Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
The rules say that enteral nutrition is considered reasonable and necessary for a patient with a functioning 
gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to 
reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition. 
Enteral therapy may be given by nasogastric, jejunostomy, or gastrostomy tubes and can be provided safely and 
effectively in the home by nonprofessional persons who have undergone special training. However, such 
persons cannot be paid for their services, nor is payment available for any services furnished by non-physician 
professionals except as services furnished incident to a physician's service. 
Typical examples of conditions that qualify for coverage are head and neck cancer with reconstructive surgery 
and central nervous system disease leading to interference with the neuromuscular mechanisms of ingestion of 
such severity that the beneficiary cannot be maintained with oral feeding. However, claims for Part B coverage 
of enteral nutrition therapy for these and any other conditions must be approved on an individual, case-by-case 
basis. Each claim must contain a physician's written order or prescription and sufficient medical documentation 
(e.g., hospital records, clinical findings from the attending physician) to permit an independent conclusion that 
the patient's condition meets the requirements of the prosthetic device benefit and that enteral nutrition therapy 
is medically necessary. Allowed claims are to be reviewed at periodic intervals of no more than 3 months by 
the A/B MAC (B) medical consultant or specially trained staff, and additional medical documentation 
considered necessary is to be obtained as part of this review. 
Medicare pays for no more than one month's supply of enteral nutrients at any one time. If the claim involves a 
pump, it must be supported by sufficient medical documentation to establish that the pump is medically 
necessary, i.e., gravity feeding is not satisfactory due to aspiration, diarrhea, dumping syndrome. Program 
payment for the pump is based on the reasonable charge for the simplest model that meets the medical needs of 
the patient as established by medical documentation. 
Nutritional Supplementation 
Some patients require supplementation of their daily protein and caloric intake. Nutritional supplements are 
often given as a medicine between meals to boost protein-caloric intake or the mainstay of a daily nutritional 
plan. Nutritional supplementation is not covered under Medicare Part B. 
 
You can find this rule in the National Coverage Determination (NCD) for Enteral and Parenteral Nutritional 
Therapy (180.2). 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.