A nutritional product is a commercially formulated substance that provides nourishment and affects the nutritive and metabolic processes of the body. Enteral nutritional products are a covered service for eligible MHCP recipients who meet criteria for medical necessity.
Parenteral nutritional products are considered drugs; only a pharmacy may dispense these solutions. See the Pharmacy Services section of the manual for information about parenteral nutrition.
Nasogastric tubes, gastrostomy, or jejunostomy tubes (feeding tubes), enteral supply kits and enteral nutrition infusion pumps are supplies used to administer enteral nutritional products to individuals who are unable to take enteral nutritional products orally.
The following providers may provide enteral nutrition products and related supplies:
Providers must meet any provider criteria, including accreditation, for third party liability (TPL) insurance or for Medicare in order to assist recipients for whom MHCP is not the primary payer. MHCP will not reimburse providers who do not meet provider criteria for the primary payer.
Enteral nutrition is covered for eligible MHCP recipients who need nutritional supplementation because solid food or the nutrients in the food cannot be properly absorbed by the body, for treatment of phenylketonuria (PKU), hyperlysinemia, maple syrup urine disease (MSUD) or a combined allergy to human milk, cow’s milk and soy formula. Enteral nutrition may be covered for recipients with other specific medical conditions that are discussed in the Covered Services section.
Program HH recipients are eligible for up to $100 per month toward enteral nutritional supplements without authorization. For questions about this benefit, contact Program HH customer care at 800-657-3761.
Refer to Medical Supply Coverage Guide (PDF) for information about items not specified in this policy.
Codes: B4149-B4162 (For these codes 100 calories = one unit), S9435
Only products classified by Medicare’s Pricing, Data Analysis and Coding (PDAC) contractor are covered. If you are unsure of what HCPCS code to use, refer to the DMECS Product Classification List. Up to 1,050 units per month of enteral nutrition are covered for recipients who meet criteria. Documentation must support the need for the number of units requested. Up to 400 units of enteral nutrition products may be dispensed to be taken orally by recipients over age one before authorization is required. Oral enteral nutrition for treatment of PKU, hyperlysinemia or MSUD do not require authorization unless the recipient is under age one.
Nutrition for Recipients under Age One
Children under age one may be able to get infant formula through the Women, Infants and Children (WIC) program. Instruct families to contact their county human services or county public health office.
All enteral nutrition products for children under age one require authorization. Document that the specific formula that is required is not available to the child through WIC or that WIC does not provide the formula in quantities sufficient to meet the child’s medical need. The child must meet one of the medical necessity criteria below.
Nutrition for Recipients with Feeding Tubes
Enteral nutritional products are medically necessary for recipients with feeding tubes. Authorization will be approved for recipients under age one with documentation that WIC cannot meet the child’s medical needs. Authorization is not required for recipients over age one.
Oral Nutrition for Recipients with Inborn Errors of Metabolism
Enteral nutritional products are medically necessary for recipients with many inborn errors of metabolism. Oral enteral nutritional products manufactured for the treatment of PKU, hyperlysinemia or MSUD are covered with authorization for recipients under age one and without authorization for recipients over age one if the recipient has the associated diagnosis. Oral enteral nutritional products manufactured for the treatment of other inborn errors of metabolism are covered with authorization if the recipient has the associated diagnosis.
Solid food products specially manufactured for treatment of amino-acid transport and metabolism including PKU and MSUD are covered up to $525 per calendar month when obtained from an enrolled medical food supplier.
Oral Nutrition for Recipients with Allergies
Enteral nutritional products may be medically necessary for recipients with a combined allergy to cow’s milk, human milk and soy milk. Oral enteral nutritional products are covered with authorization if the recipient has a combined allergy to cow’s milk, human milk, and soy, which is supported by appropriate medical testing and documentation. It is expected that the need for oral enteral nutritional products will decrease as the recipient ages and additional foods are added to the diet. If the recipient gets less than 75 percent of daily nutrition from a nutritionally complete enteral nutrition product, a nutritionist, a speech-language pathologist, or a physician must write a detailed plan to decrease dependence on the supplement.
Oral Nutrition for Recipients Who Cannot Properly Absorb Solid Food or Nutrients
Enteral nutritional products are medically necessary if the recipient has a medical condition that causes an inability to absorb adequate nutrients, and that has led to weight loss. Oral enteral nutritional products are covered with authorization if the recipient meets criteria. Documentation must establish all of the following:
Oral Nutrition for Recipients with Non-Healing Wounds
High protein enteral nutritional products are covered for up to six months with authorization if the recipient has one or more wounds that have not responded to treatment for at least 30 days, and a dietary assessment has determined that the recipient has a nutritional deficit which may be impeding healing. Documentation must include a nutritional plan written by a nutritionist, physician or other health care provider.
Enteral Feeding Supply Kits
Thirty-one enteral feeding supply kits per month are medically necessary for recipients receiving enteral nutritional products through a feeding tube. The feeding supply kit must correspond with the method of administration, and must contain all supplies necessary for feeding using that method of administration for one day. For recipients who use the same or a different method of administration at work or school, up to 20 additional enteral feeding supply kits per month are covered. Documentation on file at the provider’s office must support the need for additional feeding supply kits. MHCP will cover only 51 enteral feeding supply kits per month without authorization.
Most people who use a feeding tube require only one tube every two to three months. Up to two tubes per month may be medically necessary for people with more than one tube site or for those with highly acidic GI tracts. Low-profile feeding tubes are medically necessary for infants, children, and adults with cognitive impairments who are at risk of dislodging a standard feeding tube or those determined by a physician to need this type of feeding tube. The provider must maintain documentation to support the quantity and type of feeding tubes supplied.
Codes: B9002-B9006, E0791 (Enteral/Parenteral Infusion Pumps)
A parenteral infusion pump is medically necessary for recipients for whom parenteral nutrition is required. An enteral infusion pump is medically necessary for recipients with feeding tubes for whom gravity or syringe feeding is not appropriate. Authorization is required only for maintenance service or for repairs when parts and labor exceed $400. One pump is covered every five years. Consider the recipient’s current and expected lifestyle when selecting a stationary versus portable pump. If a pump must be replaced due to theft or damage, providers must submit a claim with an attachment explaining the circumstances. Authorization is required for maintenance service contracts or for repairs to patient owned pumps where parts and labor exceed $400. Refer to Non-Mobility Equipment Repairs section for more information.
Supplies Not Otherwise Classified
Codes: B9998-B9999 (For Enteral/Parenteral Supplies)
Up to 31 extension sets per month are medically necessary for recipients with low-profile feeding tubes. Up to thirty 35 ml or 60 ml syringes per month are medically necessary for people receiving medication through a feeding tube. One carrying case per year is covered for recipients with portable feeding pumps.
Code: B4100 (For this code, one ounce = one unit)
Food thickeners (Simply Thick, Thicken-It) may be medically necessary for individuals at risk of choking or aspirating liquids.
MHCP does not cover the following:
Submit authorizations and required documentation to the authorization medical review agent.
For all requests for authorization of enteral nutritional products, documentation must include all of the following:
For requests for thickeners for recipients under age one, documentation must include gestational age at birth. Documentation must include a swallowing study or swallowing evaluation by a speech and language pathologist and a history of any aspiration. Documentation must also include a plan of care and a plan for follow-up at least annually.
A valid diagnosis of phenylketonuria, hyperlysinemia, maple syrup urine disease or tube-feeding must be on the claim or the claim will deny for needing authorization.
HCPCS codes and modifiers on submitted claims must be identical to the approved authorization to prevent a denial.
Enter the following information on all claims for enteral nutritional products:
Enteral infusion pumps that were originally dispensed as B9000 are now appropriately coded as B9002. When requesting authorization for a repair to a pump, include the HCPCS code under which the pump was originally dispensed in the supporting documentation. When billing for a repair, enter the HCPCS code under which the pump was originally dispensed in the notes field.Report/Rate this page