S9435, Medical foods for inborn errors of metabolism
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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
12 Active Policies
ANTHEM-CG-MED-08, CG-MED-08 Home Enteral Nutrition
CIGNA-0136, Infant Nutritional Formula
UHC-POL-enteral-nutrition, Enteral Nutrition (Oral and Tube Feeding)
MED201.011, Nutritional Support
BCBSIL-MED201.011, Nutritional Support
Related Codes
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