B4157, Enteral formula, nutritionally complete, for special metabolic needs for
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before claim submission; for DMEPOS base items requiring WOPD, the supplier must have a signed SWO/WOPD prior to delivery.
- Medical record documentation must justify medical necessity for special formulas, pump use, and any other special enteral items; lack of justification will result in denial.
- Documentation of beneficiary diagnosis of exocrine pancreatic insufficiency is required to support coverage of in-line digestive enzyme cartridges (HCPCS B4105).
- For refill dispensing of recurring DMEPOS items and supplies, suppliers must contact the beneficiary and document an affirmative response prior to dispensing a refill; contact must occur no sooner than 30 calendar days before expected end of current supply and delivery no sooner than 10 calendar days prior to expected end.
Key Coverage Criteria
- Enteral nutrition is covered when a beneficiary requires feedings via an enteral access device to provide sufficient nutrients to maintain weight and strength commensurate with overall health and has a permanent full or partial non-function of structures that normally permit food to reach the small bowel or a disease that impairs digestion and/or absorption by the small bowel.
- Adequate nutrition must not be possible by dietary adjustment and/or oral supplements for the beneficiary to qualify for enteral nutrition coverage.
- Enteral formulas consisting of semi-synthetic intact protein/protein isolates (HCPCS B4150 or B4152) are appropriate and covered for the majority of beneficiaries requiring enteral nutrition.
- Beneficiaries with non-function of oral/pharyngeal structures due to conditions such as head and neck cancer with reconstructive surgery or central nervous system disease causing severe neuromuscular ingestion impairment may meet coverage criteria.
- Beneficiaries with impaired small bowel digestion/absorption from conditions such as inflammatory bowel disease, surgical small bowel resection, cystic fibrosis, chronic pancreatitis, or advanced liver disease may meet coverage criteria.
- Infant (i.e., ≤ 12 months of age) nutritional formula is considered medically necessary when specifically formulated for the treatment of an inborn error of metabolism (e.g., disorder of amino acid or organic acid metabolism).
13 Active Policies
ANTHEM-CG-MED-08, CG-MED-08 Home Enteral Nutrition
CIGNA-0136, Infant Nutritional Formula
L38955, Enteral Nutrition
UHC-POL-enteral-nutrition, Enteral Nutrition (Oral and Tube Feeding)
MED201.011, Nutritional Support
Related Codes
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