Infant Nutritional Formula - (0136)

Cigna covers infant (≤12 months) nutritional formula only when specifically formulated to treat listed inborn errors of metabolism (ICD‑10 codes as specified) and expressly excludes formulas for other indications (e.g., food allergies, lactose intolerance, prematurity, non‑hospital banked breast milk, and other specialized/standard formulas). Coverage requires documentation of infant age ≤12 months, the specific IEM diagnosis from the policy, submission of the appropriate HCPCS/CPT code(s), and—if claimed as enteral nutritional support—evidence the formula provides ≥60% of caloric intake; plan benefits vary and claims without covered codes will be denied.

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