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
- Prescription or order from a physician, advanced practitioner (NP, CNS, or PA), or registered dietician authorizing Specialized Nutrient Formula therapy.
- Documentation that the condition is chronic and is expected to last for an undetermined or prolonged period of time.
- Documentation that adequate nutrition is not possible by dietary adjustment (e.g., dietitian notes, failed dietary interventions).
- Evidence that the formula to be used is a Medical Food specially formulated for a specific condition (labeling or product documentation indicating 'Medical Food' and intended use).
Key Coverage Criteria
- Enteral nutrition administered by tube feeding (e.g., nasogastric, gastrostomy, or jejunostomy tube) is medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Durable Medical Equipment, Enteral and Parenteral Nutrition Therapy.
- Specialized Nutrient Formula administered orally, as a primary or supplementary source of nutrition, is considered medically necessary when all of the following criteria are met:
- A physician, advanced practitioner (NP, CNS, or PA), or registered dietician prescribes the therapy;
- The condition is chronic and is expected to last for an undetermined or prolonged period of time;
- Adequate nutrition is not possible by dietary adjustment;
- The formula used is a Medical Food that is specially formulated for a specific condition;
11 Active Policies
CIGNA-0136 — Infant Nutritional Formula - (0136)
ANTHEM-CG-MED-08 — CG-MED-08 Home Enteral Nutrition
UHC-POL-enteral-nutrition — Enteral Nutrition (Oral and Tube Feeding)
UMR-POL-UMR-enteral-nutrition — Enteral Nutrition (Oral and Tube Feeding)
SUREST-POL-SUREST-enteral-nutrition
Related Codes
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