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Coverage criteria policies

Nutritional support - Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

For pediatric feeding and oral function speech therapy, please refer to the Feeding/oral function therapy, pediatric coverage policy

For medical nutrition therapy, including diabetic outpatient self-management and weight management, please refer to the Nutrition (medical) therapy- Minnesota Health Care Programs coverage policy

For fluoride, folic acid, iron, or vitamin D supplements, please refer to the Preventive care services coverage policy.

For Amino Acid-Based Elemental Formula, please refer to the Formula - amino acid-based elemental – Minnesota Health Care Programs policy

Prior authorization is required for:

Formula or nutritional supplements taken orally or via feeding tube

Prior authorization is not required for:

  • Supplies related to the administration of covered nutritional therapy given via feeding tube
  • Parenteral nutrition and related supplies. Parenteral nutrition refers to nutrition that is brought into the body through some way other than the digestive tract. Products and supplies are covered when ordered by a medical practitioner for use with total parenteral nutrition (given through the veins), intradialytic parenteral nutrition (given during hemodialysis), or intraperitoneal dialysis nutrition (given during peritoneal dialysis).
  • Oral nutritional therapy (including formula and medical foods) or nutritional therapy given via feeding tube for members diagnosed with inborn errors of metabolism.

Coverage

Formula and / or nutritional supplements are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. Nutrition for Members with Feeding Tubes - Enteral nutritional products are covered for members with feeding tubes.
  2. Oral Nutrition for Members with Inborn Errors of Metabolism - Enteral nutritional products are covered for members with many inborn errors of metabolism. Oral enteral nutritional products manufactured for the treatment of inborn errors of metabolism in addition to PKU, MSUD and hyperlysinemia are covered if the member has the associated diagnosis.
  3. Oral Nutrition for Members with Allergies - Oral enteral nutritional products are covered if the member has a combined allergy to cow’s milk, human milk, and soy milk which is supported by appropriate medical testing and documentation. It is expected that the need for oral enteral nutritional products will decrease as the member ages and additional foods are added to the diet. If the member gets less than 75% of daily nutrition from a nutritionally complete enteral nutrition product, there should be a detailed plan to decrease dependence on the supplement. The plan may be written by a nutritionist, a speech-language pathologist or a physician.
  4. Oral Nutrition for Members Who Cannot Properly Absorb Solid Food or Nutrients - Enteral nutritional products are medically necessary if the member has a medical condition which causes an inability to absorb adequate nutrients, and which has led to weight loss. Oral enteral nutritional products are covered if the member meets criteria. Documentation must establish all of the following:
    1. The member has a diagnosed medical condition such as, but not limited to:
      1. Mechanical inability to chew or swallow solid or pureed/blenderized foods
      2. Malabsorption problem due to disease or infection
      3. Oral aversion which significantly limits the ability to get adequate nutrition through solid or pureed/blenderized foods
      4. Weaning from TPN or feeding tube
    2. The medical condition leads to inability to consume or absorb adequate nutrients
    3. The member has experienced significant weight loss over the past 6 months or, for children under age 21, has experienced significantly less than expected weight gain
    4. If the member gets less than 75% of daily nutrition from a nutritionally complete enteral nutrition product, there should be a detailed plan to decrease dependence on the supplement. The plan may be written by a nutritionist, a speech-language pathologist or a physician.
  5. Oral Nutrition for Members with Non-Healing Wounds - High protein enteral nutritional products are covered for up to six months if the member has one or more wounds that have not responded to treatment for at least 30 days, and a dietary assessment has determined that the member has a nutritional deficit which may be impeding healing. Documentation must include a nutritional plan which is written by a nutritionist, physician or other health care provider.
  6. Food thickeners – Food thickeners (Simply Thick, Thicken-It) are covered for members over age one at risk of choking or aspirating liquids.
  7. Supplies related to the administration of covered nutritional therapy given via tube - are covered per the benefits outlined in your plan documents. Feeding Pumps are covered for members with feeding tubes for whom gravity or syringe feeding is not appropriate.
Documentation Requirements

The following information should be submitted for authorization of enteral nutritional products: (See related content for Medical Necessity form).

  1. Date of medical provider’s order and estimated duration of therapy;
  2. Diagnoses that relate to the need for nutritional product;
  3. Product requested;
  4. Route of administration;
  5. Total calories needed per day;
  6. Total calories from enteral products per day;
  7. Total calories from other ingested foods and liquids per day;
  8. Height, weight, targeted weight;
  9. Other therapy/treatment that may justify the need for the nutritional product.

Indications that are not covered

  1. Nutritional products for healthy newborns.
  2. Nutritional products for persons living in Skilled Nursing or Long Term Care facilities (included in the per diem cost of the facility).
  3. Nutritional products for which the need is nutritional rather than medical or is related to an unwillingness to consume solid or pureed foods.
  4. Nutritional products that are requested as a convenient alternative to preparing/consuming regular foods
  5. Nutritional products for which coverage is requested because of an inability to afford regular foods or supplements (refer member to county human services)
  6. Food thickeners for persons living in Skilled Nursing or Long Term Care facilities (included in the per diem).
  7. Food thickeners for infants under age one who were born at less than 37 weeks gestation, due to FDA caution.
  8. SimplyThick brand thickener for infants under age one, regardless of gestational age at birth, is not covered due to FDA caution.
  9. Energy drinks.
  10. Sport shakes.

Definitions

Hemodialysis is a process by which waste products and water are removed from the blood in a person whose kidneys are not properly functioning.

Enteral nutrition is nutritional support given via any route connected to the gastrointestinal system (i.e., the enteral route). This includes oral feeding, sip feeding, and tube feeding using nasogastric, gastrostomy, and jejunostomy tubes.

Formula or nutritional supplement: a commercially formulated substance that provides nourishment and affects the nutritive and metabolic processes of the body.

Inborn errors of metabolism are genetic disorders in which the body cannot properly turn food into energy. The disorders are usually caused by defects in specific proteins (enzymes) that help break down (metabolize) parts of food

Parenteral nutrition (also referred to as total parenteral nutrition or TPN) is nutritional support given by via a route other than the gastrointestinal system. An example would be nutrition given through the veins.

Peritoneal dialysis is a process by which waster products and water are removed from the body via the abdominal area in a person whose kidneys are not properly functioning.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

    Codes

    Description

    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

    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

    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

    B4100

    Food thickener, administered orally, per oz.

    S9435

    Medical foods for inborn errors of metabolism

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

  • Items must be received from a contracted vendor or pharmacy for in-network benefits to apply.
  • Full line vendors provide a wide range of equipment and supplies, such as hospital beds, aids for ambulating and toileting, phototherapy lights, wheelchairs, custom seating devices, monitors, pumps, oxygen and etc.

References

Portions of the contents of this policy relating to Minnesota Public Programs medical coverage criteria are taken directly from the Minnesota Health Care Programs Provider Manual at: http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_145320

Refer to the Medical Supply Coverage Guide (PDF) for information about items not specified in this policy. Link in Related Content Section at right