B4162, Enteral formula, for pediatrics, special metabolic needs for inherited disease
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.
- Treatment: Pharmacotherapy for the treatment of bulimia (e.g., selective serotonin reuptake inhibitors such as fluoxetine, tricyclic anti-depressants, trazodone, topiramate).
14 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)
AETNA-CPB-0511, Eating Disorders
Related Codes
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