CurrentUnitedHealthcarePolicy CS136PAP

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

UnitedHealthcare medical policy (Pennsylvania only) on enteral nutrition (oral specialized formulas and tube feeding) specifying medical necessity criteria, definitions, applicable HCPCS codes, benefit exclusions/limitations, and clinical evidence references. Applies to requests in Pennsylvania; exceptions evaluated case-by-case per state rules.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS136PAP

Change TypeNo material change

Effective DateAug 1, 2025

Next Review Date

Key ActionTherapy must be prescribed by a physician, advanced practitioner (NP, CNS, or PA), or registered dietician and documentation must show a chronic condition expected to be prolonged with inability to obtain adequate nutrition by dietary adjustment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update

MultipleHCPCS codes referenced

ConditionalOral specialized formula coverage

InterQualTube feeding criteria delegated

Coverage Summary

Policy: UnitedHealthcare Pennsylvania medical policy CS136PAP on Enteral Nutrition (Oral and Tube Feeding), effective August 1, 2025. Scope: applies to Pennsylvania only and will be evaluated per applicable state/contractual rules.

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Coverage stance: Tube feeding (enteral nutrition administered via nasogastric, gastrostomy, or jejunostomy tube) medical necessity determination is delegated to InterQual CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy. Oral Specialized Nutrient Formulas (medical foods) are covered when ALL criteria are met: the condition is chronic and expected to be prolonged; therapy is prescribed by a physician, advanced practitioner (NP, CNS, or PA), or registered dietitian; adequate nutrition cannot be achieved by dietary adjustment; and the individual has one of the listed qualifying conditions (for example, inborn errors of metabolism such as PKU, Crohn's disease, CKD in specified pediatric ages, severe malabsorption syndromes, cystic fibrosis-related needs, malnutrition/failure to thrive, gastroesophageal reflux with failure to thrive in children, or severe food allergies including EoE, FPIAP, and FPIES).

Quick facts

policy_numberCS136PAP

dates.effectiveAugust 1, 2025

scope_summaryUnitedHealthcare medical policy (Pennsylvania only) on enteral nutrition (oral specialized formulas and tube feeding) specifying medical necessity criteria, definitions, applicable HCPCS codes, benefit exclusions/limitations, and clinical evidence references. Applies to requests in Pennsylvania; exceptions evaluated case-by-case per state rules.

coverage_stanceConditional/mixed: Oral specialized formulas covered when specific criteria met; tube feeding medical necessity delegated to InterQual criteria.

stats.HCPCS codes referencedMultiple (B41xx, S9432-S9435)

stats.Oral specialized formula coverageConditional

stats.Tube feeding criteriaDelegated to InterQual

Medical Necessity Criteria

Enteral Nutrition by Tube Feeding (Tube Feeding)

Enteral nutrition administered by tube feeding (e.g., nasogastric; gastrostomy; or jejunostomy tube) is medically necessary in certain circumstances; refer to InterQual CP for medical necessity clinical coverage criteria.

Medical necessity clinical coverage criteria are met per InterQual CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy

Policy delegates tube feeding clinical criteria to InterQual; link provided in original document

Oral Nutrition (Specialized Nutrient Formula administered orally)

Specialized Nutrient Formula administered orally is medically necessary when ALL of the following are met:

Top-level criteria

Prescriber and condition: The condition is chronic and is expected to last for an undetermined or prolonged period of time.
Prescriber and condition: A physician, advanced practitioner (NP, CNS, or PA) or registered dietician prescribes the therapy.
Prescriber and condition: Adequate nutrition is not possible by dietary adjustment.
Individual has one of the following conditions
- Inborn errors of metabolism: Inborn Errors of Metabolism (examples include phenylketonuria (PKU); maple syrup urine disease; homocystinuria; methylmalonic acidemia; propionic acidemia; isovaleric acidemia; other disorders of leucine metabolism; glutaric aciduria type I; tyrosinemia types I and II; urea cycle disorders).
- Crohn's disease.
- Chronic kidney disease (pediatric): Chronic kidney disease (CKD) stages 2 to 5 (or on dialysis) for individuals ages less than 24 months.
- Severe malabsorption syndrome (such as fibrosis, short bowel syndrome, or intestinal failure).
- Cystic fibrosis.
Formula requirement: The formula used is a Medical Food that is specially formulated for a specific condition.