| Mountain State Medical Policy Bulletin |
| Section: | Orthotic & Prosthetic Devices |
| Number: | O-6 |
| Topic: | Enteral Nutrition |
| Effective Date: | August 1, 2005 |
| Issued Date: | January 30, 2006 |
| Date Last Reviewed: | 01/2006 |
Indications and Limitations of Coverage
Enteral feeding solutions (enteral formulas, procedure codes B4157, B4162) administered by any method are eligible when necessary for the therapeutic treatment of the following hereditary genetic disorders. 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: Phenylketonuria (PKU) - 270.1 Infant formulas, administered either by mouth or through a tube, may be considered eligible for coverage based on the content of the formula and the reason for use of a special formula as noted above. Lactose intolerance, milk protein intolerance, or other milk allergies are not indications for coverage. However, any hemorrhagic colitis secondary to these conditions is eligible. Basic milk or soy formulas are not eligible. Enteral feeding via nasogastric, jejunostomy, or gastrostomy tubes is an alternative to parenteral nutrition for the patient 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 Blenderized baby food or regular shelf food used with an enteral system, and nutritional supplements, are not covered. Codes B4102, B4103, and B4104 are not covered. A network provider can bill the member for these denied services. 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 reasonable and necessary for the treatment of the patient's condition. Enteral feeding by any method for any eligible condition is covered under the prosthetic benefit and is subject to any contract deductibles. 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 Coverage for Durable Medical Equipment/Prosthetics is determined according to individual or group customer benefits. See Medical Policy Bulletin G-12 for information on inpatient hyperalimentation. See Medical Policy Bulletin O-3 for information on Parenteral Nutrition in the Home. Description 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, a patient 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. In the presence of such disorders, severe mental retardation and chronic physical disabilities may occur without proper therapeutic management. |
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| B4034 | B4035 | B4036 | B4081 | B4082 | B4083 |
| B4086 | B4102 | B4103 | B4104 | B4149 | B4150 |
| B4152 | B4153 | B4154 | B4155 | B4157 | B4158 |
| B4159 | B4160 | B4161 | B4162 | B9000 | B9002 |
| B9998 |
PRN References |
MCM 2130 |
| [Version 001 of O-6] |