Medical Policy: 01.02.01
Original Effective Date: May 1995
Reviewed: April 2019
Revised: April 2019
This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.
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.
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.
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.
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:
Blenderized baby food, food additives, and over the counter food administered with an enteral feeding system are NOT considered eligible for benefits.
Food thickener and food additives 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.
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:
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.