Medical Policy: 01.02.01 

Original Effective Date: May 1995 

Reviewed: June 2018 

Revised: June 2018 

 

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:

Enteral nutrition is used for patients with a functioning intestinal tract but who have disorders of the pharynx, esophagus, or stomach that prevent nutrients reaching the absorbing surfaces of the small intestine, thus placing the patient at risk of severe malnutrition. Enteral nutrition involves administering non-sterile liquids directly into the gastrointestinal tract through nasogastric, gastrostomy, or jejunostomy tubes. Feedings may be regulated with an infusion pump and may be administered intermittently or continuously.

 

‘Specialized formula’ means a nutritional formula for children up to age eight that is exempt from the general requirements for nutritional labeling under the statutory and regulatory guidelines of the federal Food and Drug Administration and is intended for use solely under medical supervision in the dietary management of specific diseases.

 

Contract benefits exclude the use of enteral nutrition preparations when given orally. Contract benefits exclude the use of specialized and over the counter formula when given orally. The use of enteral nutrition preparations and specialized formula is frequently given orally for conditions that include allergies, malnutrition, gastrointestinal reflux, eating disorders, and weight loss.

 

Relizorb™ immobilized lipase cartridge was recently approved for in-line use to include digestive enzymes into the enteral feeding. It is designed to mimic the action of pancreatic lipase for use in adults receiving enteral tube feedings. Large studies with human subjects are not available.

 

Enteral nutrition therapy/exempt specialized formula given for inborne errors of metabolism

This includes only diseases that are permanent and present at birth. For additional information regarding nutrition for inborne errors of metabolism, please refer to policy 10.01.15 Medical Foods and Specialized Formula for Inborn Errors of Metabolism.

 

Prior Approval:

Not applicable

 

Policy:

Food supplements, specialized infant formulas (e.g., Alimentum, Elecare, Neocate, and Nutramigen), lactose-free foods, vitamins and/or minerals may be used to replace intolerable foods, for lactose intolerance, to supplement a deficient diet, or to provide alternative nutrition in the presence of such conditions as allergies, gastrointestinal disorders, hypoglycemia, and obesity. Food supplements, lactose-free foods, specialized infant formulas, vitamins and/or minerals taken orally are not a covered benefit, regardless of whether these are prescribed by a physician.

 

Benefits are available for enteral nutrition therapy ONLY when the prescribed feeding solution is administered through a tube. There is no medical benefit for formula given orally, regardless of medical need. This is not a contract benefit.

 

Non-standard formulas are currently not eligible for coverage when given orally. This non-standard list includes, but is not limited to, the following:

  • Elecare®;
  • Nutramigen®;
  • Progestimil®;
  • Neocate®;
  • Portagen®;
  • Alimentum®;
  • NeoSure®

 

Blenderized baby food, food additives, and over the counter food administered with an enteral feeding system are NOT considered eligible for benefits.

 

Digestive enzymes added to enteral formula via a cartridge device attached to the tubing used for enteral feeding is considered investigational (eg, Relizorb™ immobilized lipase cartridge). Efficacy and necessity has not been shown in current literature.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.

 

The following HCPCS per Diem code ranges may be used to report TPN or enteral nutrition therapy:

  • B4102 Enteral formula, for adults, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit
  • B4103 Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit
  • B4149 Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4150 Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4152 Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4153 Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4154 Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4155 Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4157 Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4158 Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4159 Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4160 Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4161 Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
  • B4162 Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
  • Q9994 In-line cartridge containing digestive enzyme(s) for enteral feeding, each

 

Selected References:

  • Blue Cross Blue Shield Association. Medical Policy Reference Manual.
  • American Gastroenterological Association position statement: Parenteral Nutrition. Gastroenterology 2001 Oct; 121(4):966-9.
  • American Society for Parenteral and Enteral Nutrition. Standards of practice: Standards for home nutrition support.
  • National Institute for Health and Clinical Excellence (NICE). Clinical Guideline 32 Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. February 2006.
  • Yi F, GE L Zhao J, et al. Meta-analysis: total parenteral nutrition versus total enteral nutrition in predicted severe acute pancreatitis. Intern Med. 2012;51(6):523-30.
  • Quan H, Wang X, Guo C. A meta-analysis of enteral nutrition and total parenteral nutrition in patients with acute pancreatitis. Gastroenterol Res Pract. 2011; 2011: 698248.
  • Poulia KA. Enteral Nutrition. In: Katsilambros, N, ed. Clinical Nutrition in Practice. EBSCO Publishing via HEAL-WA: Wiley=Blackwell; 2010: Chapter 17, 197-204
  • Freedman SD. Options for addressing exocrine pancreatic insufficiency in patients receiving enteral nutrition supplementation. Am J Manag Care. 2017;23(12 Suppl):S220-S228.
  • Freedman S, Orenstein D, Black P, et al. Increased fat absorption from enteral formula through an in-line digestive cartridge in patients with cystic fibrosis. J Pediatr Gastroenterol Nutr. 2017;65(1):97-101.
  • Medscape, LLC. FDA clears Relizorb for use with enteral tube feedings. Medscape, LLC. New York, NY. December 03, 2015. Accessed March 23, 2016.

 

Policy History:

  • June 2018 - Interim Review, Policy Revised
  • April 2018 - Annual Review, Policy Renewed
  • April 2017 - Annual Review, Policy Renewed
  • April 2016 - Annual Review, Policy Resurrected
  • August 2013 - Annual Review, Policy Retired
  • September 2012 - Annual Review, Policy Renewed
  • September 2011 - Annual Review, Policy Renewed

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.

 

*CPT® is a registered trademark of the American Medical Association.