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Medical Policy: 10.01.15
Original Effective Date: May 2010
Reviewed: September 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Amino acid-based elemental formulas are prepared from individual (single) non-allergenic amino acids different from regular dairy (milk or soy based) formulas and foods that include numerous complete proteins. Amino acid-based elemental formulas are made of proteins broken down to their “elemental level” (simplest and purest form) making them easily absorbed and digested by the body. Amino acid-based elemental formulas are the only thing an infant or child can appropriately digest and tolerate due to a variety of allergies or gastrointestinal conditions. Examples of amino acid-based elemental formulas are Neocate®, EleCare®, Nutramigen® AA™ LIPIL®.
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Prior Approval:
Not applicable
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Policy:
Amino acid-based elemental oral formulas may be considered medically necessary when ordered by a physician for diagnosed cases of cystic fibrosis, amino acid, organic acid, and fatty acid metabolic and malabsorption disorders.
Amino acid-based elemental oral formulas may be considered medically necessary when ordered by an allergist or gastroenterologist for diagnosed cases of IgE mediated allergies to food proteins; food protein-induced enterocolitis syndrome; eosinophilic esophagitis; eosinophilic gastroenteritis; and eosinophilic colitis.
Coverage of amino acid-based elemental formulas for patients diagnosed with an IgE mediated condition is limited to age five years and under.
The covered formula must contain 100% free amino acids as the protein source.
Amino acid-based elemental formulas are considered investigational for all other diagnoses and for patients diagnosed with an IgE mediated condition who are six years of age and older.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- S9433 Medical food nutritionally complete, administered orally, providing 100% of nutritional intake
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Selected References:
- Nowak-Wegrzyn A, Sampson HA, Wood RA, Sicherer SH. Food protein-induced enterocolitis syndrome caused by solid food proteins. Pediatrics. 2003 Apr;111(4 Pt 1):829-35.
- Crittenden RG, Bennett LE. Cow's milk allergy: a complex disorder. J Am Coll Nutr. 2005 Dec;24(6 Suppl):582S-91S.
- Kemp AS, Hill DJ, Allen KJ, Anderson K, Davidson GP et al. Guidelines for the use of infant formulas to treat cows milk protein allergy: an Australian consensus panel opinion. Med J Aust. 2008 Jan 21;188(2):109-12.
- Vanderhoof JA. Hypoallergenicity and effects on growth and tolerance of a new amino acid-based formula with DHA and ARA. J Pediatr Gastroenterol Nutr. 2008 Nov;47 Suppl 2:S60-1.
- Bone J, Claver a, Guallar I, Plaza AM. Allergic proctocolitis, food-induced enterocolitis: immune mechanisms, diagnosis and treatment. Allergol Immunopathol (Madr). 2009 Jan-Feb;37(1):36-42.
- Benhamou AH, Schappi Tempia MG, Belie DC, Eigenmann PA. An overview of cow's milk allergy in children. Swiss Med Wkly. 2009 May 30;139(21-22):300-7.
- Putnam PE. Evaluation of the child who has eosinophilic esophagitis. Immunol Allergy Clin North Am. 2009 Feb;29(1):1-10, vii.
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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