CurrentUnitedHealthcarePolicy CS136TN.P

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

State-specific medical policy governing enteral nutrition (standard and Specialized Nutrient Formula / Medical Foods) coverage for Tennessee Medicaid and CoverKids (pediatric focus under 21); references TennCare exclusions for adults and InterQual criteria for individuals under 21. Includes applicable HCPCS/DME codes, definitions, benefit limitations, and clinical evidence summaries for conditions such as inborn errors of metabolism, CKD, Crohn disease, and severe food allergies.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS136TN.P

Change TypeRevised sections (Description of Services, Clinical Evidence, References)

Effective DateJun 1, 2026

Next Review Date

Key ActionObtain a prescription and documentation from a physician, advanced practitioner, or registered dietitian showing criteria are met (chronic condition, inadequate nutrition by dietary adjustment, and Medical Food labeling); for tube feeding in individuals <21, follow InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

1State-specific policy (Tennessee)

Under 21Primary covered population specified

MultipleCovered conditions listed

Many

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Coverage Summary

Policy Number CS136TN.P; Effective Date June 1, 2026. Scope: State-specific medical policy governing enteral nutrition (oral and tube feeding), including standard formulas and Specialized Nutrient Formulas (Medical Foods), for Tennessee Medicaid and CoverKids. The policy’s primary covered population is individuals under 21 years of age (pediatric focus) with coverage determinations for pediatric tube feeding aligned to InterQual criteria. For adults (age 21 years and older), the policy defers to TennCare Medicaid Chapter 1200-13.13-.10 for medical necessity clinical coverage criteria and exclusions. (Applies to Tennessee Medicaid and CoverKids.)

Key thresholds and quick facts

Eosinophilic esophagitis histologic remission threshold< 15 eosinophils/high-power field

ASPEN/Academy pediatric Weight-for-height z score - Mild-1 to -1.9 z score

ASPEN/Academy pediatric Weight-for-height z score - Moderate-2 to -2.9 z score

ASPEN/Academy pediatric Weight-for-height z score - Severe-3 or greater z score

Weight gain velocity (<2 years) - Mild< 75% of norm

Weight gain velocity (<2 years) - Moderate< 50% of norm

Weight gain velocity (<2 years) - Severe< 25% of norm

NICE malnutrition BMI thresholdBMI < 18.5 kg/m2 or BMI < 20 with >5% unintentional weight loss in 3-6 months or >10% unintentional weight loss in 3-6 months

Primary covered populationUnder 21

State-specific policyTennessee Medicaid & CoverKids

Medical-Necessity Criteria

Individuals under 21 — Tube Feeding (Non-State-Specific)

Enteral nutrition administered by tube feeding is medically necessary when InterQual criteria are met.

ALL of the following

Patient is under 21 years of age.
Enteral nutrition (standard or Specialized Nutrient Formula) is administered by tube feeding (nasogastric, gastrostomy, or jejunostomy tube).
Medical necessity determined per InterQual® CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy (referenced).
Note: Standard formula may be considered medically necessary for tube feeding because standard foods cannot be administered through a tube.

Not Covered / Benefit Limitations

Coding (HCPCS)

Enteral / Medical Food HCPCSHCPCS

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 (>= 1.5 kcal/ml) with intact nutrients, administered through enteral feeding tube, 100 calories = 1 unit.
B4153	Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), 100 calories = 1 unit.
B4154	Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, 100 calories = 1 unit.
B4155	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, 100 calories = 1 unit.

1–10 of 20

1/2

Provider Actions & Documentation Requirements

Documentation Required

Prescribing and clinical documentation required for pediatric oral Specialized Nutrient Formula

A prescription from a physician, advanced practitioner, or registered dietician is required. Clinical documentation must demonstrate: (1) the condition is chronic and expected to be prolonged; (2) adequate nutrition cannot be achieved by dietary adjustment alone (i.e., dietary modification insufficient); and (3) the product is a Medical Food labeled for enteral use and intended for the specific dietary management of the condition. For tube feeding in individuals under 21 years of age, follow InterQual® CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy criteria for medical necessity.

Documentation Required

Reference state adult criteria

For adults (age 21 and older), this policy defers to state rules. Providers should reference TennCare Medicaid Chapter 1200-13.13-.10 for medical necessity clinical coverage criteria and exclusions for enteral nutrition (including oral liquid nutrition and tube feeding) applicable to adult members.

Documentation Required

Background & Evidence Summary

Background: Enteral nutrition uses the gastrointestinal tract to provide nutrition and calories and includes a normal oral diet, liquid supplements, or tube feeding. Enteral formula can be delivered orally or via tubes (nasogastric, gastrostomy, jejunostomy).

Specialized Nutrient Formulas (classified as Medical Foods) are specially formulated enteral products intended for the dietary management of diseases with distinctive nutritional requirements, to be used under medical supervision and when standard formulas cannot meet those requirements (consistent with 21 U.S.C. §360ee(b)(3) and 21 CFR 101.9(j)(8)).

Pediatric coverage: For individuals under 21 years, tube feeding (standard or Specialized Nutrient Formula) is medically necessary when InterQual® CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy criteria are met (policy aligns pediatric tube-feeding determinations with InterQual).

Adult coverage: This policy defers to state-specific TennCare regulations for adults (≥ 21 years); medical necessity clinical coverage criteria and exclusions for enteral nutrition in adults are governed by TennCare Medicaid Chapter 1200-13.13-.10.

Evidence	Summary
PAH/Phenylketonuria review	Systematic review (Adams et al. 2023) found lower phenylalanine (PHE) consistently associated with better outcomes; achieving PHE ≤ 360 μmol/L before conception substantially lowered offspring risk (OR 0.07; 95% CI 0.04–0.14).
PKU dietary RCT evidence	Randomized and crossover trials show amino acid (AA)-based and glycomacropeptide (GMP) medical foods help control blood PHE and support neurodevelopment; evidence on optimal dosing is limited (small RCTs, variable duration).
EoE efficacy	Meta-analysis (Arias et al. 2014) found amino acid-based elemental diets effective in ~90.8% of EoE cases for histologic remission (<15 eos/HPF).
Crohn disease diet RCT	Levine et al. (2019) RCT: Crohn disease exclusion diet (CDED) plus partial enteral nutrition was better tolerated than exclusive enteral nutrition (EEN) and induced sustained corticosteroid-free remission at 12 weeks (75.6% vs 45.1%; p=0.01).
Elemental diet efficacy (meta-analysis)	Amino acid-based elemental formulas shown effective in 90.8% of EoE cases in a systematic review/meta-analysis (Arias et al. 2014).
Six-food elimination diet efficacy (meta-analysis)	Meta-analysis (Arias et al. 2014) reported combined efficacy of six-food elimination diets of 72.1% for inducing histologic remission in EoE.
Protein-enriched enteral diet RCT (critically ill children)	Prospective RCT (Botrán et al. 2011) in critically ill children: protein-enriched enteral diet improved biochemical protein markers; differences significant only for retinol-binding protein; safe and well tolerated.

Definitions

Term	Definition
Medical Food	A specially formulated product intended for the dietary management of a disease under medical supervision; must be used enterally and labeled for medical use per 21 U.S.C. §360ee(b)(3) and 21 CFR 101.9(j)(8); intended to be used under physician supervision and for patients receiving active ongoing medical care.
Specialized Nutrient Formula	Formula produced to meet unique nutrient needs for specific disease conditions; designed for individuals requiring specific dietary components or altered nutrient composition due to metabolic, digestive, or disease-related needs.
Inborn Errors of Metabolism	Group of disorders that cause a block in a metabolic pathway leading to clinically significant consequences (examples: phenylketonuria, maple syrup urine disease, homocystinuria, methylmalonic acidemia, propionic acidemia, isovaleric acidemia, other leucine metabolism disorders; glutaric aciduria type I; tyrosinemia types I and II; urea cycle disorders).
Intellectual Disability	A neurodevelopmental disorder characterized by deficits in both intellectual functioning and adaptive functioning, with onset in the developmental period.
Medical food	A food formulated to be consumed or administered enterally under physician supervision for specific dietary management of a disease with distinctive nutritional requirements (21 U.S.C. 360ee(b)(3)); specially formulated and processed for partial or exclusive feeding and intended to provide nutritional support modified for the unique nutrient needs of the disease.

Revision History

unknownrevised

Policy version archived: previous policy version CS136TN.O; Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.