Nutritional Products and Related Supplies

Revised: October 1, 2023

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Enteral Nutrition Coverage Criteria

· Noncovered Services

· Authorization Requirements

· Billing

· Legal References

Overview

A nutritional product is a commercially formulated substance that provides nourishment and affects the nutritive and metabolic processes of the body.

Parenteral nutrition products are considered drugs; only a pharmacy may dispense these solutions. Refer to the Pharmacy Services section of the MHCP Provider 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 nutrition products to individuals who are unable to take enteral nutrition products orally.

Eligible Providers

The following providers may provide enteral nutrition products and related supplies:

· Federally qualified health centers

· Home health agencies

· Indian health services

· Medical suppliers

· Pharmacies

· Rural health clinics

Third-party liability (TPL) and Medicare

Providers must meet any provider criteria, including accreditation, for TPL insurance or for Medicare to assist members for whom MHCP is not the primary payer. MHCP will not reimburse providers who do not meet provider criteria for the primary payer.

Eligible Members

Enteral nutrition is covered for eligible MHCP members who need nutritional supplementation and meet the criteria listed under Enteral Nutrition Coverage Criteria.

Program HH members are eligible for up to $100 per month toward enteral nutrition supplements without authorization. Contact Program HH customer care at 800-657-3761 for questions about this benefit.

Program HH members also enrolled in MinnesotaCare or Medical Assistance are eligible for benefits if they meet the medical necessity criteria listed under Enteral Nutrition Coverage Criteria.

Covered Services

Refer to Medical Supply Coverage Guide (PDF) for information about items not specified in this manual section.

Enteral Nutrition Coverage Criteria

Enteral Nutrition Products

Codes: B4149–B4162 (For these codes 100 calories = one unit), S9435 (Medical food for inborn errors of metabolism)
Only products classified by Medicare’s Pricing, Data Analysis and Coding (PDAC) contractor are covered. Refer to the DMECS Product Classification List if you are unsure what HCPCS code to use.

Enteral Nutrition for Feeding Tubes

Enteral nutrition products are medically necessary for members with feeding tubes. Up to 1,050 units of enteral nutrition per month are covered for members who meet criteria. Prior authorization is required for any amount over 1,050 units and documentation must support the medical necessity of the amount requested.

Oral Enteral Nutrition

Prior authorization is NOT required for the following diagnoses up to 1,050 units (Diagnosis must be on the claim):

· Combined allergy to soy milk, cow’s milk, and human milk

· Phenylketonuria

· Hyperlysinemia

· Maple syrup urine disease

You may dispense 400 units up front to meet the member’s need while you are requesting authorization for all other medically necessary oral enteral nutrition. (This is a one-time allowance when the enteral nutrition is initially requested by an approved prescriber, for example, a treating practioner who can be a physician, physician assistant or advanced practice nurse.) All units beyond that require prior authorization.

Members who get more than 75% of their daily nutrition from oral enteral nutrition products must have a detailed plan for decreasing their dependence on oral enteral products. (The plan must be written by a nutritionist, speech-language pathologist, or other approved medical professional working within their scope of practice.)

Nutrition for pediatric members
Enteral nutrition products are covered when an eligible provider has diagnosed and documented significant risk factors for malnutrition. These COULD include (but are not limited to):

· Weight loss greater than 5% of the usual body weight for ages 2 to 20 years

· Less than 75% of the norm for expected weight gain for ages under 2 years

· Deceleration in weight/length or height by 1 z score

· Weight/length or body mass index (BMI) z score minus 1 to minus 1.9

· Weight/length or BMI z score minus 2 or less

· Height/age below 5th percentile or length/height-for-age z score of minus 3 or less

· Weight consistently less than 80% of the median for age

· Weight on more than one occasion falling below the 3rd percentile for age

Potential diagnoses COULD include (but are not limited to):

· Intrauterine Growth Restriction (IUGR)

· Impaired gastrointestinal function

· Sensory issues related to medical conditions or maternal drug or alcohol use

· Metabolic conditions

· Kidney, heart, pulmonary diseases

· Malabsorption

· Combined allergy to cow’s milk, soy milk, and human milk

Oral Nutrition for Malabsorption or Malnutrition
Enteral nutrition products may be medically necessary for medical conditions related to malabsorption or malnutrition. The condition must have resulted in weight loss or difficulty maintaining a healthy weight. Medical necessity for enteral nutrition must demonstrate that if the member were left untreated by oral enteral nutrition they would risk detrimental effects to their health.

Examples of a condition CAN include:

· Mechanical inability to chew or swallow solid or pureed or blenderized foods

· Malabsorption due to disease or infection

· An oral aversion which significantly limits the ability to get adequate nutrients

· Weaning from total parenteral nutrition (TPN) or feeding tube

· Inborn errors of metabolism

Oral Nutrition for members with Non-Healing Wounds
High-protein enteral nutrition products are covered for up to six months with authorization if the member has one or more wounds that have not responded to treatment for at least 30 days, and a dietary assessment has determined that the member has a nutritional deficit which may be impeding healing. Documentation must include a nutrition plan written by a nutritionist, physician or other health care provider.

Food Thickeners

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. Authorization is always required for food thickener. A member must have a history of aspiration to qualify.

Authorization requests must include all of the following:

· A swallow study (or a swallow evaluation) completed by a speech and language pathologist

· A plan of care

· A plan for follow-up at least annually

Requests for thickeners for members under age 1 must include gestational age at birth.

Supplies for Enteral or Parenteral Nutrition

Enteral Feeding Supply Kits
Codes: B4034–B4036, B4148
Thirty-one enteral feeding supply kits per month are medically necessary for members receiving enteral nutrition 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 members 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.

Feeding tubes
Codes: B4081–B4088
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. When billing B4088 for a kit, not a single tube, use modifier U3. Review the Pricing for enteral nutrition products information under Billing for more information.

Feeding pumps
Codes: B9002–B9006, E0791 (Enteral/Parenteral Infusion Pumps)
A parenteral infusion pump is medically necessary for members for whom parenteral nutrition is required. An enteral infusion pump is medically necessary for members 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 member’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 of the MHCP Provider Manual 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 members 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 members with portable feeding pumps.

In-line cartridge containing digestive enzymes

Code: B4105
Authorization is always required. Member must meet the criteria for enteral feeding and have a diagnosis of exocrine pancreatic insufficiency as shown in clinical documentation (not just a letter of medical necessity). This is a noncovered service for children younger than 5 years per FDA approval guidelines.

Noncovered Services

MHCP does not cover the following:

· Nutrition products for healthy newborns

· Nutrition products for people living in long-term care (LTC) facilities (included in the per diem)

· Nutrition products for which the need is nutritional rather than medical or is related to an unwillingness to consume solid or pureed foods

· Nutrition products that are requested as a convenient alternative to preparing or consuming regular foods

· Nutrition products for which coverage is requested because of an inability to afford regular foods or supplements (refer member to county human services)

· Food thickeners for people living in LTC facilities (included in the per diem)

· Food thickeners for infants under age 1 who were born at less than 37 weeks gestation due to FDA caution

· SimplyThick brand thickener for infants under age 1 regardless of gestational age at birth is not covered due to FDA caution

· Energy drinks

· Sport shakes

Authorization Requirements

Review the Equipment and Supplies section of the MHCP Provider Manual for general authorization requirements.

When authorization is required, the claim must match HCPCS code, modifiers and product code as noted on the authorization letter.

Prior authorization requests for enteral nutrition products must include all of the following:

· The member’s diagnosis

· What is preventing adequate nutritional intake or consumption

· Weight history and concerns

· Documentation that includes a care plan from a speech-language pathologist, nutrionist, or a physician if less than 75% of daily nutrition is from an enteral product

· The specific enteral nutrition product requested

· The average number of calories to be obtained per day from the enteral nutrition product

· The average number of calories to be obtained per day from other sources

· The medical condition that requires an enteral nutrition product

· All authorization requests must include either an invoice or documentation of Manufacturer’s Suggested Retail Price (MSRP) as pricing documentation

All of the following require authorization:

· All food thickeners

· B4105

· More than 1,050 units of enteral nutrition for tube feeding or oral enteral nutrition

· All oral enteral nutrition (unless it is the initial 400 units or the member has a diagnosis of combined allergy to soy milk, cow’s milk, and human milk; phenylketonuria; hyperlysinemia; or maple syrup urine disease)

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section in the Provider Basics of the MHCP Provider Manual for general billing information.

Bill using MN–ITS 837P Professional. Refer to the MN–ITS User Guide for DME/Med Supply/ Prosthetics/Orthotics for general billing requirements and guidance when submitting claims.

Use modifier U3 if you are a home infusion therapy (HIT) pharmacy billing enteral nutrition supplies (B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B9002, E0776) not related to the HIT services.

Enteral nutrition products when authorization is not required

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.

Enteral nutrition products when authorization is required

HCPCS codes and modifiers on submitted claims must be identical to the approved authorization to prevent a denial.

All claims for enteral nutrition products

Enter the following information on all claims for enteral nutrition products:

· Modifier BO for members taking their enteral nutrition orally

· A valid diagnosis code to the greatest specificity indicating the medical condition that requires the product

· The date of service is the date the product was dispensed to the member. Do not use a date span

· The appropriate HCPCS code for the product dispensed

· The appropriate number of units dispensed (one unit = 100 calories)

· The product name in the service line level notes field when product-specific pricing is requested

· The type of product billed must match what was on the prior authorization request for name and price

Pricing for enteral nutrition products

Follow these pricing guidelines:

· B4149–B4155 and B4157–B4162 with modifier NU, with or without modifier BO, requires by-report or product-specific pricing

· B4088 with modifier U3, billing for a kit, requires by-report or product-specific pricing

· Pricing documentation must include the following:

· Product name

· Product code (the UPC or NDC)

· Package size (amount per case or individual)

· Total calories per can or packet

· Information that identifies whether pricing attachment is manufacturer’s suggested retail price (MSRP) or invoice

Gastrostomy or jejunostomy tubes and supplies not otherwise classified

Follow these billing guidelines:

· Bill B4087–B4088 only for the feeding tubes. Use B9998 for all related supplies including extension sets

· Include a valid diagnosis code to the greatest specificity indicating the medical condition that requires the tube feeding

· The date of service is the date the item was dispensed to the member; do not use a date span

· Enter the item name in the comments or description field

· Do not use B9998 for feeding supply kits or for syringes smaller than 35 ml.

Enteral feeding kits

Follow these billing guidelines for enteral feeding kits:

· Use the HCPCS code that is appropriate to the ordered method of feeding

· The date of service is the date the item was dispensed to the member; do not use a date span

Repairs to pumps originally dispensed as B9000

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.

Legal References

Minnesota Statute 256B.766 (i) (Reimbursement for Basic Care Services)
Minnesota Rule 9505.0325 (Nutrition Products)
Code of Federal Regulations, title 42, section 414.104 (PEN Items and Services)