Enteral feeding is the provision of nutrition through the use of special enteral formulae either by mouth or through a tube placed into the gastrointestinal tract.
Enteral feeding is provided when because of trauma or illness, an individual cannot ingest enough food orally to support healing and maintain activities of daily life. It is also provided when the body cannot properly process normal food taken orally, as in rare hereditary genetic disorders.
Mandated Enteral Nutrition
Delaware law (18 Del. C. Sections 3355 and 3571) which applies to insured business requires that both individual and group benefit plans provide coverage for medical formulas, medical food products and low protein modified formulas and modified food products if such formula and foods:
Note: “Inherited metabolic diseases include any diseases for which the State of Delaware pursuant to the Delaware Health and Social Services guidelines, screens newborn babies and medical formula.”
Enteral feeding solutions (enteral formulas, procedure codes B4157, B4162, B9998) administered by any method are eligible when necessary for the therapeutic treatment of Inherited Metabolic Diseases. Benefits for medically necessary enteral formulas, administered under the direction of a physician for these conditions are exempt from any contract deductibles.
Non-mandated Enteral Nutrition
Infant formulas, administered either by mouth or through a tube, may be considered medically necessary based on the content of the formula and the reason for use of a special formula as noted above.
Infant formulas, administered either by mouth or through a tube for lactose intolerance, milk protein intolerance, or other milk allergies are not indications for coverage and therefore considered not medically necessary. However, any hemorrhagic colitis secondary to these conditions is medically necessary. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.
Enteral feeding via nasogastric, jejunostomy, or gastrostomy tubes is an alternative to parenteral nutrition for the individual with a functioning gastrointestinal tract but for whom regular, oral feeding is impossible.
Indications for enteral feeding solutions (enteral formulas, procedure codes B4149-B4155, B4158-B4161) via tube feeding include but are not limited to:
Catheter sepsis from hyperalimentation
Central nervous system diseases
Fistula
Gastrointestinal cancer
Granulomatous colitis
Head and neck cancer and reconstructive surgery
Infection, chronic
Intestinal atresia (infants)
Irradiated bowel
Ischemic bowel disease
Jaw fracture
Malabsorption syndrome
Obstruction of gastric outlet due to ulcer diathesis
Pancreatitis, acute or chronic
Partial obstruction
Renal failure
Short-gut syndrome
Stroke
Ulcerative colitis, acute
Enteral feeding by any method for any eligible condition is covered and is subject to any contract deductibles.
B4100 |
B4102 |
B4103 |
B4104 |
B4105 |
B4149 |
B4150 |
B4152 |
B4153 |
B4154 |
B4155 |
B4157 |
B4158 |
B4159 |
B4160 |
B4161 |
B4162 |
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Enteral Accessories and Supplies
Accessories and/or supplies that are used directly with enteral systems to achieve therapeutic benefit or assure proper functioning of the feeding system are eligible durable medical equipment (DME). They include:
Catheters
Concentrated nutrients
Dressings
Enteral nutrition preparation
Extension tubing
Filters
Infusion bottles
IV pole
Liquid diet (for catheter administration)
Needles
Pumps (food or infusion)
Tape
No more than one month's supply of enteral nutrients, equipment or supplies may be dispensed at one time.
The codes for feeding supply kits (B4034-B4036) are specific to the route of administration. Claims for more than one type of kit code delivered on the same date or provided on an ongoing basis will be denied as not medically necessary. The feeding supply kit must correspond to the method of administration.
More than three nasogastric tubes (B4081-B4083), or one gastrostomy/jejunostomy tube (B4087, B4088) every three months is not medically necessary.
The codes for the enteral feeding supplies (B4034-B4036) include all supplies, other than the feeding tube itself, required for the administration of enteral nutrients to the individual for one day. Codes B4034-B4036 describe a daily supply fee rather than a specifically defined "kit." Some items are changed daily; others may be used for multiple days. Items included in these codes are not limited to pre-packaged "kits" bundled by manufacturers or distributors. These supplies include, but are not limited to, feeding bag/container, flushing solution bag/container, administration set tubing, extension tubing, feeding/flushing syringes, gastrostomy tube holder, dressings (any type) used for gastrostomy tube site, tape (to secure tube or dressings), Y connector, adapter, gastric pressure relief valve, declogging device, etc. These items must not be separately billed using the miscellaneous code (B9998)) or using specific codes for dressings or tape. The use of individual items may differ from individual to individual and from day to day. Only one unit of service may be billed for any one day. Units of service in excess of one per day will be denied as not separately payable.
B4034 |
B4035 |
B4036 |
B4081 |
B4082 |
B4083 |
B4087 |
B4088 |
B9000 |
B9002 |
B9998 |
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Reasons for Noncoverage
Basic milk or soy formulas are not eligible.
Food thickener, blenderized baby food or regular shelf food used with an enteral system, and nutritional supplements, are not covered.
Codes B4100, B4102, B4103, and B4104 are not covered.
Prosthetic devices which are dispensed to a patient prior to performance of the procedure that will necessitate use of the device are not covered. Dispensing a prosthetic device in this manner would not be considered medically necessary for the treatment of the patient's condition.
B4100 |
B4102 |
B4103 |
B4104 |
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Covered Diagnosis Codes for B4157, B4162 and B9998
E70.0 |
E71.0 |
E72.11 |
E72.12 |
E72.19 |
E74.21 |
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
