ModifiedUnitedHealthcarePolicy CS136TN.O

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

Defines medical necessity, coverage criteria, and coding guidance for enteral nutrition (oral and tube feeding) for Tennessee Medicaid and CoverKids populations; includes separate criteria for individuals under 21 and references TennCare exclusions for adults.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS136TN.O

Change TypeModified — state-specific adult exclusions removedtube-feeding language clarified

Effective DateMarch 1, 2026

Next Review DateN/A

Key ActionFor individuals under 21, obtain prior authorization demonstrating InterQual clinical criteria are met for tube feeding or specialized oral formulas.

SourceLink

POLICY UPDATE CHANGES

Replaced language to explicitly include 'standard or Specialized Nutrient Formula' administered by tube feeding as medically necessary in certain circumstances.

Removed state-specific coverage guidelines for enteral nutrition administered by tube feeding for adults.

Removed state-specific coverage statement for oral nutrition for adults (age 21 and older).

Updated references/supporting information to reflect most current literature and guidance.

TNTennessee-only

B4xxx/S943xCodes listed

Refer TennCare

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.

≤360 μmol/LPKU target

Coverage Criteria

Enteral Nutrition by Tube Feeding (Individuals under 21)

Covered when criteria per InterQual CP are met:

Tube feeding (pediatric): Enteral nutrition (standard or Specialized Nutrient Formula) administered via tube (nasogastric, gastrostomy, or jejunostomy) is medically necessary in certain circumstances when the InterQual CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy criteria are satisfied.

Standard formula may be considered medically necessary for tube feeding when standard foods cannot be administered through a tube.

Examples of covered clinical indications

Covered when clinical indication and supporting documentation are present (examples from the document):

Inborn errors of metabolism: Enteral medical foods or elemental/amino-acid formulas are covered for management of PAH deficiency/PKU and other inborn errors when used to achieve target metabolic control (e.g., Phe goal ≤ 360 μmol/L) or when immediate dietary restriction is clinically indicated (for example, suspected classical galactosemia in an infant).Phe ≤ 360 μmol/L

Guideline-based monitoring and dietitian involvement recommended

Pediatric chronic kidney disease: Enteral nutrition (supplemental or tube feeding) may be covered for infants/children with CKD and growth deficits when energy and protein needs cannot be met orally; documentation should include growth parameters and a nutrition plan and consider renal-specific specialized formulas and dietitian oversight.Documented inadequate intake and growth deficit

Follow pediatric renal nutrition guidance (e.g., AAP/KDOQI) for targets and monitoring

Severe food allergies and EoE: Amino acid-based (elemental) formulas are supported for infants/children with severe non-IgE–mediated food allergies, eosinophilic esophagitis, or when extensively hydrolyzed formulas fail; evidence shows high efficacy for inducing remission in EoE (~90.8%).Used when symptoms do not resolve on hydrolyzed formulas or in severe presentations such as failure to thrive

Multidisciplinary management and dietitian involvement recommended

Cystic fibrosis with malabsorption/growth deficits: Oral or enteral nutritional supplements (including tube feeding) are recommended for children with CF and growth or weight deficits to improve weight gain; coverage may require demonstration of growth deficit and prior nutritional interventions and alignment with CF Foundation nutrition and PERT guidance.Use alongside appropriate PERT dosing per CF Foundation guidance

Document growth response and dietitian involvement

Coverage rationale and directive

Coverage supported when enteral nutrition (standard or specialized formulas) is used for documented malnutrition, disease-specific nutrition needs, or other supported indications:

Guideline-supported indications: Use of elemental diets, empiric elimination diets, allergy testing–based elimination diets, oral nutritional supplements, or home enteral nutrition is supported by cited guidelines (AGA for EoE; CF Foundation for cystic fibrosis; ESPEN/Academy/ASPEN for HEN and enteral nutrition) for patients who are malnourished, at risk of malnutrition, or have disease-specific nutritional requirements.

Refer to condition-specific guideline recommendations for diagnostic thresholds and monitoring.

Tube feeding formulas: Enteral nutrition administered by tube feeding using standard formula or Specialized Nutrient Formula is medically necessary in certain circumstances; standard formula may be used when standard foods cannot be administered through a tube.

Policy revised to explicitly include standard formula via tube feeding.

State-specific adult criteria: Coverage determinations for adults (age ≥21) are governed by TennCare Medicaid Chapter 1200-13-.13-.10: Exclusions for medical necessity clinical coverage criteria; prior state-specific coverage statements were removed and reviewers should reference TennCare rules for adult coverage and exclusions.

For adults (age 21 and older), medical necessity clinical coverage criteria for oral nutrition and enteral nutrition administered by tube feeding are determined by TennCare Medicaid, Chapter 1200-13-.13-.10. Refer to TennCare for specific exclusions and for determination of coverage for standard oral formulas and other oral nutrition products for members ≥21. See the Benefit Considerations section for examples of items that are generally not covered when criteria are not met.

The evidence base evaluating the optimal timing or degree for relaxing lifelong phenylalanine (Phe) restriction is limited. A systematic review identified few high-quality randomized trials and concluded that, while nonrandomized data support benefit of a low‑Phe diet for reducing blood Phe and improving neurocognitive outcomes, there is insufficient evidence to define precise Phe thresholds or when a restricted diet may safely be relaxed; further large, well‑designed RCTs are needed.

This policy removed prior Tennessee-specific coverage statements for adults and now directs users to consult TennCare Medicaid, Chapter 1200-13-.13-.10 for medical necessity clinical coverage criteria and exclusions applicable to members age 21 and older.

Benefit Considerations list examples of items that are generally not covered when criteria are not met, including specialized formulas and standard oral formulas for oral intake (if state criteria are not satisfied), self‑blenderized formulas for oral intake, commercial food thickeners, enteral formula additives for oral intake, and electrolyte‑containing fluids used to replace fluids/electrolytes.

Relaxing or stopping a low‑phenylalanine diet in older individuals without documented medical monitoring and evidence that blood Phe levels are within a safe range is not supported by the available high‑quality randomized trial evidence and therefore is not recommended without individualized clinical justification and monitoring.

Previous state‑specific oral nutrition coverage statements for adults were removed in this revision. Providers must consult TennCare Medicaid, Chapter 1200-13-.13-.10 for the adult exclusions that now govern coverage determinations for oral liquid nutrition and related products.

Coding and Billing Guidance

Applicable HCPCS codes for enteral formulas and medical foodsHCPCS

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, 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.

1–10 of 20

1/2

inv-12: Billing unit thresholds — Examples

Billing unit — B41xx adult fluid/electrolyte formulas500 ml = 1 unit for specified B41xx enteral formula codes (e.g., B4102)

Billing unit — B41xx pediatric fluid/electrolyte formulas500 ml = 1 unit for specified pediatric B41xx codes (e.g., B4103)

Billing unit — Most B41xx complete formulas100 calories = 1 unit for many B41xx enteral formula codes (e.g., B4150, B4152, B4157, B4158, B4159, B4160, B4161, B4162)

Billing unit — Blenderized and modular formulasBlenderized natural food formulas (B4149) and modular nutrients billed per 100 calories = 1 unit where specified

inv-13: Phenylalanine target

Phenylalanine target

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization may be required and is tied to clinical criteria. For individuals under 21, enteral nutrition (standard or Specialized Nutrient Formula) administered by tube feeding is medically necessary only when InterQual® CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy clinical criteria are met. Check federal, state, and contractual benefit requirements before submitting a request.

Prior authorization: verify plan/federal/state/contractual requirements
Use InterQual® criteria for pediatric (<21) tube feeding medical necessity
Document how criteria are met in the PA submission

Documentation Required

Enteral Nutrition for Pediatric CKD and CF — Documentation Expectations

For pediatric patients with chronic kidney disease (CKD) or cystic fibrosis (CF), supplemental enteral nutrition may be covered to address growth deficits. Coverage requires documentation that nutrition goals are unmet with regular dietary intake and that a qualified renal or CF dietitian is involved in the plan of care.

Background

Enteral nutrition delivers nutrition via the gastrointestinal tract and may be provided orally as specialized nutritional formulas or as tube feeding via nasogastric, gastrostomy, or jejunostomy access. Formulas include standard formulas and Specialized Nutrient Formulas/Medical Foods, which are specially formulated to meet the nutritional requirements of specific diseases or metabolic conditions and are intended to be used under medical supervision when ordinary diet cannot meet needs.

Definitions

inv-28: Medical Food

Definition (Medical Food)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; intended for use under ongoing medical supervision (21 CFR 101.9(j)(8)).

PurposeProvides nutritional support specifically modified for management of unique nutrient needs that cannot be met by modifying the normal diet alone.

Formulation and useSpecially formulated and processed product for partial or exclusive feeding by oral intake or enteral tube; typically provided through medical channels.

inv-29: Specialized Nutrient Formula

DefinitionSpecialized Nutrient Formula: formula produced to meet unique nutrient needs for specific disease conditions.

Intended use

Medical Necessity

DME medical necessity examples

Examples of DME medical necessity derived from guidelines and trial evidence:

Galactosemia (infants): Immediate initiation of a galactose-restricted diet (e.g., soy-based, casein hydrolysate, or elemental formula) is medically necessary when classical galactosemia is suspected in an infant; do not wait for diagnostic confirmation.Clinical suspicion in infants

Recommendation per GalNet guidelines; document rationale and prompt initiation.

EoE and severe allergy indications: Amino acid–based elemental formula is medically necessary for induction of remission in eosinophilic esophagitis and for severe non-IgE–mediated food allergies or failure of hydrolyzed formula, particularly in patients with failure to thrive; evidence demonstrates high efficacy (~90.8%) for EoE remission with elemental diets.Failure of hydrolyzed formula or severe clinical presentation

Document prior dietary trials and dietitian involvement.

Rental & Purchase Rules

Procedure / HCPCS Code	Description	Rental vs Purchase Rule
B4100
Food thickener, administered orally, per oz.
Not specified in this policy; follow federal, state, or contractual benefit plan terms and applicable UnitedHealthcare DME purchasing/rental rules.

Item	Representative HCPCS Code(s)	Purchase Rule / Notes
Enteral formula, adult (fluid replacement/electrolytes)
B4102
Consumable — billed per unit (policy examples: 500 ml = 1 unit for some B41xx codes); purchase of supply (not rental).

Topic	Policy Statement / Instruction	Action
Rental vs Purchase rules
The document segment does not specify explicit rental versus purchase rules for enteral equipment or supplies. Applicable procedure and billing codes are listed for reference.
Follow standard UnitedHealthcare DME policy, federal/state/contractual benefit terms, and applicable billing guidance when determining rental or purchase treatment.

Replacement and Supplies

inv-40: Replacement

Replacement policy — general placeholderReplacement rules referenced by policy: follow applicable billing/code lists and UnitedHealthcare DME policy; specific replacement intervals not specified in this document excerpt.

Consumeable suppliesEnteral formulas are consumable supplies and are billed per prescription and applicable HCPCS/unit thresholds rather than durable replacement rules.

Policy instructionFollow standard UnitedHealthcare DME policy and contractual terms for rental/purchase and replacement determinations where not specified herein.

inv-41: Enteral feeding supplies (tubes, pumps) and consumables

Replacement interval guidanceEnteral feeding supplies (tubes, pumps) and consumables: replace as clinically indicated based on clinical need and device condition.

Documentation

Documentation Requirements

Documentation Required

Prescriber signature and statement of medical necessity and supervision

Ensure prescriptions specify the appropriate prescriber and state that the Medical Food or enteral formula is medically necessary and is to be used under medical supervision; include clinical rationale in the prescription or accompanying documentation.

Include clinical indication, expected duration, and monitoring plan with the prescription.
Attach dietitian or prescriber notes supporting medical necessity.

Documentation Required

Submit anthropometrics, labs, intake records, and dietitian notes for review

For coverage review, submit anthropometrics, clinical signs/symptoms, documented nutrient intake, laboratory indexes of metabolic control or nutrition adequacy, and dietitian/nutritionist notes to support medical necessity determinations.

Provide baseline and serial measurements where available (weight, height, z‑scores, growth velocity).
Include lab results relevant to metabolic control (e.g., phe levels) and dietitian assessments.

Not Covered / Exclusions

The policy lists several items as not covered when criteria are not met, including self‑blenderized formulas for oral intake, commercial food thickeners, enteral formula additives for oral intake, and examples of electrolyte‑containing fluids used to replace fluids and electrolytes.

Dietary relaxation strategies for phenylketonuria (PKU) or other PAH‑deficiency management that lack documented monitoring or evidence that blood phenylalanine is maintained at safe levels are not supported by the available randomized trial data and therefore are considered not medically necessary without appropriate monitoring and documentation.

Specific exclusions established by TennCare Medicaid, Chapter 1200-13-.13-.10 apply for adults. This policy intentionally removed prior state‑specific coverage rules and defers to TennCare for adult exclusions and medical necessity determinations.

Revision History

2026-03-01policy_revisionLatest

Revised coverage rationale to explicitly state that enteral nutrition (standard or Specialized Nutrient Formula) administered by tube feeding is medically necessary in certain circumstances and added that standard formula may be considered medically necessary when standard foods cannot be administered through a tube; removed prior state-specific coverage guidelines and updated instructions to refer to TennCare Medicaid Chapter 1200-13-.13-.10 for adult (age ≥21) clinical coverage criteria; archived prior policy version CS136TN.N.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS136TN.O

Change TypeModified — state-specific adult exclusions removedtube-feeding language clarified

Effective DateMarch 1, 2026

Next Review DateN/A

Key ActionFor individuals under 21, obtain prior authorization demonstrating InterQual clinical criteria are met for tube feeding or specialized oral formulas.

SourceLink

On This Page

Operational direction to reference TennCare rules.

Goal: ≤ 360 μmol/L (association with improved outcomes; preconception target linked to substantially lower offspring risk)

Evidence summaryLower Phe consistently associated with better neurologic/physiologic outcomes in PAH deficiency (systematic review of 350 studies)

Clinical implicationDietary or pharmacologic interventions aiming to reduce Phe to ≤ 360 μmol/L considered effective per cited review

inv-14: Protein substitute dose (reference)

Reference protein substitute doseUK MRC guideline reference: maintain children >2 years on protein substitute dose of 2 g/kg/day

Study findingRandomized crossover trial (MacDonald et al., 2006) showed higher protein substitute dose associated with lower blood Phe concentrations

Clinical noteDose of 2 g/kg/day used as benchmark in guideline-derived management and trials comparing lower vs higher doses

Document growth parameters (weight, length/height, BMI, growth velocity) and target goals
Provide evidence of dietitian involvement and specific nutrition prescription (calories, protein, formula type, route)
Include prior attempts at oral/behavioral interventions when applicable and rationale for enteral supplementation or tube feeding

Prior Authorization

Prior Authorization and Decision Tools

UnitedHealthcare may require use of third-party decision support tools (e.g., InterQual®) and will follow federal, state, and contractual rules when determining coverage. Always confirm tool usage requirements and supply the tool output or supporting documentation with the authorization request.

If InterQual® is used, include the InterQual® determination or relevant sections in the PA file
Follow any plan-specific submission templates or decision-tool outputs required by the contract

Documentation Required

Immediate Diet Initiation for Suspected Galactosemia

If classical galactosemia is suspected in an infant, clinicians should immediately commence a galactose-restricted diet without waiting for diagnostic confirmation. Document the clinical suspicion, diet initiated (e.g., soy-based, casein hydrolysate, or elemental formula), and communication with the payer in the patient record and authorization materials.

Record date/time of suspicion and diet initiation in the medical record
Include rationale for immediate diet change and planned confirmatory testing in PA documentation

Denial Risk

State Exclusions Referenced

State-specific exclusions apply for adults. For Tennessee (TennCare) reference Chapter 1200-13-.13-.10 for exclusions related to enteral nutrition (tube feeding) and oral liquid nutrition. Failure to follow state-specific rules may result in denial for members age 21 and older.

Adults (≥21): follow TennCare Chapter 1200-13-.13-.10 for medical necessity and exclusions
Include state/contract identifiers on the PA to ensure correct rule set is applied

Documentation Required

Prescriber and Supervision Requirements

Prescriptions and medical foods must be ordered and supervised by an appropriate clinician. Medical Foods are intended to be used under supervision and enteral nutrition therapies should be prescribed by a physician, advanced practice provider, or registered dietitian as applicable.

Prescriber: physician or advanced practitioner; dietitian involvement recommended for nutrition planning
Medical Foods: must be ordered and used under physician supervision

Documentation Required

Nutrition Monitoring and Dietitian Involvement

Ongoing nutrition monitoring and documented dietitian involvement are expected for both initiation and continuation of enteral or specialized oral nutrition. Monitoring should include anthropometrics, intake assessment, relevant laboratory studies, and clinical signs of tolerance or efficacy.

Provide baseline and follow-up anthropometrics, intake records, and labs in continuation PA requests
Document dietitian visits and nutrition plan adjustments (frequency, calories, formula composition)

Documentation Required

Documentation and Governing Rules

All documentation submitted for authorization or claims should align with governing rules and cited state guidance. Refer to TennCare Chapter 1200-13-.13-.10 where specified and include applicable clinical notes, growth data, dietitian assessments, and decision-tool outputs.

Include clinical notes, measurement data, dietitian assessment, and tool outputs (e.g., InterQual®) as applicable
Cite the governing state or contractual rule that applies to the member

Step Therapy

Crohn's Disease Dietary Therapy Sequencing

For pediatric Crohn's disease, evidence supports use of combined dietary approaches. A trial of Crohn's Disease Exclusion Diet (CDED) plus partial enteral nutrition or Exclusive Enteral Nutrition (EEN) for induction is supported by clinical studies and may be considered prior to other therapies when clinically appropriate. Document tolerance, regimen details, and response when requesting coverage.

Document which regimen was used (CDED + partial EN vs EEN), duration, formula used, and clinical response time points
Include reasons for selecting dietary induction (e.g., mild–moderate disease, desire to avoid steroids)

Note

Guideline-Recommended Sequencing

Follow guideline-recommended sequencing when applicable: trials of elemental/elemental-like diets, elimination diets, or enteral nutrition are recommended by specialty societies (AGA, CF Foundation, ESPEN, AGA/JTF) depending on the condition. Provide documentation of guideline-based clinical decision-making in the authorization request.

Reference relevant guideline(s) in the clinical rationale for therapy selection
Document prior appropriate dietary trials and outcomes when seeking coverages based on sequencing

Designed for disease-specific nutrient composition when ordinary diets are insufficient.

Examples in policyIncludes formulas for special metabolic needs and for inherited metabolic disorders (see B4154, B4157, B4162 descriptions).

inv-30: Inborn Errors of Metabolism

DefinitionInborn Errors of Metabolism: a group of disorders causing blockages in metabolic pathways (examples: phenylketonuria (PKU), maple syrup urine disease, urea cycle disorders).

Clinical consequenceCan lead to clinically significant metabolic derangements requiring disease-specific dietary management.

Management implicationMay require Medical Foods or specialized enteral formulas to meet distinctive nutritional needs.

inv-31: PAH deficiency / Phenylketonuria (PKU)

Condition descriptionPAH deficiency / Phenylketonuria (PKU): biallelic pathogenic variants in PAH causing elevated serum phenylalanine that can impair neurodevelopment.

ManagementManaged with low-phenylalanine diets, Medical Foods, protein substitutes, and pharmacologic Phe-lowering treatments; monitoring of blood Phe is required.

Treatment targetPolicy cites target Phe ≤ 360 μmol/L associated with improved outcomes and reduced offspring risk when achieved preconception.

inv-32: Elemental (amino acid-based) formula

Definition and compositionElemental (amino acid-based) formula: an amino acid–based enteral formula used for severe food allergies and eosinophilic esophagitis (EoE).

Efficacy evidenceSystematic review/meta-analysis (Arias et al.) reported ~90.8% effectiveness of amino acid–based elemental formulas in inducing remission of EoE.

Clinical roleUsed when extensively hydrolyzed formulas fail or in severe non–IgE-mediated food allergy presentations and for induction of remission in EoE.

inv-33: Medical food (alternate entry)

Alternate Medical Food entryA food formulated to be consumed or administered enterally under physician supervision for dietary management of a disease with distinctive nutritional requirements; regulated as a food (not a drug) and intended for use under medical supervision.

Key attributesSpecially formulated and processed, labeled for the dietary management of a medical disorder, and intended to be used under medical supervision.

Regulatory noteMedical foods are not drugs and are subject to FDA food regulations; manufacturers must comply with applicable FDA requirements.

CKD with growth deficits: Enteral supplementation or tube feeding is medically necessary when energy and protein requirements cannot be met orally to support growth in children with CKD; documentation should include inadequate intake, growth parameters, and planned nutrition regimen consistent with pediatric renal nutrition guidance.Documented inadequate intake and growth deficit

Consider KDOQI/AAP recommendations for targets and monitoring.

Replacement or re-supply should be supported by clinical documentation demonstrating ongoing need (prescription, monitoring notes).

Billing implicationConsumable items (formulas) are billed per use/prescription; durable feeding equipment follow standard DME rules for replacement/rental per plan terms.

inv-42: Replacement

Additional replacement rules — placeholderWhere explicit replacement intervals are not provided in this policy excerpt, providers must refer to UnitedHealthcare DME replacement/rental policies and contractual terms.

Adjudication noteLack of specified interval in this document does not change applicability of federal/state/contractual coverage rules; reviewers should consult plan terms.

Clinical discretionClinical indication and device condition guide replacement decisions when policy is silent; document rationale in the medical record.

Documentation Required

Align medical necessity documentation with state rules and InterQual when requested

When UnitedHealthcare or reviewers request medical necessity support, align documentation with applicable federal, state, or contractual benefit plan terms and be prepared to reference InterQual® or other utilized decision tools; documentation should clearly support the requested service per those criteria.

Reference the specific decision tool or TennCare rule used to support the request.
Provide evidence demonstrating how the member meets the cited criteria.