Formula/Enteral Nutrition-DME

These services may or may not be covered by all HealthPartners plans. Please see your plan documents
for your own coverage information. If there is a difference between this general information and your plan
documents, your plan documents will be used to determine your coverage.

Administrative Process
The following requires prior approval:
• Enteral Nutrition/Formula - For members residing (private pay) in Skilled Nursing Facilities (SNF) see related
policy “Equipment in SNF”.

The following do not require prior approval:

• Formula required to treat persons with a diagnosis of Phenylketonuria (PKU), Hyperlysinemia, or Maple
Syrup Urine Disease
• Feeding pumps (e.g. kangaroo), bags, or administration sets used to administer enteral formula that is
approved for coverage. These items are not covered if enteral nutrition is not authorized for approval.

Related Policies:
1. PKU Food Products & Formula
2. Formula, Oral – Amino Acid Based Elemental
3. Equipment in Skilled Nursing Facility (SNF) / Long Term Care Facility.
4. Gastrostomy Supplies

Coverage
Generally covered subject to the indications listed below and the following limits from your member contract:
• Durable medical equipment (DME) is limited by the following:
a. All covered DME items should be the acceptable standard model, considering the member's medical
condition. If a member requests an additional item/part, which is safe and effective, HealthPartners may
cover the cost up to the cost of the acceptable standard model.
b. Payment will not exceed the cost of an alternate piece of equipment or service that is effective and
medically necessary. Prosthetic benefits have some variation. Please see your member contract or
specific medical coverage criteria for details.
c. We reserve the right to determine if an item will be approved for rental vs. purchase.
• DME items will not be approved which are primarily educational in nature or for hygiene, vocation, comfort,
convenience or recreation.
• DME and supplies must be obtained from or repaired by approved vendors.
• Duplicate or similar items are not covered. Requests for replacement DME when existing DME is not
broken, requires a physician statement documenting a change in the covered person's physical condition,
and the medical reasons for the replacement DME.

Indications that are covered

Must meet all of the following criteria:

1. Enteral nutrition must meet the definition of sole source of nutrition, and needed as the result of, or to treat a
medical condition.

2. The Member must have a condition involving the gastrointestinal tract somewhere between the mouth and the
duodenum, inclusive, which prevents adequate ingestion. This condition could be either anatomic (e.g.
obstruction due to head and neck cancer or reconstructive surgery etc.) or due to a motility disorder such as
severe dysphagia following a stroke, etc. To be considered for coverage, enteral nutrition must be needed as
the result of, or to treat one of the following medical conditions:

A. Permanent non-function or disease of the structures that normally permit food to reach the small bowel; OR

B. Disease of the small bowel which impairs digestion and absorption of an oral diet.

3. Adequate nutrition must not be possible by dietary adjustments and/or oral supplements.

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4. Must have the ability to comply with and tolerate tube feedings.

5. Must have a current physician’s written order or prescription.

6. The following supplies are covered if the enteral formula is authorized for approval: gauze, tape, feeding tubes
(gastrostomy, nasogastric, jejunostomy) and syringes related to the gastrostomy feeding, feeding pump, feeding
bags or administration sets, feeding supply kit, IV pole, feeding tube anchoring device. Syringes are limited to no
more than one (1) syringe per day. Feeding tubes (e.g. MIC KEY tube) uses are not limited to administering
formula and are covered for other uses even if formula is not covered for an individual member. Uses of tubing
include but are not limited to administering formula, medications, venting the stomach (artificial burping) and
other therapeutic back up uses, etc.

Other Indications for coverage:

Enteral nutrition may be a reasonable and necessary alternative for patients with a functioning gastrointestinal tract
for whom regular, oral feeding is impossible. These cases will be reviewed on a case by case basis.
The following information must be documented by the ordering physician and submitted:
1. Estimated duration of need
2. Diagnosis and how it relates to the need for nutritional product
3. Other diagnosis
4. Product requested
5. Route of administration
6. Total calories from enteral products
7. Total calories from other ingested foods or liquids
8. Height, weight and targeted weight
9. Other therapy/treatment that may justify the need for the nutritional product.

Indications that are not covered

1. Enteral feedings unless they are the sole source of nutrition used to treat a life-threatening condition;

2. Nutritional supplements, over-the-counter electrolyte supplements and infant formula, except as required by MN
law. This non-coverage does not apply to oral amino acid based elemental formula if it is authorized for
approval.
3. Enteral nutrition for patients with a functioning gastrointestinal tract whose need for enteral nutrition is due to
reasons such as anorexia or nausea associated with mood disorder, end-stage disease, etc.

4. Nutritional supplements given as a medicine between meals to boost protein-caloric intake or the mainstay of a
daily nutritional plan.

5. Enteral products, including dietary and food supplements that are administered orally and related supplies.

6. Baby foods and other grocery items/products that can be blenderized and used with the enteral system.

7. Thickening or fiber products

8. Sport shakes

9. Lactose-free products; products to aid in lactose digestion

10. Gluten-free food products

11. Weight-loss foods and formula; products to aid weight loss

12. Normal grocery items

13. Low carbohydrate diets

14. Nutritional supplement puddings

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15. Supplies that are associated with non-covered enteral nutrition. Supplies include gauze, tape, feeding tubes
(gastrostomy, nasogastric, jejunostomy) and syringes related to the gastrostomy feeding, feeding pump, feeding
bags or administration sets, feeding supply kit, IV pole, feeding tube anchoring device, etc. NOTE: Feeding
tubes (e.g. MIC KEY or Mickey tube) uses are not limited to administering formula and are covered for other
uses even if formula is not covered for an individual member. Uses of tubing include but are not limited to
administering formula, medications, venting the stomach (artificial burping) and other therapeutic back up uses,
etc. They do not require prior approval.

Definition
Enteral nutrition: tube feedings consisting of a nutritional replacement product (a commercially-formulated
substance that provides nourishment, and affects the nutritive and metabolic processes of the body) administered
through a tube (e.g. nasogastric, gastrostomy, jejunostomy) that is placed directly into the gastrointestinal tract
(stomach or small intestine) which is required to provide sufficient nutrients to maintain weight and strength
commensurate with the patients overall health status. Enteral nutrition may be administered by syringe, gravity or
pump.

Sole source is the primary source of sufficient caloric/nutrient intake to achieve or maintain appropriate body weight.
Enteral feeding of at least 75% of daily caloric needs is considered sole source. For example, a total caloric intake of
at least 20 calories per kilogram per day for adults and at least 45 calories per kilogram per day for children is
considered sufficient to achieve or maintain appropriate body weight in most people.

Codes (list may not be all inclusive)

CPT Copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 

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-B4162 Enteral formulae

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan
has limits or will not cover some items. If there is a difference between this general information and your plan
documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to
Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage
criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor
• Items must be received from a contracted vendor for in-network benefits to apply.
• Full line vendors provide a wide range of equipment and supplies, such as hospital beds, aids for ambulating
and toileting, phototherapy lights, wheelchairs, custom seating devices, monitors, pumps, oxygen and etc.

Number: D048-05; Approved: Medical Director Committee; Approved: 07/01/97; Revised: 04/09/02, 3/14/08, 4/16/09;
Annual Review: 04/09/02, 2003, 2004, 2005, 6/1/06, 8/1/07, 3/14/08, 4/16/09, 8/18/10.

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