CurrentMolina HealthcarePolicy N/A

Hydrolyzed/Elemental (Amino Acid) Pediatric Formula Reimbursement

Defines Molina Healthcare's reimbursement policy and coverage criteria for oral amino acid-based (elemental) pediatric enteral formulas (B4161, B4153) and the ICD-10-CM diagnoses that support payment. Applies to Molina providers and claims processing.

Policy Summary

PayerMolina Healthcare

PolicyHydrolyzed/Elemental (Amino Acid) Pediatric Formula Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefit plan terms and ensure documentation shows a listed definitive diagnosis to support payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Affected CPT/B codes listed

7+Definitive diagnosis categories

manyCovered ICD-10-CM codes

WAState exception listed

Definitive Diagnoses and Medical Necessity

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Definitive Diagnoses That May Support Payment

Oral amino acid-based elemental formula (B4161, B4153) may be payable when one of the following documented conditions/diagnoses is present on the submitted claim and coverage is consistent with the member's benefit plan.

ANY of the following

Cystic fibrosis
IgE-mediated allergies to food proteins
Amino acid, organic acid, and fatty acid metabolic and malabsorption disorders (e.g., phenylketonuria, maple syrup urine disease, homocystinuria, tyrosinemia, methylmalonic acidemia, propionic acidemia)
Food protein-induced enterocolitis syndrome
Eosinophilic gastroenteritis
Eosinophilic esophagitis
Eosinophilic colitis

Supporting ICD-10-CM codes (examples)

K52.2 - Allergic and dietetic gastroenteritis and colitis
K52.21 - Food protein-induced enterocolitis syndrome
K52.81 - Eosinophilic gastritis or gastroenteritis
K52.22 - Food protein-induced enteropathy
K52.82 - Eosinophilic colitis
E70, E70.0, E70.1, E70.2 - Disorders of aromatic amino-acid and tyrosine metabolism (including phenylketonuria, tyrosinemia)

Coverage is subject to the specific terms of the member's benefit plan; listing of service or code does not guarantee coverage.

Washington (WA) has specific exclusions and billing rules as noted in supplemental/state‑specific information.

Billing unit definition: 100 calories = 1 unit for enteral formula.

Molina will monitor compliance with this policy and take corrective action as necessary to ensure adherence to coding and billing standards.

Codes, Units, and State Exceptions

Amino acid-based elemental pediatric enteral formulaCPTCovered

B4161	Enteral formula (pediatrics), hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals; 100 calories = 1 unit (per policy text)
B4153	Enteral formula (pediatrics), hydrolyzed/amino acids and peptide chain proteins (per policy header)

State-specific exclusions (WA)mixed

Excluded CPTs/HCPCS and Rev Codes

Various CPT/HCPCS and revenue codes excluded for State WA as listed in policy supplemental information (e.g., exclude modifiers AY, 59, 91; exclude CPTs J0606, J0604, J0610, J0882, J0887, J1200, J1270, J1756, J1940, J2501, J2916, Q0163, Q4081, Q5105 and many laboratory/test CPTs; exclude revenue codes 0800-0889, 800-889, etc.)

Unit definition

Billing unit100 calories = 1 unit

ApplicationUnit definition applies to enteral pediatric amino acid–based (elemental) formulas billed under listed procedure/CPT codes

Use in claimsProviders should calculate units by dividing total calories dispensed by 100 to determine billed units

Coverage Conditions, Compliance and Provider Requirements

Documentation Required

Coverage, Documentation, and Compliance Monitoring

Coverage for oral amino acid–based elemental pediatric enteral formula is subject to the specific terms of the member's benefit plan. Providers must document that services meet the member’s plan benefits and applicable clinical criteria. Molina will monitor compliance with this policy and take corrective action as necessary to ensure adherence to coding and billing standards.

Verify member benefit plan terms before billing; coverage is not guaranteed by code listing alone.
Maintain clinical documentation that supports the billed diagnosis and medical necessity for the formula.
Be aware Molina will audit claims for coding and billing compliance and may implement corrective actions if standards are not met.

Key Terms

Amino acid-based elemental enteral formula — pediatric

DefinitionEnteral formula for pediatrics composed of hydrolyzed/amino acids and peptide chain proteins; includes fats, carbohydrates, vitamins and minerals; may include fiber; administered via enteral feeding tube

RegulationRegulated by the U.S. Food and Drug Administration (FDA)

IndicationPrescribed for infants or children who cannot digest or tolerate whole proteins due to allergies or gastrointestinal/metabolic conditions

Composition & purposeProteins are broken down into elemental amino acids to improve digestibility and reduce allergic/absorption reactions