Current through Register Vol. 24-18, September 15, 2024
(1) Subject to the prior authorization
requirements and limitations in this section, and in the Enteral
Nutrition Program Billing Guide, the agency covers orally administered
enteral nutrition products for clients age twenty and younger.
(2) The agency's enteral nutrition program is
not a food benefit. All clients under age five who qualify for supplemental
nutrition from the women, infants, and children (WIC) nutrition program must
receive products and formulas directly from that program. The agency may cover
orally administered enteral nutrition products for a client under age five if
the client has a WIC information form that verifies:
(a) The client is not eligible for the WIC
program;
(b) The client is eligible
for the WIC program, but the client's need for an oral enteral nutrition
product or formula exceeds the amount allowed by WIC rules; or
(c) The client is eligible for the WIC
program, but a medically necessary product or formula is not available through
the WIC program.
(3)
With expedited prior authorization, the agency covers orally administered
enteral nutrition products for a onetime, initial one-month supply if the
client:
(a) Has or is at risk of growth or
nutrient deficits due to a condition that prevents the client from meeting
their needs using food, over-the-counter nutrition products, standard infant
formula, or standard toddler formula; and
(b) Has completed the agency's enteral
nutrition products prescription form (HCA 13-961).
(4) With prior authorization (PA), the agency
covers a monthly supply of orally administered enteral nutrition products if
the client:
(a) Has or is at risk of growth
or nutrient deficits due to a condition that prevents the client from meeting
their needs using food, over-the-counter nutrition products, standard infant
formula, or standard toddler formula;
(b) Has a valid prescription that states the
product is medically necessary as defined in WAC
182-500-0070; and
(c) Has a nutrition assessment from a
registered dietitian (RD) that includes all of the following:
(i) Evaluation of the client's nutritional
status, including growth and nutrient analysis;
(ii) An explanation about why the product is
medically necessary as defined in WAC
182-500-0070;
(iii) A nutrition care plan that monitors the
client's nutrition status, and includes plans for transitioning the client to
food or food products, if possible; and
(iv) Recommendations, as necessary, for the
primary care provider to refer the client to other health care providers (for
example, gastrointestinal specialists, allergists, speech therapists,
occupational therapists, applied behavioral analysis providers, and mental
health providers) who will address the client's growth or nutrient deficits as
described in (a) of this subsection, and facilitate the client's transition to
food or food products.
(5) If a client requires orally administered
enteral nutrition products for longer than one month, the client must continue
to meet criteria in subsection (4) of this section and receive periodic
reevaluations from an RD. Periodic reevalu-ations:
(a) Must be performed at least three times a
year for a client age three or younger;
(b) Must be performed at least two times a
year for a client older than age three; and
(c) May be performed face-to-face, or by
medical record and growth data review and phone contact with the client or the
client's caregiver.
(6)
If a client requires orally administered enteral nutrition products for longer
than one month, the DME or pharmacy provider must obtain PA from the agency.
The request for PA must include all of the following:
(a) Documentation of the client's diagnosis
that supports the client's need for the orally administered enteral nutrition
product;
(b) The client's nutrition
care plan, which must monitor the client's nutrition status, and transition the
client to food or food products, if possible, or document why the client cannot
transition to food or food products;
(c) Updates to the client's nutrition care
plan resulting from subsequent reevaluations;
(d) Updates to the client's growth
chart;
(e) Documentation that shows
through regular follow up and weight checks how the prescribed product is
treating the client's growth or nutrient deficits, or is necessary to maintain
the client's growth or nutrient status;
(f) Referrals, if necessary, to other health
care providers (for example, gastrointestinal specialists, allergists, speech
therapists, occupational therapists, applied behavioral analysis providers, and
mental health providers) and show communication of recommendations and
treatment plans for the client; and
(g) Documentation of any communication the
treating provider has had with other providers, such as those in subsection
(4)(c)(iv) of this section, directly or indirectly treating the client's growth
or nutrient deficits while the client is receiving orally administered enteral
nutrition products.
11-14-075, recodified as §182-554-500, filed 6/30/11,
effective 7/1/11. Statutory Authority: 2009 c 564 § 1109,
RCW
74.04.050, and
74.08.090. 10-01-138, §
388-554-500, filed 12/21/09, effective 1/21/10. Statutory Authority:
RCW
74.04.050,
74.08.090,
74.09.530, and
74.09.700. 06-24-036, §
388-554-500, filed 11/30/06, effective 1/1/07. Statutory Authority:
RCW
74.08.090,
74.09.530 and chapter 74.09 RCW.
05-04-059, § 388-554-500, filed 1/28/05, effective
3/1/05.
