Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral feeding supply kit; pump fed, per day, includes but 
not limited to feeding/flushing syringe, administration set tubing, dressings, tape (CPT Code B4035), 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 (CPT Code 
B4150) and enteral formula, nutritionally complete, for special metabolic needs, excludes 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  (CPT Code B4154) provided 
from March 5, 2019 through April 23, 2019. 
 
You asked the Plan to pay for the items. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. 
 
Healthcare Common Procedural Coding System (HCPCS) code B4150 (288 Units) remains not supported. The 
submitted medical records do not support the units billed; therefore, the billed service cannot be verified. It is 
noted that multiple attempts were made to contact the provider for additional information. We have insufficient 
documentation to corroborate the services so we can confirm Medicare coverage has been met. 
 
Healthcare Common Procedural Coding System (HCPCS) code B4035 (50 Units) remains not supported. The 
submitted medical records do not support the units billed; therefore, the billed service cannot be verified. It is 
noted that multiple attempts were made to contact the provider for additional information. We have insufficient 
documentation to corroborate the services so we can confirm Medicare coverage has been met. 
 
Healthcare Common Procedural Coding System (HCPCS) code B4154 (999 Units) remains not supported. The 
submitted medical records do not support the units billed; therefore, the billed service cannot be verified. It is 
noted that multiple attempts were made to contact the provider for additional information. We have insufficient 
documentation to corroborate the services so we can confirm Medicare coverage has been met.  
 
Healthcare Common Procedural Coding System (HCPCS) code B4035 (50 Units) remains not supported. The 
submitted medical records do not support the units billed; therefore, the billed service cannot be verified. It is 
noted that multiple attempts were made to contact the provider for additional information. We have insufficient 
documentation to corroborate the services so we can confirm Medicare coverage has been met.  
 
Therefore, we decided that the Plan does not have to pay for enteral feeding supply kit; pump fed, per day, 
includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape (CPT Code 
B4035), 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 
(CPT Code B4150) and enteral formula, nutritionally complete, for special metabolic needs, excludes 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  (CPT Code B4154) 
provided from March 5, 2019 through April 23, 2019.