Nutritional Supplements Guidelines

Authorization for Nutritional Products

TCHP performs authorization of most nutritional products.

B4105 Prior Authorization Required

Immobilized lipase cartridges (B4105) are a benefit when provided by a durable medical equipment supplier in the home setting and require prior authorization.

• Member has exocrine pancreatic insufficiency.
• Member utilizes an enteral feeding pump and a compatible formula; the daily formula volume in mL must be documented.
• One cartridge may be used per 500 mL of formula, with a maximum of two cartridges per day and a limit of 62 cartridges per month.

Portable Pump Carrying Case

A backpack or carrying case for a portable enteral nutrition infusion pump may be covered as a Home Health Service when medically necessary and prior authorized under B9998.

• Member requires continuous enteral feeding for more than 8 hours or feeding intervals exceeding time away from home for school/work, extensive physician-ordered outpatient therapy, or frequent multiple medical appointments.
• Member is ambulatory or uses a wheelchair that cannot support the portable pump by another means, such as an IV pole.
• The portable enteral feeding pump is client-owned.

Youth Prior Authorization Exception

Prior authorization is not required for nutritional products for members age 20 and younger who meet at least one qualifying exception.

• Member receives all or part of nutritional intake through a tube.
• Member has a documented metabolic disorder with a diagnosis code listed in the current Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook.

Authorization Duration

Initial prior authorization may be issued for up to 6 months. Recertification may be issued for up to 12 months when the ordering physician or allowed practitioner documents ongoing medical necessity.

• For members over age 21, authorization may be given for up to 6 months; recertification requires documentation supporting ongoing medical necessity.

Change in Member Status

If the member’s status changes before the authorization expires, the MCO must ensure that the DME provider works with the requesting physician or allowed practitioner to modify the plan of care and obtain a new or amended authorization.

• Do not continue relying on the existing authorization when the member’s status or plan of care changes.

Submission Channels

Requests for prior authorization of nutritional products are received by the Utilization Management Department by fax, mail, or electronic submission and are processed during normal business hours.

• The Utilization Management professional evaluates the submitted information to determine whether the nutritional supplement request is a covered benefit.

CCP Prior Authorization Form

Submit a completed CCP Prior Authorization Form prescribing the nutritional supplement.

• The form must be signed and dated by a prescribing physician who was familiar with the member before making the request.
• Include the procedure codes and numerical quantities for all requested services.

Clinical and Nutritional History

Requests must include accurate clinical and nutritional history supporting the requested formula, supplies, or equipment.

• Overall health status, height, and weight.
• Growth history and growth charts for members under age 20.
• Why the member cannot be maintained on an age-appropriate diet, or confirmation that enteral nutrition is the member’s sole or primary source of nutrition.
• Other formulas tried and why they did not meet the member’s needs.

Diagnosis and ICD-10-CM Coding

Document the member’s diagnoses and conditions, including the appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code.

• Include the underlying diagnosis or condition and any other relevant medical diagnoses or conditions.

Plan of Care and Calorie Documentation

Provide the medical plan of care and the prescribed nutritional requirements with the authorization request.

• State the goals and timelines in the medical plan of care.
• Document the total caloric intake prescribed by the physician.
• Acknowledge that a feeding tube is in place when applicable.

Lipase Cartridge Documentation

Requests for B4105 must document the clinical and equipment details needed to establish eligibility and calculate the requested quantity.

• Exocrine pancreatic insufficiency diagnosis.
• Use of an enteral feeding pump and compatible formula.
• Daily formula volume in mL.
• Requested quantity must comply with one cartridge per 500 mL, no more than two cartridges per day, and the 62-cartridge monthly limit.

Electrolyte Replacement Documentation

Requests for electrolyte replacement products, such as Pedialyte or Oralyte, must include documentation of medical necessity.

• Underlying acute or chronic diagnoses or conditions indicating the need to replace fluid and electrolyte losses.
• Presence of mild to moderate dehydration due to persistent mild to moderate diarrhea or vomiting.

Excluded Nutritional Products

TCHP does not cover the following nutritional products under the Comprehensive Children’s Program; requests must be submitted according to the applicable coverage and billing category.

• Products traditionally used for infant feeding.
• Products requested for a primary diagnosis of failure to thrive, failure to gain weight, or lack of growth; the underlying cause is required.
• Nutritional bars.
• Products for members who could be sustained on an age-appropriate diet.
• Potentially reimbursable nutritional product codes include B4100, B4103, B4104, B4105, B4149, B4150, and B4152, subject to applicable criteria and authorization requirements.
• WIC nutritional products are carved out and must be billed to TMHP; products for other Medicaid managed care clients must be submitted to the MCO administering the member’s benefits.

Oral Nutrition Coverage Limits

Certain oral nutrition requests are not medically necessary or covered under the stated indications and formula limitations.

• Oral nutrition for lack of appetite or cognitive conditions, including lack of appetite secondary to stimulant medications or picky eating, is not covered.
• Formulas for mild or moderate food allergies or food intolerance are not covered unless the request meets the applicable medical-necessity criteria.
• For members age 20 and younger, oral nutrition may be medically necessary for severe conditions that would cause malnutrition, severe disability, mental retardation, or death without therapy; gastroesophageal reflux causing failure to thrive; severe food allergies with those risks; and when adequate nutrition cannot be achieved through age-appropriate foods.
• Food thickener may be considered for members under age 20 with a swallowing disorder; additional amounts beyond the standard 0.2 ounces per 4 ounces of liquid require documentation of medical necessity.
• Nutritional pudding may be considered for members under age 20 with documented oropharyngeal motor dysfunction when it provides more than 50% of daily caloric intake.

Electrolyte Replacement Limitations

Electrolyte replacement products are limited to medically necessary treatment of documented fluid and electrolyte losses and are not intended for certain conditions or uses.

• Products are not intended for intractable vomiting, adynamic ileus, intestinal obstruction or perforated bowel, anuria, oliguria, impaired homeostatic mechanisms, or severe continuing diarrhea when used as the sole therapy.

Requests Not Meeting Criteria

Requests that do not meet the established criteria are referred to a TCHP Medical Director or Physician Reviewer, and the Denial Policy is followed.

• Preauthorization is based on medical necessity and is not a guarantee of benefits or eligibility.
• Approved services remain subject to benefit limitations and exclusions; providers must comply with state and federal requirements and may be subject to retrospective audit and financial recoupment.

Exceptional Circumstances for Members Over Age 21

For members over age 21, providers must submit requests for medically necessary DME and supplies not listed as covered benefits under Texas Medicaid through TCHP’s exceptional-circumstances process.

• DME and supplies allowed under the exceptional-circumstances provision require prior authorization under the TCHP Case by Case Procedure Guideline.
• The exceptional-circumstances process is not available after a medical-necessity or technical denial, including missing essential fields or incomplete documentation.