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HealthPartners

Coverage criteria policies

Nutritional support

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

Under many HealthPartners plans, nutritional support is not covered for any indication unless it is mandated by state law or specifically included in the benefit plan document. Please refer to your plan documents for further information.

This policy does not apply to members permanently residing in Skilled Nursing Facilities (SNF). Please refer to the Equipment in Skilled Nursing/ Long Term Care Facility coverage policy.

For dietician consultation, please refer to the Dietician Consultation coverage policy.

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

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

Prior authorization is required for:
  • Amino acid based elemental formula
  • Enteral nutritional therapy
Prior authorization is not required for:
  • Supplies related to the administration of covered enteral nutritional therapy. The following supplies are eligible for coverage when the coverage criteria for enteral nutritional therapy are met:
    • Feeding supply kit
    • Feeding tube anchoring device
    • Feeding tubes
    • Gauze dressings
    • IV pole
    • Syringes (limit of one per day)
    • Tape
  • Parenteral nutrition and related supplies. Parenteral nutrition products and supplies are covered when ordered by a medical practitioner for use with total parenteral nutrition (TPN), intradialytic parenteral nutrition (IDPN), or intraperitoneal dialysis nutrition (IPDN).
  • Oral nutritional therapy (including formula and medical foods) or parenteral nutritional support for inborn errors of metabolism

Coverage

Oral or enteral nutritional therapy is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered for oral nutritional therapy

Oral amino acid-based elemental formula

Oral amino acid-based elemental formulas (AABF) are covered when all of the following criteria are met.

  1. The formula contains 100% free amino acids as the protein source
  2. The member is five years of age or younger
  3. The oral formula is ordered by a physician for a member who has a definitive diagnosis of any of the following conditions:
    1. Immunoglobulin E (IgE)-mediated allergies to food proteins
    2. Food protein-induced enterocolitis syndrome (FPIES)
    3. Eosinophilic esophagitis
    4. Eosinophilic gastroenteritis
    5. Eosinophilic colitis
    6. Amino acid, organic acid, and fatty acid metabolic and malabsorption disorders
    7. Cystic fibrosis
  4. The condition must be diagnosed by an allergist, gastroenterologist, or pediatrician
  5. Documentation must include a description of the member’s symptoms, diagnosis (supported by lab and/or diagnostic test results), and the expected course of treatment with AABF.
  6. Interim coverage may be provided for up to 90 days when requested by a physician while actively seeking diagnosis
  7. For administration of amino acid-based formula via a feeding tube, the coverage criteria for enteral nutritional therapy must also be met.
  8. Requests for coverage of oral AABF in members greater than 5 years of age will be reviewed by a medical director to determine medical necessity. Documentation must clearly explain why the member remains at nutritional risk due to inability to tolerate or adequately absorb food.
Oral nutritional support for members with a diagnosis of an inborn error of metabolism

The following are considered medically necessary when prescribed by physician following a diagnosis of inborn error of metabolism.

  1. Amino-acid based, infant, or oral formula as determined appropriate by the physician.
  2. Pre-packaged medical foods labeled and used for dietary management of inborn errors of metabolism. Please see below for a list of applicable diagnoses.

Indications that are not covered for oral nutrition therapy

  1. Any nutritional formula (commercial or prescribed) other than AABF administered orally.
  2. Oral amino acid-based formula for conditions not listed under Indications that are covered is considered not medically necessary.
  3. For the treatment of conditions listed under Indications that are covered, formulas which do not provide 100% free amino acids as the protein source, including, but not limited to: Casein Hydrolysate formulas with added Amino Acids, (examples include Nutramigen LGG, Enfamil Pregestimil, Similac Alimentum Advance,and Similac Alimentum) ,Hydrolyzed Whey-based formulas (examples include Carnation Good Start and Nestle Peptamen), Modified amino acid formulas, (examples include formulas such as I-Valex and Glutarex), and semi-elemental formulas (such as Vital Jr.).
  4. Pre-packaged medical foods labeled and used for dietary management of any condition other than inborn errors of metabolism are considered not medically necessary.
  5. Food products that are not labeled as medical foods, such as grocery products for low protein, low carbohydrate, ketogenic, lactose-free, or gluten-free diets are considered not medically necessary.

Indications that are covered for enteral nutritional therapy

Enteral nutritional therapy is covered when the following criteria are met.

  1. The member has documented non-function or disease of the pharynx, esophagus, or stomach that prevents nutrients from reaching the small intestine (examples include an anatomic obstruction, a gastrointestinal motility disorder, or small bowel disease); or
  2. The member has central nervous system disease leading to sufficient interference with the neuromuscular coordination of chewing and swallowing such that a risk of aspiration exists; and
  3. The enteral therapy will provide at least 75% of the member’s daily caloric requirements demonstrated through documentation of all of the following:
    1. The member’s daily caloric requirements based on height, weight, and target weight
    2. The total calories to be obtained from enteral formula
    3. The total calories to be obtained from other specified nutritional sources
  4. Adequate nutrition is not possible with dietary adjustments or supplementation with commercially available food products alone
  5. The member has feeding assistance or an ability to comply with the feeding regimen
  6. The member can tolerate tube feedings
  7. The submitted documentation contains both of the following
    1. The name of the requested enteral formula
    2. The expected duration of enteral formula use

Indications that are not covered for enteral nutritional therapy

  1. Enteral formula that will not provide at least 75% of the member’s daily caloric requirements is considered not medically necessary.
  2. Enzyme packed cartridges for enzyme replacement in members receiving enteral nutritional therapy are considered investigational (e.g. RELiZORB).
  3. Baby foods and/or intact, table-food products which are liquefied in a food blender to allow administration through an enteral system are not considered medically necessary.
  4. Supplies for use in administering non-covered enteral nutrition
  5. Syringes above the limit of one per day

The following nutritional support items are considered not medically necessary for either oral or enteral administration

  1. Dietary additives and nutritional supplements to boost caloric or protein intake or supplement a deficient diet. Examples include but are not limited to sport shakes, puddings, and electrolyte supplements.
  2. Vitamin and mineral supplements (except as mandated by United States Preventive Services Task Force and described in the HealthPartners Preventive Care Services policy), including those which require a prescription
  3. Thickening or fiber products
  4. Weight-loss foods and formula, including low-carbohydrate products

Definitions

Amino-acid based formula (AABF), are one of four main classes of oral formula. AABFs contains proteins which are broken down into their simplest and purest form, making them easier for the body to absorb and digest. This is in contrast to regular dairy (milk or soy based) formulas that contain many complete proteins. An infant or child may be placed on an AABF if he/she is unable to digest or tolerate whole proteins found in other formulas, due to certain allergies or gastrointestinal conditions. Vivonex and Tolerex manufactured by Novartis Nutrition, ‘Neocate’ manufactured by Nutricia North America, ‘Elecare’ by Abbott, Nutramigen and PurAmino manufactured by Mead Johnson and ‘E028 Splash’ manufactured by SHS International are examples of 100% amino acid based elemental formulas.

Dietary ingredients are one or any combination of the following: vitamins, minerals, herbs/botanicals, amino acids, concentrates, metabolites, constituents, extracts, dietary substances which increase the total dietary intake

Dietary supplements are products intended for ingestion that contains a dietary ingredient intended to add further nutritional value to the diet.

Enteral nutrition therapy refers to delivery of a nutrient solution to the gastrointestinal (GI) tract by use of a tube which may be placed at different access sites: Through the nose into the stomach (i.e. nasogastric) through the nose into the small bowel (i.e. nasoenteral) , through the skin into the stomach (i.e .gastrostomy) or through the skin into the small bowel (i.e. jejunostomy) via bolus, gravity, or pump controlled infusion.

Enteral formula refers to liquid nutrition in ready-to-use or powdered form intended for use in tube feedings.

Extensively-hydrolyzed formula, also known as predigested formula, is a hypoallergenic, cow’s milk-based formula treated with enzymes to break down most proteins

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. They are classified as follows:

  1. Disorders that result in toxic accumulation
    1. Disorders of protein metabolism (amino acidopathies, organic acidopathies, urea cycle defects). Examples include but are not limited to phenylketonuria (PKU), maple syrup urine disease, homocystinuria, and tyrosinemia.
    2. Disorders of carbohydrate intolerance (examples include but are not limited to galactosemia, glycogen storage disease (types I-VI), and hereditary fructose intolerance
    3. Lysosomal storage disorders (examples include but are not limited to Fabry disease, Gaucher disease, and Pompe disease.
  2. Disorders of energy production, utilization
    1. Fatty acid oxidation defects (examples include but are not limited to include medium-, long-, and very long-chain acyl-CoA dehydrogenase deficiency; trifunctional protein deficiency (types 1 and 2); and carnitine uptake defect).
  3. Disorders of carbohydrate utilization, production
    1. Mitochondrial disorders (examples include but are not limited to mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS); mitochondrial neurogastrointestinal encephalopathy disease (MNGIE); myoclonic epilepsy with ragged-red fibers (MERRF); neuropathy, ataxia, and retinitis pigmentosa (NARP); and pyruvate carboxylase deficiency
    2. Peroxisomal disorders (examples include but are not limited to Zellweger Syndrome Spectrum and adrenoleukodystrophy)

Infant formula is a substitute for breast milk for feeding infants, including powders, concentrated liquids, and ready-to-use formulations.

Medical food The FDA specifies that medical foods are foods specially formulated for dietary management of diseases or conditions with distinctive nutritional needs that cannot be met by diet alone. Generally, a product must meet the following criteria to be labeled a “medical food”.

  • A specific formulation (as opposed to a naturally occurring foodstuff in its natural state) for oral or tube feeding
  • Labeled for the dietary management of a specific medical disorder, disease, or condition with distinctive nutritional requirements;
  • Intended for use under medical supervision; and
  • Intended only for a patient receiving active and ongoing medical supervision for a condition requiring medical care on a recurring basis so that instructions on the use of the medical food can be provided.

Milk protein allergy is an immunologically-mediated hypersensitivity reaction to cow milk.

Ketogenic diet refers to a high-fat, adequate-protein, and low-carbohydrate diet that in medicine is used primarily to treat difficult-to-control (refractory) epilepsy in children. The diet forces the body to burn fats rather than carbohydrates for energy.

Oral formula refers to a commercially formulated substance, ingested through the mouth, that provides nourishment, and affects the nutritive and metabolic processes of the body; nourishment that is required to provide sufficient nutrients to maintain weight and strength related to the persons overall health status.

Parenteral nutrition is a method of nutrition which bypasses the gastrointestinal tract and provides nutrients though another route, usually intravenously.

  • Total parenteral nutrition (TPN) is a way of supplying all the nutritional needs of the body by bypassing the digestive system and giving nutrients intravenously
  • Intradialytic parenteral nutrition (IDPN) is nutrition administered directly into the bloodstream during hemodialysis.
  • Intraperitoneal dialysis nutrition (IPDN) is nutrition administered directly into the peritoneal during peritoneal

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

CPT/HCPCS/ICD-10-CM Codes
The services associated with these codes require prior authorization:

    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 incomplete, 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 complete/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

The services associated with these codes do not require prior authorization:

    Codes

    Description

    B4034

    Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

    B4035

    Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

    B4036

    Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

    B4081

    Nasogastric tubing with stylet

    B4082

    Nasogastric tubing without stylet

    B4083

    Stomach tube – Levine type

    B4087

    Gastrostomy/jejunostomy tube, standard, any material, any type, each

    B4088

    Gastrostomy/jejunostomy tube, low-profile, any material, any type, each

    B4164

    Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml = 1 unit), home mix

    B4168

    Parenteral nutrition solution: amino acid, 3.5% (500 ml = 1 unit), home mix

    B4172

    Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix

    B4176

    Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) – home mix

    B4178

    Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml = 1 unit), home mix

    B4180

    Parenteral nutrition solution: carbohydrates (dextrose), greater than 50% (500 ml = 1 unit), home mix

    B4185

    Parenteral nutrition solution, per 10 grams lipids

    B4189

    Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 g of protein, premix

    B4193

    Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 g of protein, premix

    B4197

    Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 74 to 100g of protein, premix

    B4199

    Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein – premix

    B4216

    Parenteral nutrition, additives (vitamins, trace elements, Heparin, electrolytes), home mix, per day

    B4220

    Parenteral nutrition supply kit; premix, per day

    B4222

    Parenteral nutrition supply kit; home mix, per day

    B5000

    Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolyes, trace elements, and vitamins, including preparation, any strength, renal – Amirosyn RF, NephrAmine, RenAmine – premix

    B5100

    Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic-HepatAmine-premix

    B5200

    Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids-FreAmine-HBD-premix

    B9000

    Enteral nutrition infusion pump – without alarm

    B9002

    Enteral nutrition infusion pump – with alarm

    B9998

    NOC for enteral supplies

    B9999

    NOC for Parenteral supplies

Prior authorization is not required for the services associated with these codes when paired with a diagnosis code for a specific inborn error of metabolism. The services are considered not medically necessary for any other diagnosis:

    Codes

    Description

    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

Prior authorization is not applicable for the following codes as they are considered not medically necessary:

    Codes

    Description

    B4100

    Food thickener, administered orally, per oz

    B4104

    Additive for enteral formula (e.g., fiber)

The following services are considered investigational and are not covered:

    Codes

    Description

    No specific code

    RELiZORB enzyme packed cartridge for use with enteral feeding sets

Diagnosis codes for specific inborn errors of metabolism:

    Codes

    Description

    D81.81

    Biotin deficient carboxylase deficiency

    D82.4

    Hyperimmunoglobulin E [IgE] syndrome

    E70.0

    Classical phenylketonuria (PKU)

    E70.1

    Other hyperphenylalaninemias

    E70.21

    Tyrosinemia

    E70.29

    Other disorders of tyrosine metabolism

    E70.8

    Other disorders of aromatic amino-acid metabolism

    E71.0

    Maple syrup urine disease

    E71.110

    Isovaleric acidemia

    E71.111

    3-methylglutaconic aciduria

    E71.118

    Other branched-chain organic acidurias

    E71.120

    Methylmalonic acidemia

    E71.121

    Propionic acidemia

    E71.128

    Other disorders of propionate metabolism

    E71.19

    Other disorders of branched-chain amino-acid metabolism

    E71.310

    Long chain/very long chain acyl CoA dehydrogenase deficiency

    E71.311

    Medium chain acyl CoA dehydrogenase deficiency

    E71.313

    Glutaric aciduria type II

    E71.314

    Muscle carnitine palmitoyltransferase deficiency

    E71.318

    Other disorders of fatty-acid oxidation

    E71.32

    Disorders of ketone metabolism

    E71.39

    Other disorders of fatty-acid metabolism

    E71.41

    Primary carnitine deficiency

    E71.42

    Carnitine deficiency due to inborn errors of metabolism

    E71.510

    Zellweger syndrome

    E71.511

    Neonatal adrenoleukodystrophy

    E71.518

    Other disorders of peroxisome biogenesis

    E71.520

    Childhood cerebral X-linked adrenoleukodystrophy

    E71.528

    Other X-linked adrenoleukodystrophy

    E71.53

    Other group 2 peroxisomal disorders

    E72.11

    Homocystinuria

    E72.19

    Other disorders of sulfur-bearing amino-acid metabolism

    E72.21

    Argininemia

    E72.22

    Arginosuccinic aciduria

    E72.23

    Citrullinemia

    E72.29

    Other disorders of urea cycle metabolism

    E72.3

    Disorders of lysine and hydroxylysine metabolism

    E72.4

    Disorders of ornithine metabolism

    E72.8

    Other specified disorders of amino-acid metabolism

    E74.01

    von Gierke disease

    E74.02

    Pompe disease

    E74.03

    Cori disease

    E74.04

    McArdle disease

    E74.09

    Other glycogen storage disease

    E74.12

    Hereditary fructose intolerance

    E74.19

    Other disorders of fructose metabolism

    E74.21

    Galactosemia

    E74.29

    Other disorders of galactose metabolism

    E74.4

    Disorders of pyruvate metabolism and gluconeogenesis

    E75.21

    Fabry (-Anderson) disease

    E75.22

    Gaucher disease

    E88.41

    MELAS syndrome

    E88.42

    MERRF syndrome

    E88.49

    Other mitochondrial metabolism disorders

    G71.3

    Mitochondrial myopathy, not elsewhere classified

Other related diagnosis codes (not associated with a specific error of inborn metabolism):

    Codes

    Description

    E70.20

    Disorder of tyrosine metabolism, unspecified

    E70.9

    Disorder of aromatic amino-acid metabolism, unspecified

    E71.2

    Disorders of branched-chain amino-acid metabolism, unspecified

    E71.30

    Disorders of fatty-acid metabolism, unspecified

    E71.40

    Disorder of carnitine metabolism, unspecified

    E71.50

    Peroxisomal disorder, unspecified

    E71.529

    X-linked adrenoleukodystrophy, unspecified type

    E72.10

    Disorders of sulfur-bearing amino-acid metabolism, unspecified

    E72.20

    Disorder of urea cycle metabolism, unspecified

    E72.9

    Disorder of amino-acid metabolism, unspecified

    E74.00

    Glycogen storage disease, unspecified

    E74.10

    Disorder of fructose metabolism, unspecified

    E74.20

    Disorders of galactose metabolism, unspecified

    E74.9

    Disorder of carbohydrate metabolism, unspecified

    E84.0-E84.9

    Cystic fibrosis

    E88.40

    Mitochondrial metabolism disorder, unspecified

    K20.0

    Eosinophilic esophagitits

    K52.2

    Allergic and dietetic gastroenteritis and colitis

    K52.81

    Eosinophilic gastritis or gastroenteritis

    K52.82

    Eosinophilic colitis

    K90.4

    Malabsorption due to intolerance, not elsewhere classified

    L27.2

    Dermatitis due to ingested food

    T78.00-T78.09

    Anaphylactic reaction due to food

    Z91.010-Z91.018

    Food allergy status

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.

Low-protein medical food items/supplements for the treatment of inborn errors of metabolism can be purchased where available and are eligible for reimbursement when request is submitted to the Claims Department with a copy of the receipt.

References

  1. American Academy of Pediatrics Committee on Nutrition. (2000). Hypoallergenic Infant Formulas. Pediatrics, 106, 346-349.
  2. American Gastroenterological Association (1995). American Gastroenterological Association medical position statement: guidelines for the use of enteral nutrition. Bethesda, MD: Author.
  3. American Society for Parenteral and Enteral Nutrition. Guidelines for the use of parenteral and enteral nutrition inadult and pediatric patients. Journal of Parenteral and Enteral Nutrition. January-February 2002;26(1 Suppl):1SA-138SA
  4. American Society for Parenteral and Enteral Nutrition. Special Considerations for Managing Food Allergies. Journal of Parenteral and Enteral Nutrition. January 2012; 36(Suppl 1):56S-59S.
  5. Bodamer, O. Overview of phenylketonuria. In: UpToDate, Hahn, S. (Ed), UpToDate, Waltham, MA. (Accessed on March 22, 2017).
  6. Boyce, J., Assa’ad, A., Burks, A., Jones, S. Sampson, H., Wood, R., Plaut, M. …and Schwaninger, J. (2010). Guidelines for the Diagnosis and Management of Food Allergy in the United States- Report of the National Institute of Allergy and Infectious Diseases (NIAID)-Sponsored Expert Panel. Journal of Allergy and Clinical Immunology. Dec; 126(6 0): S1-58.
  7. Chung, C. K., Whitney, R., Thompson, C. M., Pham, T. N., Maier, R. V., & O’Keefe, G. E. (2013). Experience with an enteral-based nutritional support regimen in critically ill trauma patients. Journal of the American College of Surgeons, 217, 1108-1117.
  8. Collier, S. Overview of enteral nutrition in infants and children. In: UpToDate, Motil, K. (Ed), UpToDate, Waltham, MA. (Accessed on April 4, 2018)
  9. ECRI Institute. (2017). Indications for Outpatient Nutritional Support for Neonates, Infants, Children, and Adolscents (Age <17 Years). Plymouth Meeting, PA: ECRI Institute.
  10. ECRI Institute. (2017). Indications for Outpatient Nutritional Support in Adults (age 18 Years or Older). Plymouth Meeting, PA: ECRI Institute.
  11. Harvey, B. M., Langford, J. E., Harthoorn, L. F., Gillman, S. A., Green, T. D., Schwartz, R. H., & Burks, A. W. (2014). Effects on growth and tolerance and hypoallergenicity of an amino acid-based formula with synbiotics. Pediatric Research, 75, 343-351.
  12. Hayes, Inc. Hayes Medical Technology Directory Report. Ketogenic Diet for Refractory Seizure Control. Lansdale, PA: Hayes, Inc.; June, 201. Reviewed May, 2015/Archived May, 2016.
  13. Hayes, Inc. Hayes Search and Summary. Medical Foods for Treatment of Inborn Errors of Amino Acid Metabolism. Lansdale, PA: Hayes, Inc.; June, 2016.
  14. Hayes, Inc. Hayes Search and Summary. Medical Foods for the Treatment of Non-Amino Acid Inborn Errors of Metabolism. Lansdale, PA: Hayes, Inc.; June, 2016. Archived July, 2017.
  15. Kieweit, M. B. G., Gros, M., van Neerven, R. J. J., Faas, M. M., & de Vos P. (2015). Immunomodulating properties of protein hydrolysates for application in cow’s milk allergy. Pediatric Allergy and Immunology, 26, 206-217.
  16. Kossoff, E. The ketogenic diet and other dietary therapies for the treatment of epilepsy. In: UpToDate, Nordli, D. (Ed), UpToDate, Waltham, MA. (Accessed on April 2, 2018).
  17. Li, J. Y., Yu, T., Chen, G. C., Yuan, Y. H., Zhong, W., Zhao, L. N. & Chen, Q. K. (2013). Enteral nutrition within 48 hours of admission improves clinical outcomes of acute pancreatitis by reducing complications: a meta-analysis. PLoS One, 8, e64926.
  18. Luyt, D., Ball, H., Makwana, N., Green, M. R., Bravin, K., Nasser, S. M., & Clark, A. T. (2014). BSACI guideline for the diagnosis and management of cow’s milk allergy. Clinical and Experimental Allergy, 44, 642-672.
  19. Markowitz, J., Spergel, J., Ruchelli, E. and Liacouras, C. (2003) Elemental Diet Is an Effective Treatment for Eosinophilic Esophagitis in Children and Adolescents. The American Journal of Gastroenterology. 98:4, 777- 782.
  20. National Institute for Health and Clinical Excellence. Nutrition support in adults: oral nutrition support, enteral tube feeding, and parenteral nutrition-Clinical guideline #32. Published Feb, 2006. https://www.nice.org.uk/guidance/cg32. Accessed 7/19/2017.
  21. National Institute for Health and Care Excellence. Nutrition support in adults-NICE Pathway. Published Nov, 2012. Updated, March, 2017. https://www.nice.org.uk/Search?q=nutritional+support. Accessed on 7/19/2017.
  22. Papadopoulou, A., Koletzko, S., Heuschkel, R., Dias, J. A., Allen, K. J., Murch, S. H., . . . Vandenplas, Y. (2014). Management guidelines of eosinophilic esophagitis in childhood. Journal of Pediatric Gastroenterology and Nutrition, 58, 107-117.
  23. Rock, C. L., Doyle, C., Demark-Wahnefried, W., Meyerhardt, J., Courneya, K. S., Schwartz, A. L., . . . Gansler, T. (2012). Nutrition and physical activity guidelines for cancer survivors. CA: A Cancer Journal for Clinicians, 62, 243-274.
  24. Roehl, K. (2017). Practice Paper of the Academy of Nutrition and Dietetics: Classic and Modified Ketogenic Diets for Treatment of Epilepsy. Journal of the Academy of Nutrition and Dietetics. 117(8); 1279-1292.
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  27. Vandenplas, Y., De Greef, E., & Devreker, T. (2014). Treatment of cow’s milk protein allergy. Pediatric Gastroenterology, Hepatology, and Nutrition, 17, 1-5.
  28. Vandenplas, Y., De Greef, E., & Hauser, B. (2014). An extensively hydrolysed rice protein-based formula in the management of infants with cow’s milk protein allergy: preliminary results after 1 month. Archives of Disease in Childhood, 99, 933-936.
  29. Weiner, D. (2015). Inborn Errors of Metabolism Background, Pathophysiology, Epidemiology. Retrieved from http://emedicine.medscape.com/ on July 3, 2017.

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Policy activity

  • 03/08/2016 - Date of origin
  • 11/01/2017 - Effective date
Review date
  • 03/2018
Revision date
  • 08/16/2017

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