Enteral feeding is the provision of nutrition into the gastrointestinal tract. Nutrition, in the form of formula or a food-based solution, is administered orally or through a feeding tube that can go into the stomach or directly into the small intestines.
Enteral feeding is provided due to an individual’s inability to consume needed calories and nutrition by mouth to sustain life and growth.
Mandated Enteral Nutrition
Effective June 20, 1997, enteral feeding solutions administered by ANY method are eligible when necessary for the therapeutic treatment of the following hereditary genetic disorders as defined in Act 191 - 1996. Except for HDHP and CAT plans under this Act, benefits for medically necessary enteral formulas, such as PKU 1 or 2, Lofenalac, or Ketonex 1 or 2, administered under the direction of a physician for these specified conditions are exempt from any contract deductibles:
B4157 |
B4162 |
B9998 |
|
|
|
|
Effective April 20, 2015, coverage for amino acid-based elemental medical formulas is determined according to individual or group customer benefits.
Amino acid-based elemental medical formulas, made of 100% free amino acids as the protein source, are eligible when ordered by a physician as medically necessary for oral or enteral administration in infants and children as set forth in Act 158-2014 and (except for HDHP and CAT plans) are exempt from any contract deductibles for the following conditions:
B4154 |
B4161 |
S9432 |
S9433 |
|
|
|
Non-Mandated Enteral Nutrition
Infant formulas administered either by mouth or through a tube for lactose intolerance, milk protein intolerance or other milk allergies may be considered medically necessary when the infant has at least ONE of the following persistent indications:
· Atopic dermatitis;
· Colic;
· Diarrhea;
· Frequent regurgitation;
· Persistent failure to thrive;
· Symptoms of allergic reaction such as, vomiting, wheezing, rashes;
· Vomiting.
Enteral feeding via nasogastric, nasojejunal, nasoduodenal, jejunostomy, or gastrostomy tubes are 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 via tube feeding include but are not limited to:
o Hepatic insufficiency
o Pulmonary insufficiency
o Renal failure
o Neurological deficits:
§ Cerebral palsy
§ Coma
§ Stroke,
o Head and neck cancer
o Jaw fracture
Enteral feeding solutions are considered medically necessary when they are provided orally, and they are the sole source of nutrition for:
· Individuals who require a hydrolyzed protein predigested or amino acid-based formula,
for special metabolic needs, modular components formula or standardized nutrient formula; or
· Individuals who require a defined formula with specialized contents for specific metabolic needs; or
· Individuals who require a modular component formula.
Once eligible for coverage, they will remain eligible until an individual is able to take at least 50% of their daily caloric requirement in regular foods.
Enteral nutrition is considered not medically necessary when above criteria are not met.
B4149 |
B4150 |
B4152 |
B4153 |
B4154 |
B4155 |
B4158 |
B4159 |
B4160 |
B4161 |
B4162 |
|
|
|
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 considered durable medical equipment (DME) and may be considered medically necessary. They include:
Three month’s supply of enteral
nutrients, equipment or other related supplies may be dispensed at one time.
Enteral feeding supply kits may be considered medically necessary when enteral feeding solution and route of administration are medically necessary.
The codes for the enteral feeding supplies include all supplies, other than the feeding tube itself, required for the administration of enteral nutrients to the individual for one day. 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 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.
Digestive Enzyme Cartridge
A digestive enzyme cartridge for example, RELiZORB ® for use with enteral tube feeding will be considered medical necessary for individuals five (5) years and older to hydrolyze fats in enteral formula.
B4105 |
B4036 |
B4148 |
|
|
|
|
Use of the digestive enzyme cartridge for any other indication will be considered experimental investigational (E/I) and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Quantity Level Limits (QLL) for nasogastric/nasojejunal tubes/ nasoduodenal, gastrostomy/jejunostomy tubes
Three (3) nasogastric/nasojejunal/nasoduodenal tubes per every three (3) months may be considered medically necessary.
Three (3) gastrostomy/jejunostomy tube per every three (3) months may be considered medically necessary.
QLL or quantity of supplies for nasogastric/nasojejunal tubes/ nasoduodenal, gastrostomy/jejunostomy tubes that exceed the frequency guidelines listed on the policy are considered not medically necessary.
B4034 |
B4035 |
B4036 |
B4081 |
B4082 |
B4083 |
B4087 |
B4088 |
B9002 |
B9998 |
|
|
|
|
Reasons for Noncoverage for Non-mandated Enteral Nutrition
Basic milk or soy formulas are non-covered.
Food thickener, blenderized baby food or regular shelf food used with an enteral system, and nutritional supplements, other than "nutritional supplements" described in Act 158 of 2014, are non-covered.
Prosthetic devices which are dispensed to an individual prior to performance of the procedure that will necessitate use of the device are non- covered. Dispensing a prosthetic device in this manner would not be considered medically necessary for the treatment of the individual’s condition.
B4100 |
B4102 |
B4103 |
B4104 |
|
|
|
Act 191 Covered Diagnosis Codes for B4157, B4162 and B9998
E70.0 |
E71.0 |
E72.11 |
E72.12 |
E72.19 |
E74.21 |
|
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.
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.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
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.
