CurrentUnitedHealthcarePolicy CS136KS.03

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

Medical policy governing coverage and clinical criteria for enteral nutrition (oral and tube feeding) for UnitedHealthcare Community Plan members in Kansas; applies to DME enteral nutritional products and related codes.

Policy Summary

PayerUnitedHealthcare Community Plan

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

Policy CodePolicy CS136KS.03

Change TypeNon-material revision (references updated)

Effective DateMay 1, 2026

Next Review Date

Key ActionFollow the Kansas Medical Assistance Program DME manual and InterQual criteria for prior authorization and medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

Updated References section to reflect the most current information and archived previous policy version CS136KS.02.

KSState-specific

2026-05-01Effective

CS136KS.03Policy ID

InterQualPrimary criteria

Coverage Criteria

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Medical necessity criteria (referenced external criteria)

Enteral tube feeding is considered medically necessary in certain circumstances when clinical criteria are met per referenced sources.

Medical necessity determination: Coverage requires meeting the Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Manual clinical criteria and the InterQual CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy.

Providers must refer to those documents for specific indication-level criteria.

The HCPCS/CPT code list in this policy is provided for informational purposes only. Listing of a code does not imply that the service described by the code is a covered or non‑covered health service, nor does inclusion guarantee reimbursement or payment. Benefit coverage is determined by federal, state, or contractual requirements and applicable law; other policies and guidelines may also apply.

Determinations of whether enteral nutrition is medically necessary or not are made using the referenced clinical sources. This policy defers to the Kansas Medical Assistance Program Durable Medical Equipment Fee‑for‑Service Manual and the InterQual® CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy for the specific clinical criteria that establish medical necessity.

Coding and Code Guidance

Applicable HCPCS/CPT codes (informational)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.
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.

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Applicable HCPCS/CPT codes (informational) - continuedHCPCS

No codes listed

Caloric density thresholds for adult and pediatric formulas

Adult caloric density threshold>= 1.5 kcal/ml (HCPCS B4152)

Pediatric caloric density threshold>= 0.7 kcal/ml (HCPCS B4160)

Unit reporting for calorically dense formulasB4152 and B4160 reported per 100 calories = 1 unit

Provider Actions and Billing Notes

Documentation Required

Follow state DME manual and InterQual for medical necessity

Follow the Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Manual and the InterQual® criteria for medical necessity determinations for enteral nutrition products and related DME.

Document medical necessity per state DME manual and InterQual requirements
Ensure documentation aligns with Kansas program rules and InterQual criteria

Step Therapy

Step therapy not specified

This policy does not specify any step therapy requirements for enteral nutrition or related DME. Do not apply step therapy rules based on this policy; instead, refer to the member's specific plan, federal/state, or contractual requirements if applicable.

No step therapy enforced by this policy
If plan-specific step therapy exists, follow the member's plan or contractual requirements

Note

Reference plan-specific requirements and coding notes

When determining coverage and billing, always reference federal, state, and contractual benefit requirements as they may supersede this policy. Coding lists are informational only and do not guarantee coverage or reimbursement.

Verify coverage against applicable federal/state/contractual rules before billing
Treat the provided code list as informational; presence of a code does not imply coverage

Definitions

Definition — Medical food

Statutory definition sourceDefined in section 5(b)(3) of the Orphan Drug Act [21 U.S.C. 360ee(b)(3)] as 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 established by medical evaluation.

Regulatory statusMedical foods are not drugs and are regulated as foods; manufacturers must comply with applicable FDA food requirements, not drug-specific regulations.

Usage contextIntended to be administered enterally under the supervision of a physician for specific dietary management.

Background

Enteral nutrition refers to provision of nutrients via a feeding tube and includes standard and specialized nutrient formulas administered by tube feeding modalities such as nasogastric, gastrostomy, or jejunostomy tubes. These products are intended to provide complete or supplemental nutrition when oral intake is inadequate or unsafe. Clinical coverage for enteral nutrition is determined by the referenced state DME manual and InterQual criteria, which specify the circumstances and clinical indications under which tube feeding is considered medically necessary.

Medical Necessity Determinations

DME medical necessity (referenced)

Clinical coverage for DME enteral nutritional products is determined by external referenced criteria; this policy defers to those sources for itemized criteria.

Referential criteria: Providers must meet clinical criteria in the Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Manual and InterQual CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy for enteral nutrition items and formulas to be considered medically necessary.

This policy does not enumerate specific clinical sign/measure criteria; see referenced documents and InterQual for indication-level requirements.

Rental and Purchase Rules

Equipment / Product	Rental vs Purchase Rule	Notes
Enteral feeding equipment and enteral nutritional formulas (oral and tube feeding)	Unspecified in this policy — providers must follow the Kansas Medical Assistance Program DME Fee-for-Service Manual and applicable contractual/plan documents for rental vs purchase determinations	Policy defers to state DME manual and plan-specific rules; inclusion of a code in this policy is informational and does not guarantee coverage

Replacement

Replacement rules (not specified)

Replacement intervals specified in policyNot specified in this policy; follow federal, state, or contractual requirements and applicable laws.

Where to find replacement rulesRefer to the Kansas Medical Assistance Program DME Fee‑for‑Service Manual and applicable plan documents for replacement guidance.

Provider actionCheck contractual and state requirements before submitting claims or prior authorization requests regarding replacements.

Documentation Requirements