E72.50 — Disorder of glycine metabolism, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of infant age (≤ 12 months) when requesting coverage under the infant nutritional formula indication.
- Documentation that the formula is specifically formulated for the treatment of an inborn error of metabolism and medical necessity for that IEM.
- Use of appropriate ICD-10-CM diagnosis code(s) from the policy's listed IEM diagnoses to support the claim.
- Use of appropriate HCPCS/CPT codes as listed in the policy (examples: B4154, B4155, B4157, B4162, S9435) and submission with the covered code(s) in order to be considered for reimbursement.
Key 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).
- Individuals with malabsorption syndromes may benefit from enteral nutritional support. Enteral nutritional support may be indicated when the formula comprises the primary source of nutrition (i.e., 60% or more of caloric nutritional intake).
- D81.810 - Biotinidase deficiency
- D81.818 - Other biotin-dependent carboxylase deficiency
- E70.0 - Classical phenylketonuria
- E70.1 - Other hyperphenylalaninemias
2 Active Policies
CIGNA-0136 — Infant Nutritional Formula - (0136)
ANTHEM-CG-LAB-30 — CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing
Related Codes
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