Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-017 - Prosthetics Update #117 & Hyperalimentation Update #110

Universal Citation: AR Admin Rules 016.06.08-017

Current through Register Vol. 49, No. 9, September, 2024

Section II Hyperalimentation

221.000 Prior Authorization

Hyperalimentation fluids, equipment and supplies must be prior authorized by the Arkansas Foundation for Medical Care, Inc. (AFMC).

242.120 Enteral (Sole Source) Formulas

The following pages provide the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients.

Modifiers in this section are indicated by the headings M1, M2 and M3.

Enteral formulas are divided into several categories. Each unit of service equals 100 calories of formula. All supplies and equipment necessary to administer the nutrients in the beneficiary's place of residence, except the infusion pump and pump supply kit are included in the unit description.

For a non-covered prescribed formula a review for medical necessity will be performed upon request. The product information, with assigned HCPCS code and physician documentation of the medical necessity of the formula for a specific beneficiary, must be submitted to Utilization Review. View or print the Utilization Review Section contact information. If approved, the formula will be added to the list of covered formulae and the provider will be notified. If denied, the provider and beneficiary will be notified.

For beneficiaries ages birth through four years of age, the use of modifier U8, as well as additional documentation will be required when a non-WIC formula is prescribed or WIC guidelines are not followed when prescribing special formula.

An EPSDT screening, which documents the PCP's medical rationale for prescribing a formula, as well as medical records documenting the beneficiary's failed trials of WIC formula, must be submitted for review. Flavor preference will not be considered for medical necessity.

A separate prior authorization must be obtained for the enteral infusion pump and the pump supply kit. The enteral infusion pump and the pump supply kit may be billed separately.

Exceptions to Use of Formula

The following exceptions must be followed in order to use formulas listed in this section.

The exceptions are indicated by an alpha letter in parenthesis that precedes the product description. For example:(A-) Nestle Good Start Supreme with DHA & ARA Powder.

A. Nestle Good Start Supreme with DHS & ARA - sensitive to intact protein - Enfamil Gentlease Lipil must first have been tried.

B. Nestle Good Start Supreme Soy with DHA & ARA, - sensitive to intact protein - Enfamil Gentlease Lipil must first have been tried.

C. Nutramigen Lipil - sensitivity or allergy to milk and soy protein - chronic diarrhea, food allergies, Gl bleeds - Enfamil Gentlease Lipil and Good Start Supreme must first have been tried.

D. EleCare - allergy to intact protein and casein hydrolysates - severe food allergies, short bowel syndrome and/or malabsorption - Alimentum, Nutramigen and Pregestimil must first have been tried.

E. Neocate - allergy to intact protein and casein hydrolysates, severe food allergies, short bowel syndrome, malabsorption, -Alimentum, Nutramigen and Pregestimil must have been tried.

HCPCS Code

M1

M2

M3

Description

Covered Formulae

B4153

U9

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

Peptamen Peptamen 1.5 Peptamen with Prebio 1 Perative Tolerex Vital HN Vivonex Plus Vivonex TEN

B4154

U9

Enteral formula, nutritionally complete, for special metabolic needs, includes 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

See list below

Covered formulae:

Boost Diab Glucerna Nutren Glyl Hepatic Aic Impact

etic trol i

Impact with Fiber

IsoSource VHN

Ketocal

Nepro with Carb

NutriHep

Pulmocare

Resource Diabetic TF Similac 60/40 Suplena with

Carb Steady Traumacal

B4155

U9

3r (Indie ne of claims.;

:ate

I

Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit

MCT Oil

Bill on Pap[LESS THAN] specific nar formula on

Procel Protein Supplement Provimin

B4159

U9

Enteral formula, for pediatrics, nutritionally complete soy base 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

Enfamil Next Step Prosobee

Lipil Enfamil Prosobee Lipil (B)Nestle Good Start Supreme Soy-with DHA & ARA Powder

B4159

(Ages 0-4 Years)

U9

U8

Enteral formula, for pediatrics, nutritionally complete soy base 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

Similac Isomil

Similac Isomil Advance Soy-Formula with Iron

B4160

U9

Enteral formula, for pediatrics, nutritionally 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

(G-) Enfamil Enfacare Lipil

Powder Enfamil Kindercal Enfamil Kindercal with Fiber

B4160

(Ages 0-4 Years)

U9

.0.8

Enteral formula, for pediatrics, nutritionally 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

Nutren Jr.

Nutren Jr. with Fiber

Pediasure

Pediasure with Fiber

Resource Just For Kids

Resource Just for Kids-with Fiber

B4162

U9

Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

See list below

Covered Formulae:

Calcilo XD

MSUD Maxamaid

Phenex-2

Cyclinex-1

MSUD Maxamum

Phenyl Free 1

Cyclinex-2

MSUD Analog

Phenyl Free 2

Hominex-1

Periflex Advance

Propimex-1

Hominex-2

Periflex Infant

Propimex-2

l-Valex-1

Periflex Junior

XLys, XTrp Maxamaid

l-Valex-2

Phenex-1

Xphe Maxamaid

Ketonex-1

Xphe Maxamum

Ketonex-2

XPhe, XTyr Analog

XPhe, XTyr Maxamaid

B4162

U9

U1

Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

XMTVI Maxamaid

Section II

Prosthetics_______

242.150 Nutritional Formulae for Child Health Services (EPSDT)

Beneficiaries Under 21 Years of Age

The following list provide the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients.

The coverage listed is payable only if the service is prescribed as a result of a Child Health Services (EPSDT) screening/referral.

There is no prior authorization required for nutritional formulas for EPSDT beneficiaries from age five years through twenty years.

Prior authorization is required for beneficiaries from birth through four years. Use of modifier U7 in the following list will be necessary, as indicated.

To request prior authorization, providers should complete the Arkansas Foundation for Medical Care, Inc. Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components (AFMC-103), attaching a copy of the EPSDT screening/referral as well as a prescription signed by the beneficiary's PCP. View or print form AFMC-103.

NOTE: The Women, Infant and Children program (WIC) must be accessed first for children from birth through their fifth birthday.

For beneficiaries from birth through four years of age, the use of modifier U8, as well as additional documentation will be required when a non-WIC formula is prescribed or WIC guidelines are not followed when prescribing special formula.

An EPSDT screening, which documents the PCP's medical rationale for prescribing a formula, as well as medical records documenting the beneficiary's failed trials of WIC formula, must be submitted for review. Flavor preferences for formulas will not be considered for medical necessity.

Exceptions to Use of Formulas

The following exceptions must be followed in order to use formulas listed in this section.

The exceptions are indicated by an alpha letter in parenthesis that precedes the product description. For example:(A-) Nestle Good Start Supreme with DHA & ARA Powder.

A. Nestle Good Start Supreme with DHA & ARA - sensitive to intact protein - Enfamil Gentlease Lipil must first have been tried.

B. Nestle Good Start Supreme Soy with DHA & ARA, - sensitive to intact protein - Enfamil Gentlease Lipil must first have been tried.

C. Nutramigen Lipil - sensitivity or allergy to milk and soy protein - chronic diarrhea, food allergies, Gl bleeds - Enfamil Gentlease Lipil and Good Start Supreme must first have been tried.

D. EleCare - allergy to intact protein and casein hydrolysates - severe food allergies, short bowel syndrome and/or malabsorption - Alimentum, Nutramigen and Pregestimil must first have been tried.

Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under 21 Years of Age (section 242.150)

Procedure Code

M1

M2

M3

M4

Description

Covered Formulae

Covered For

mulae

;

Boost

Fibersource HN

Nutren 1.0 Fiber

Boost with B[LESS THAN]

snefibe

rand F

:OS

IsoSource

Osmolite

Carnation Ins

»tant Br

eakfas

;t-

IsoSource HN

Osmoiite 1.0 CAL

Lactose Fr(

3e

Jevity 1.0 CAL

Portagen

Ensure

Nutren 1.0

Probalance

Ensure Fiber

with F(

DS

Promote

Ensure High

Protein

i

Promote with Fiber

Ensure Powc

ier

Fibersource

B4150

EP

U1

BO

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

Boost Pudding Ensure Pudding

B4150

EP

U1

U7

BO

Ages 0-4 Years requires PA

B4152

EP

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

Boost Plus Carnation Instant Breakfast -

Lactose Free Plus Ensure Plus Nutren 1.5 Nutren 2.0 Osmolite 1.5 Cal Resource 2.0 Scandishake Two-Cal HN

B4152

EP

BO

B4152

EP

U7

B4152

EP

U7

BO

Ages 0-4 Years requires PA

B4153

EP

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

Peptamen

Peptamen 1.5

Peptamen with Prebio

1

Perative

Tolerex

Vital HN

Vivonex Plus

Vivonex TEN

B4153

EP

BO

B4153

EP

U7

B4153

EP

U7

BO

Ages 0-4 Years requires PA

Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under 21 Years of Age (section 242.150)

Procedure Code

M1

M2

M3

M4

Description

Covered Formulae

B4155

EP

U1

Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit

Polycose Powder Scandical

B4155

EP

U1

BO

B4155

EP

Ul

U7

B4155

EP

U1

U7

BO

Ages 0-4 Years requires PA

B4155

EP

U2

Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit

Microlipid

B4155

EP

U2

BO

B4155

EP

U2

U7

B4155

EP

U2

U7

BO

Ages 0-4 Years requires PA

B4155

EP

U3

Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit

80056

B4155

EP

U3

BO

MSUD1

MSUD2

PKU1

B4155

EP

U3

U7

PKU2

B4155

EP

U3

U7

BO

PKU3

Ages 0-4 Years requires PA

RCF

TYR1

TYP.2

B4160

EP

Enteral formula, for pediatrics, nutritionally 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

Nutren Jr

B4160

EP

BO

Nutren Jr with Fiber

Pediasure

Pediasure with Fiber

B4160

EP

U8

U7

Resource Just For

B4160

EP

U8

U7

BO

Kids

Ages 0-4 Years requires PA

Resource Just For Kids with Fiber

B4160

EP

U1

Enteral formula, for pediatrics, nutritionally 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

(F,) Enfamil Premature

B4160

EP

U1

BO

Lipil

With Iron 24 Cal

(F° Enfamil Premature

B4160

EP

U1

U7

Lipil

B4160

EP

U1

U7

BO

Low Iron 24 Ca!

Ages 0-4 Years requires PA

(F-) Enfamil Premature Lipil-with Iron 20 Cal (F' Enfamil Premature Lipil-Low Iron 20 Cal

B4160

EP

U.T

U8

Enteral formula, for pediatrics, nutritionally 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

Similac Neosure

B4160

EP

U1

U8

BO

Ages 0-4 Years requires PA

B4161

EP

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

B4161

EP

BO

(DJ EleCare

(E-) Neocate Infant

[LESS THAN]E° Neocate Jr

B4161

EP

U7

(E° Neocate One +

B4161

EP

U7

BO

Powder

Ages 0-4 Years requires PA

{C)Nutramigen Lipil Pregestimil Lipil Similac Alimentum

NOTE: Beneficiaries who require enteral nutrition as the sole source of nutrition with the formulae being administered through a nasogastric, jejunostomy or gastrostomy tube should be referred to a hyperalimentation provider enrolled in the Medicaid Program.

Each claim should reflect a "from" and "through" date of service. The claims must not be filed until after the "through" date has elapsed. Claims may be submitted on either a weekly or monthly basis.

NOTE: If a specific formula is not listed but is prescribed as the result of the EPSDT

screening of an Arkansas Medicaid beneficiary, the provider may forward a copy of the screening and prescription, along with product information, to Utilization Review for consideration.

NOTE: Beneficiaries who require enteral nutrition as the sole source of nutrition with the formulae being administered through a nasogastric, jejunostomy or gastrostomy tube should be referred to a hyperalimentation provider enrolled in the Medicaid Program.

Each claim should reflect a "from" and "through" date of service. The claims must not be filed until after the "through" date has elapsed. Claims may be submitted on either a weekly or monthly basis.

NOTE: If a specific formula is not listed but is prescribed as the result of the EPSDT

screening of an Arkansas Medicaid beneficiary, the provider may forward a copy of the screening and prescription, along with product information, to Utilization Review for consideration.

Disclaimer: These regulations may not be the most recent version. Arkansas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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