T2101, Human breast milk processing, storage and distribution only
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
- Coverage for therapy, diagnostic testing, and equipment necessary to increase quality of life for children clinically or genetically diagnosed with any disease, syndrome, or disorder that includes low tone neuromuscular impairment, neurological impairment, or cognitive impairment.
- Coverage and reimbursement for amino-acid–based elemental formulas, regardless of delivery method, for the diagnosis and treatment of eosinophilic disorders and short bowel syndrome when prescribed as medically necessary.
- Amino-acid based elemental formulas are covered for enrollees diagnosed with immunoglobulin E (IgE) and non-immunoglobulin E (non-IgE) mediated allergies to multiple food proteins when prescribed as medically necessary.
- Severe food protein‑induced enterocolitis syndrome (FPIES).
- Eosinophilic gastrointestinal disorders confirmed by biopsy.
- Disorders that impair absorptive surface, functional bowel length, or gastrointestinal motility leading to malabsorption or nutritional insufficiency.
5 Active Policies
MED201.011, Nutritional Support
BCBSIL-MED201.011, Nutritional Support
BCBSMT-MED201.011, Nutritional Support
BCBSNM-MED201.011, Nutritional Support
BCBSOK-MED201.011, Nutritional Support
Related Codes
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