UnitedHealthcare Enteral Nutrition Coverage Update

Coverage Criteria

General Medical Necessity

Covered when ALL of the following are met

Enteral Nutrition Medical Necessity: Beneficiary has medical documentation (e.g., hospital records, clinical findings) supporting a permanently inoperative internal body organ or function that prevents absorption of sufficient nutrients to maintain weight and strength commensurate with the beneficiary's general condition.permanent >1 month

For purposes of this policy, 'permanent' means an indefinite period of more than one month (see definitions).

Exclusion for temporary or convenience feeding: Enteral nutritional therapy is not approved for temporary impairments or for convenience feeding via gastrostomy.

Requests for temporary needs are considered not medically necessary under this policy.

Economical product requirement: Enteral feedings must be the most economical package equivalent in calories and ingredient content to the beneficiary's needs; physician must document reason for prescribing a particular formula.

Approved requests will be reviewed at intervals not to exceed six months; Medicaid pays for no more than one month's supply at a time.

Prescription Thresholds

Covered when ALL of the following prescription-related criteria are met

Caloric prescription threshold: Prescribed enteral feedings average at least 750 calories per day over the prescribed period and constitute at least 70% of the daily caloric intake.>=750 kcal/day and >=70% of intake

Coverage of prescribed feedings of less than an average of 750 calories per day may be considered only with additional physician documentation and justification.

Prescription documentation requirements: Request includes product name or nutrient category; number of calories prescribed per day (100 calories = 1 unit) and whether this constitutes >=70% of daily intake; frequency of administration per day; method of administration (oral or, if tube, syringe, gravity, or pump fed); route of tube feed (e.g., nasogastric, jejunostomy, gastrostomy, percutaneous enteral gastrostomy, naso-intestinal); and reason for use of a pump if prescribed.

Physician must document the reason for prescribing a specific formula, including beneficiary diagnoses.

Review and supply limits:

Inborn Errors of Metabolism

Covered when ANY of the following apply for inborn errors of metabolism

Diagnosed inborn error of metabolism: Beneficiary has a diagnosis of an inborn error of metabolism made by a physician board certified in medical genetics or by an advanced practice registered nurse collaborating with, or a physician assistant supervised by, a physician board certified in medical genetics.

When criteria met, enteral formulas are covered without prior authorization.

Suspected inborn error of metabolism pending evaluation: Beneficiary is suspected of having an inborn error of metabolism and an enteral formula is needed pending definitive evaluation to prevent morbidity; in this case the formula does not need to be ordered by a specialist.

The Genetic Disease program must maintain a completed Request for Enteral Formula for Inborn Errors of Metabolism order form signed and dated by the ordering provider in the beneficiary's record; claims are subject to post-payment review and possible recoupment for non-compliance.

Enteral nutritional therapy will not be approved for temporary impairments or for convenience feeding via gastrostomy.

Baby food and other regular grocery products that can be used with an enteral system are not covered under this policy.

Enteral therapy for temporary impairments is considered not medically necessary under this policy and therefore is not eligible for coverage.

Coding and Prescription Thresholds

Applicable HCPCS Codes (group 1)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.

Applicable HCPCS Codes (group 2)HCPCS

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.
B4157	Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
B4158	Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit.
B4159	Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit.
B4160	Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 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.
B4161	Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
B4162	Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.

Applicable S-codes / Medical FoodsHCPCS

S9432	Medical foods for noninborn errors of metabolism.
S9433	Medical food nutritionally complete, administered orally, providing 100% of nutritional intake.
S9434	Modified solid food supplements for inborn errors of metabolism.
S9435	Medical foods for inborn errors of metabolism.

Enteral caloric prescription threshold

Minimum average calories per dayPrescriptions must average at least 750 calories per day over the prescribed period.

Share of daily intakePrescribed enteral feedings must constitute at least 70% of the beneficiary's daily caloric intake.

Unit conversion for billing100 calories equals one unit for many HCPCS B-codes (used for quantity calculations).

Coverage exception for lower caloriesCoverage of prescribed feedings <750 kcal/day may be considered only with additional physician documentation justifying the lower amount.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization and Coverage Overview

Enteral formula coverage may require prior authorization except for metabolic formulas meeting the criteria below. Requests should include complete clinical and prescription documentation. Enteral feedings must be the most economical package equivalent in calories and ingredient content; the ordering physician must document the reason for prescribing a specific formula and the beneficiary's diagnoses. Prescriptions should average at least 750 calories per day and constitute at least 70% of the beneficiary's daily caloric intake; requests that do not meet these thresholds may be denied or require additional physician justification. Enteral nutritional therapy will not be approved for temporary impairments or for convenience feeding via gastrostomy.

Enteral feedings must be the most economical package equivalent in calories and ingredient content.
Physician must document reason for specific formula and beneficiary diagnoses.
Prescriptions should average >= 750 calories/day and represent >= 70% of daily caloric intake.
Temporary impairments or convenience gastrostomy feeding are excluded from coverage.

Background

Enteral nutrition provides nutritional support orally or via feeding tube when beneficiaries cannot absorb or intake sufficient nutrients to maintain weight and strength appropriate for their condition. Medical documentation must support a permanently inoperative internal body organ or function (defined here as an indefinite period of more than one month) to meet medical necessity for ongoing enteral therapy.

Definitions

Permanent (for purposes of policy)

Policy definition of 'permanent'An indefinite period of more than one month.

Context for eligibilityUsed to distinguish chronic needs from temporary impairments when determining medical necessity for enteral nutrition.

Implication for approvalsEnteral nutritional therapy for conditions lasting one month or less is considered temporary and generally not approved under this policy.

Medical food

DefinitionA medical food is a product formulated to be consumed or administered enterally under the supervision of a physician for the specific dietary management of a disease or condition with distinctive nutritional requirements.

Regulatory noteMedical foods are not drugs and are regulated as foods; manufacturers must comply with applicable FDA food requirements.

OpenPayer

Enteral Nutrition (Louisiana Medicaid)

Coverage Criteria

Coding and Prescription Thresholds

Provider Actions and Documentation Requirements

Background

Definitions