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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 covered for a beneficiary who requires feedings via an enteral access 
device to provide sufficient nutrients to maintain weight and strength commensurate with the beneficiary's 
overall health status and has a permanent: 
A. full or partial non-function or disease of the structures that normally permit food to reach the small 
bowel; OR, 
B. disease that impairs digestion and/or absorption of an oral diet, directly or indirectly, by the small 
bowel. 
Adequate nutrition must not be possible by dietary adjustment and/or oral supplements. 
 
Typical examples of conditions associated with non-function or disease of the structures that permit food from 
reaching the small bowel 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 (not all inclusive). 
 
Typical examples of conditions associated with impaired digestion and/or absorption of an oral diet by the 
small bowel that may qualify for coverage include inflammatory bowel disease, surgical resection of small 
bowel, cystic fibrosis, chronic pancreatitis, and advanced liver disease (not all inclusive). 
 
If the coverage requirements for enteral nutrition are met, medically necessary nutrients, administration 
supplies, and equipment are covered. 
For coverage of the following scenarios, see the LCD-related Policy Article: 
 Enteral nutrition for temporary impairments 
 Enteral nutrition for beneficiaries with a functioning gastrointestinal tract whose need for enteral 
nutrition is not due to reasons related to the non-function or disease of the structures that normally 
permit food to reach the small bowel 
 Orally administered enteral nutrition products, related supplies and equipment 
 
 
 NUTRIENTS 
 
Enteral formulas consisting of semi-synthetic intact protein/protein isolates (B4150 or B4152) are appropriate 
for the majority of beneficiaries requiring enteral nutrition. 
 
The medical necessity for special enteral formulas (B4149, B4153, B4154, B4155, B4157, B4161, and B4162) 
must be justified in each beneficiary. If a special enteral nutrition formula is provided and if the medical record 
does not document why that item is medically necessary, it will be denied as not reasonable and necessary. 
(Refer to the LCD-related Policy Article for policy specific documentation requirements.) 
 
EQUIPMENT AND SUPPLIES 
 
Enteral nutrition may be administered by syringe, gravity, or pump. Some enteral beneficiaries may experience 
complications associated with syringe or gravity method of administration. 
 
You can find these rules in the Local Coverage Determination: Enteral Nutrition: L38955. 
 
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.