Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-045 - Hyperalimentation Update #116 & Prosthetics Update #123
Current through Register Vol. 49, No. 9, September, 2024
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.
WIC (Women Infants Children Program) must be accessed before the Medicaid Program for children from birth to 5 years of age.
|
HCPCS Code |
M1 |
M2 |
M3 |
Description |
Covered Formulae |
|
B4149 |
U9 |
Enteral formula, 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 |
Compleat |
||
|
B4150 |
U9 |
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 |
See list below |
||
|
Covered Formulae: |
Fibersource HN IsoSource IsoSource HN Jevity 1.0 CAL Nutren 1.0 |
Nutren 1.0 Fiber Osmolite Osmolite LOCAL Portagen Pro balance Promote Promote with Fiber |
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Boost |
|||||
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Boost with Benefiberand FOS |
|||||
|
Carnation Instant Breakfast-Lactose Free |
|||||
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Ensure |
|||||
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Ensure Fiber with FOS |
|||||
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Ensure High Protein |
|||||
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Ensure Powder |
|||||
|
Fibersource |
|||||
|
B4152 |
U9 |
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 |
||
|
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: |
Impact with Fiber IsoSourceVHN Ketocal Nepro with Carb NutriHep |
Pulmocare Resource Diabetic TF Similac 60/40 Suplena with Carb Steady Traumacal |
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|
Boost Diabetic |
|||||
|
Glucerna |
|||||
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Nutren Glytrol |
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Hepatic Aid |
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Impact |
|||||
|
B4155 U9 Bill on Paper (Indicate specific name of formula on claims.) |
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 Procel Protein Supplement Provimin |
|||
|
B4155 |
U9 |
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 |
U9 |
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 |
U9 |
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 MSUD1 MSUD2 PKU 1 PKU2 PKU 3 RCF TYR1 TYR2 |
|
B4158 |
U9 |
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 |
Enfamil AR Lipil Enfamil Gentlease Lipil Powder Enfamil Lactofree Lipil Enfamil Lipil with Iron Enfamil Next Step Lipil: (A-» Nestle Good Start Supreme with DHA & ARA Powder |
|
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 Pediasure Pediasure with Fiber Effective 7-1-08, WIC no longer provides Enfamil Kindercal products due to manufacturer ceasing production of the product. WIC replaced Enfamil Kindercal products with Pediasure or Pediasure w. Fiber. |
|
|
B4160 (Ages 0-4 Years) |
U9 |
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 |
Nutren Jr. Nutren Jr. with Fiber Resource Just For Kids Resource Just for Kids-with Fiber |
|
B4160 |
U9 |
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 |
(R) Enfamil Premature Lipil With Iron 24 Cal (R) Enfamil Premature Lipil Low Iron 24 Cal (R) Enfamil Premature Lipil-with Iron 20 Cal (R) Enfamil Premature Lipil-Low Iron 20 cal |
|
|
B4160 (Ages 0-4 Years) |
U9 |
U1 |
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 |
|
B4161 |
U9 |
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 |
(D-) EleCare (E-[GREATER THAN] Neocate Infant (E'* Neocate Jr. (E-[GREATER THAN] Neocate One + Powder (C) Nutramigen Lipil Pregestimil Lipil Similac Alimentum |
||
|
B4161 Ages 5 to 99 Years B4161 (Ages 0-4 Years) |
U9 U9 |
U8 |
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 |
E028 Splash Peptamen Jr. Vivonex Pediatric |
|
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: |
MSUD Maxamaid MSUD Maxamum MSUD Analog Periflex Advance Periflex Infant Periflex Junior Phenex-1 |
Phenex-2 Phenyl Free 1 Phenyl Free 2 Propimex-1 Propimex-2 XLys, XTrp Maxamaid Xphe Maxamaid Xphe Maxamum XPhe.XTyr Analog XPhe, XTyr Maxamaid |
|||
|
Calcilo XD Cyclinex-1 Cyclinex-2 Hominex-1 Hominex-2 l-Valex-1 l-Valex-2 Ketonex-1 Ketonex-2 |
|||||
|
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 |
|
TOC not required
242.150 Nutritional Formulae for Child Health Services (EPSDT)
Beneficiaries Under 21 Years of Age
The following list provides 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 DMS-679A.
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.
Procedure codes found in this section must be billed either electronically or on paper with modifier EPfor beneficiaries under 21 years of age. Modifier BO is used to bill for oral usage. When a second or third modifier is listed, that modifier must be used in conjunction with EP.
For beneficiaries from birth through four years of age, the use of modifier U7, 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.
Modifiers in this section are indicated by the headings M1, M2, M3 and M4.
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 |
|
B4149 B4149 B4149 B4149 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
BO |
Enteral formula, 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 |
Compleat |
|
|
B4150 B4150 B4150 B4150 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
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 |
See list below |
|
Covered Formulae: |
Fibersource HN IsoSource IsoSource HN Jevity LOCAL Nutren 1.0 |
Nutren 1.0 Fiber Osmolite Osmolite 1.0 CAL Portagen Probalance Promote Promote with Fiber |
||||
|
Boost |
||||||
|
Boost with Benefiber and FOS |
||||||
|
Carnation Instant Breakfast-Lactose Free |
||||||
|
Ensure |
||||||
|
Ensure Fiber with FOS |
||||||
|
Ensure High Protein |
||||||
|
Ensure Powder |
||||||
|
Fibersource |
||||||
|
B4150 B4150 Ages 0-4 Years requires PA |
EP EP |
U1 U1 |
BO U7 |
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 |
|
B4152 B4152 B4152 B4152 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
BO |
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 |
|
|
B4153 B4153 B4153 B4153 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
BO |
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 VivonexTEN |
|
|
B4154 B4154 B4154 B4154 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
BO |
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: |
Impact with Fiber IsoSourceVHN Ketocal Nepro with Carb Steady NutriHep |
Pulmocare Resource Diabetic TF Similac 60/40 Suplena with Carb Steady Traumacal |
||||
|
Boost Diabetic |
||||||
|
Glucerna |
||||||
|
Nutren Glytrol |
||||||
|
Hepatic Aid |
||||||
|
Impact |
||||||
|
B4155 B4155 |
EP EP |
BO |
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 Procel Protein Supplement Provimin |
||
|
Bill on paper (Indicate specific name of formula on claims.) |
||||||
|
B4155 B4155 Ages 0-4 Years requires PA |
EP EP |
U7 |
BO |
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 Procel Protein Supplement Provimin |
|
|
Bill on paper (Indicate specific name of formula on claims.) |
||||||
|
B4155 B4155 B4155 B4155 Ages 0-4 Years requires PA |
EP EP EP EP |
U1 U1 U1 U1 |
BO U7 U7 |
BO |
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 B4155 B4155 B4155 Ages 0-4 Years requires PA |
EP EP EP EP |
U2 U2 U2 U2 |
BO U7 U7 |
BO |
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 B4155 B4155 B4155 Ages 0-4 Years requires PA |
EP EP EP EP |
U3 U3 U3 U3 |
BO U7 U7 |
BO |
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 MSUD1 MSUD2 PKU 1 PKU2 PKU 3 RCF TYR1 TYR2 |
|
B4158 B4158 B4158 B4158 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
BO |
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 |
Enfamil AR Lipil Enfamil Gentlease - Lipil Powder Enfamil Lactofree Lipil Enfamil Lipil with Iron Enfamil Next Step- Lipil (A[GREATER THAN]Nestle Good Start Supreme with DHA & ARA Powder |
|
|
B4159 B4159 B4159 B4159 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
BO |
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 B4159 B4159 B4159 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U8 U8 |
U7 U7 |
BO |
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 with Iron |
|
B4160 B4160 B4160 B4160 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
BO |
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 |
Enfamil Enfacare Lipil Powder Pediasure Pediasure with Fiber Effective 7-1-08, WIC no longer provides Enfamil Kindercal products due to manufacturer ceasing production of the product. WIC replaced Kindercal products with Pediasure or Pediasure w. Fiber. |
|
|
B4160 B4160 B4160 B4160 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U8 U8 |
U7 U7 |
BO |
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 Jrwith Fiber Resource Just For Kids Resource Just For Kids with Fiber |
|
B4160 B4160 B4160 B4160 Ages 0-4 Years requires PA |
EP EP EP EP |
U1 U1 U1 U1 |
BO U7 U7 |
BO |
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 |
(R) Enfamil Premature Lipil With Iron 24 Cal (R) Enfamil Premature Lipil Low Iron 24 Cal (R) Enfamil Premature Lipil-with Iron 20 Cal (F' Enfamil Premature Lipil-Low Iron 20 Cal |
|
B4160 B4160 Ages 0-4 Years requires PA |
EP EP |
U1 U1 |
U8 U8 |
BO |
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 |
|
B4161 B4161 B4161 B4161 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
BO |
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 |
(D-) EleCare (E'* Neocate Infant (E-[GREATER THAN] Neocate Jr (E'* Neocate One + Powder (C) Nutramigen Lipil Pregestimil Lipil Similac Alimentum |
|
|
B4161 B4161 B4161 B4161 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
U8 |
BO |
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 |
E028 Splash Peptamen Jr. Vivonex Pediatric |
|
B4162 B4162 B4162 B4162 Ages 0-4 Years requires PA |
EP EP EP EP |
BO U7 U7 |
BO |
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: |
MSUD Maxamaid MSUD Maxamum MSUD Analog Periflex Advance Periflex Infant Periflex Junior Phenex-1 Phenex-2 |
Phenyl Free 1 Phenyl Free 2 Propimex-1 Propimex-2 XLys, XTrp Maxamaid Xphe Maxamaid Xphe Maxamum Xphe, XTyr Maxamaid |
||||
|
Calcilo XD Cyclinex-1 Cyclinex-2 Hominex-1 Hominex-2 l-Valex-1 l-Valex-2 Ketonex-1 Ketonex-2 |
||||||
|
B4162 B4162 B4162 B4162 Ages 0-4 Years requires PA |
EP EP EP EP |
U1 U1 U1 U1 |
BO U7 U7 |
BO |
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 |
One unit of service equals 100 calories with a reimbursable maximum of 30 units per day. Supplies furnished by prosthetics providers in conjunction with the nutritional formula must be billed to Medicaid with the prosthetics medical supply codes. These formulae are covered as nutritional supplements rather than as the sole source of nutrition.
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 a 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.
