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LCD - Enteral Nutrition

Coverage Summary

Written Order Prior to Delivery

Nutrition and Enteral Pump (as applicable) separate documentation:

Nutrition

The patient has a permanent (at least 3 months) impairment due to:

  • Non-function or disease of the structures that normally permit food to reach the small bowel, OR;
  • A disease of the small bowel which impairs digestion and absorption of an oral diet.

The patient requires tube feedings to maintain weight and strength for patient’s overall health status. Adequate nutrition is not possible through a dietary adjustment and/or oral supplements.

The nutrition is being provided via tube into the stomach or small intestine and not drinking the nutrition (the patient is NPO).

Swallow test in order to document dysphagia.

NOTE: The medical necessity for special formulas such as diabetic (and others) must be justified in each patient. Lesser (standard) formulas must be documented as tried and failed with results of the failed trial.

Enteral Pump:

Must meet enteral nutrition coverage criteria stated above as well as medical need for one or more of the below listed:

  1. Gravity feeding is not satisfactory due to reflux and/or aspiration, OR;
  2. Severe diarrhea, OR;
  3. Dumping syndrome, OR;
  4. Administration rate prescribed is less than 100 ml/hr, OR;
  5. Blood glucose fluctuations, OR;
  6. Circulatory overload

Order Requirements

  1. Patient's Name
  2. Detailed description of item(s) being ordered (specific formula name)
  3. Route of Administration (bolus, pump, gravity)
  4. Quantity to be dispensed (cans and calories per day)
  5. Prescribed settings (if pump is prescribed)
  6. Prescribed frequency of use (hours per day and days per week - ie, 1-7)
  7. Length of Medical Need
  8. Ordering Physician’s NPI
  9. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  10. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  11. Start date of the order – if different than physician signature date.

Coverage Detail

Nutrition:

The patient has a permanent (at least 3 months) impairment due to:

  • Non-function or disease of the structures that normally permit food to reach the small bowel OR;
  • A disease of the small bowel which impairs digestion and absorption of an oral diet.

The patient requires tube feedings to maintain weight and strength for patient’s overall health status. Adequate nutrition is not possible through a dietary adjustment and/or oral supplements.

The nutrition is being provided via tube into the stomach or small intestine and not drinking the nutrition (the patient is NPO).

Enteral Nutrition Pump:

Must meet general enteral nutrition coverage criteria stated above as well as medical need for one or more of the below listed:

    1. Gravity feeding is not satisfactory due to reflux and/or aspiration OR;
    2. Severe diarrhea OR;
    3. Dumping syndrome OR;
    4. Administration rate prescribed is less than 100 ml/hr OR;
    5. Blood glucose fluctuations OR;
    6. Circulatory overload

NOTE:

  • Neurological diagnosis requires a swallow test in order to document dysphagia.
  • Diabetic formulas must be supported with documentation regarding the patient’s fluctuating blood glucose levels.
  • Certain specialized formulas (ie, Peptamen product line) requires supporting medical need documentation to identify why the patient cannot use a basic formula to meet their needs.
  • Self-blenderized formulas are non-covered.
  • The beneficiary's condition could be either anatomic (e.g., obstruction due to head and neck cancer or reconstructive surgery, etc.) or due to a motility disorder (e.g., severe dysphagia following a stroke, etc.). Enteral nutrition is non-covered for beneficiaries 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.
  • The beneficiary must require tube feedings to maintain weight and strength commensurate with the beneficiary's overall health status. Adequate nutrition must not be possible by dietary adjustment and/or oral supplements. Coverage is possible for beneficiaries with partial impairments - e.g., a beneficiary with dysphagia who can swallow small amounts of food or a beneficiary with Crohn's disease who requires prolonged infusion of enteral nutrients to overcome a problem with absorption.
  • Enteral nutrition products that are administered orally and related supplies are non-covered.
  • Food thickeners (B4100), baby food, and other regular grocery products that can be blenderized and used with the enteral system will be denied as non-covered.
  • Electrolyte-containing fluids that are non-covered by Medicare