S9434, Modified solid food supplements for inborn errors of metabolism
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical or genetic diagnostic documentation confirming the child has a disease/syndrome/disorder that includes low tone neuromuscular impairment, neurological impairment, or cognitive impairment.
- A written order from the prescribing physician stating the amino-acid–based elemental formula is medically necessary.
- Written order from the prescribing physician stating the amino-acid based formula is medically necessary for treatment of the enrollee.
- Physician or licensed pediatric provider prescription/order for human breast milk or human donor milk.
Key Coverage Criteria
- Oral enteral nutrition (oral feeding) is consideredmedically necessarywhenallof the following criteria are met:
- The product constitutes more than 50 percent of the individualâs caloric intake;and
- The product must be a medical food for oral feeding;and
- The product must be labeled and used for the dietary management of a specific medical disorder, disease, or condition for which there are distinctive nutritional requirements to avert the development of serious physical or mental disabilities or to promote normal development or function as listed in 1.or2. [...]
- Conditions associated with an in-born error of metabolism that interfere with the metabolism of specific nutrients, including, but not limited to:Phenylketonuria (PKU);orHomocystinuria;orMethylmalonic acidemia;or
- Phenylketonuria (PKU);or
11 Active Policies
ANTHEM-CG-MED-08, CG-MED-08 Home Enteral Nutrition
UHC-POL-enteral-nutrition, Enteral Nutrition (Oral and Tube Feeding)
MED201.011, Nutritional Support
BCBSIL-MED201.011, Nutritional Support
BCBSMT-MED201.011, Nutritional Support
Related Codes
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