services described as unproven or subject to coverage or quantity limits in the OAC may be denied. Providers should be aware that denial risk increases when requests lack OAC-aligned justification or exceed stated limits.

Denials likely when service is listed as unproven under OAC
Denials likely when requested quantities exceed OAC or contractual limits

Documentation Required

Documentation and Regulatory References

Include complete clinical documentation and reference applicable federal/state regulations and FDA information where relevant. FDA approval alone does not guarantee coverage; reference the OAC, federal statutes, and the plan contract when supporting medical necessity.

Attach clinical notes, prior therapy records, and diagnostic test results
Cite relevant OAC sections and any applicable federal or contractual requirements

Medical Necessity Determination

DME medical necessity per OAC Rule 5160-10-26; see OAC for specific clinical criteria and allowable products

Medical necessity is determined by Ohio Administrative Code Rule 5160-10-26; see OAC for specific clinical criteria and allowable products.

OAC rule governs: Products must meet the definition and clinical criteria set forth in OAC 5160-10-26 to be eligible for coverage.

Refer to the OAC text (Rule 5160-10-26) for itemized clinical criteria, allowable products, and limitations; document medical necessity per OAC.

Rental and Purchase Rules

Item	Rule / Payment Method
Enteral nutrition supplies and formulas (including enteral formulas, medical foods, additives, and related supplies)
Rental vs. purchase and payment determinations follow Ohio Administrative Code Rule 5160-10-26 and applicable plan/contract provisions (per OAC / plan).

Replacement — Equipment and Supplies

Enteral feeding equipment/supplies replacement rules per OAC / plan

Replacement rule sourceReplacement and frequency for enteral feeding equipment/supplies are determined by medical necessity per Ohio Administrative Code Rule 5160-10-26 and plan rules

ApplicabilityApplies to enteral feeding equipment, supplies, and related products covered under the Ohio-only policy

Documentation requirement for replacementsProvider must document medical necessity in accordance with OAC Rule 5160-10-26 and applicable OAC definitions to justify replacements

Documentation Requirements

Documentation Required

Document medical necessity per OAC 5160-10-26

Document medical necessity consistent with Ohio Administrative Code Rule 5160-10-26 and applicable OAC definitions when submitting requests for enteral nutrition products.

Include clinical rationale that demonstrates how the request meets OAC 5160-10-26 criteria.

Background

Enteral nutrition products — including complete and supplemental enteral formulas, medical foods, additives (e.g., fiber), and food thickeners — are intended to provide nutrition by oral intake or via enteral feeding tubes for patients with specific nutritional needs. Medical foods are formulated for the dietary management of disease conditions and require physician supervision. Coverage and medical necessity determinations for these products are governed by applicable rules (for Ohio, refer to OAC Rule 5160-10-26) and must meet the clinical criteria established by those regulations.

Definitions

Definition of medical food per Orphan Drug Act sec 5(b)(3)

Statutory definition (Orphan Drug Act sec 5(b)(3))A medical food is a food formulated to be consumed or administered enterally under physician supervision for the specific dietary management of a disease or condition with distinctive nutritional requirements.

Physician supervisionMedical foods must be consumed or administered under the supervision of a physician (per the statutory definition).

Regulatory statusMedical foods are not drugs and are not subject to drug-specific regulatory requirements; manufacturers must comply with applicable FDA food requirements.

Not Covered / Limitations

Items and codes listed in this policy are not automatically covered. Coverage decisions are subject to federal, state, and contractual requirements and may vary by benefit plan and jurisdiction. Providers must verify coverage and applicable limitations for each member; some codes may be non-covered or limited under the member’s plan or by applicable law.