Nutritional Support

This policy covers medically necessary nutritional support — including therapy, diagnostic testing, equipment, amino‑acid–based and extensively hydrolyzed formulas, medical foods, enteral supplies (e.g., Relizorb for cystic fibrosis ≥1 year), and prescribed human or donor milk — for conditions such as pediatric low‑tone neuromuscular/neurological/cognitive impairment, eosinophilic gastrointestinal disorders, short bowel syndrome, severe FPIES and other food‑protein allergies, inborn errors of metabolism, malabsorption, dysphagia, and related disorders. Coverage is governed by the member’s benefit plan, medical‑necessity and evidence‑based criteria, and state‑specific mandates/limits (e.g., donor milk eligibility/duration, inpatient room‑and‑board treatment of infant formula, plan type applicability and ASO carve‑outs); the benefit contract prevails if it conflicts with this policy.

"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 ..."