Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.09-027 - Prosthetics Update #146 & Hyperalimentation Update #135

Current through Register Vol. 49, No. 6, June, 2024
Section II
Prosthetics
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
(DMS-679A), 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 to their fifth
				birthday.
The Arkansas Medicaid program mirrors coverage of
				approved WIC nutritional formulas. As stated in current policy, the WIC Program
				must be accessed first for Arkansas Medicaid beneficiaries aged 0 to five (5)
				years, prior to requesting supplemental amounts of WIC approved nutritional
				formula. The Medicaid nutritional formula list will be updated accordingly to
				continue compliance with the WIC Program in Arkansas. Changes will be reflected
				in the appropriate Medicaid provider manual.
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.
A.
			 Nutramigen Lipil - sensitivity or allergy to milk and/or soy protein - chronic
			 diarrhea, food allergies, GI bleeds - Enfamil Gentlease Lipil must first have
			 been tried.
B. Nutramigen Enflora
			 LGG - Sensitivity or allergy to milk and/or soy protein; chronic diarrhea, food
			 allergies, GI bleeds - Enfamil Gentlease Lipil must first have been
			 tried.
C. Pregestimil Lipil -
			 Allergy to milk and/or soy protein; chronic diarrhea, short gut; cystic
			 fibrosis; fat malabsorption due to GI or liver disease.
D. Alimentum - allergy to milk and/or soy
			 protein; severe malnutrition; chronic diarrhea; short bowel syndrome; known or
			 suspected corn allergy - Enfamil Gentlease Lipil must first have been
			 tried.
E. EleCare - allergy to
			 intact protein; and casein hydrolysates - severe food allergies, short bowel
			 syndrome; malabsorption - Alimentum, Nutramigen Lipil or Pregestimil Lipil must
			 first have been tried.
F. Neocate -
			 allergy to intact protein and casein hydrolysates, severe food allergies; short
			 bowel syndrome; malabsorption - Alimentum, Nutramigen Lipil or Pregestimil
			 Lipil must first have been tried.
G. Nutramigen AA Lipil - Allergy to intact
			 protein and casein hydrolysates; severe food allergies; short bowel syndrome;
			 malabsorption. Alimentum, Nutramigen Lipil or Pregestimil Lipil must first have
			 been tried.
H. Portagen -
			 Pancreatic insufficiency, bile acid deficiency or lymphatic anomalies; biliary
			 atresia; liver disease; chylothorax.
I. Similac PM 60/40 - Renal, cardiac or other
			 condition that requires lowered minerals.
J. Phenyl - Free 1 - PKU;
			 Hyperphenylalaninemia; for infants and toddlers.
K. Phenex I - PKU; Hyperphenylalaninemia; for
			 infants and toddlers.
L.
			 Phenyl-Free 2 - PKU; Hyperphenylalaninemia; for children and adults.
M. Phenex II - PKU; Hyperphenylalaninemia;
			 for children and adults.
N. Enfamil
			 Premature Lipil - 20 or 24 calories - Preterm, low birth weight baby to 44
			 weeks gestational age or to a maximum weight of 8 pounds - Not approved for an
			 infant previously on term formula or a term infant for increased
			 calories.
O. Enfamil Enfacare Lipil
			 Powder - Preterm infant transitional formula - for use between premature
			 formula and term formula, the infant must have a minimum weight of 1800 grams
			 (four pounds). Not approved for an infant previously on term formula or a term
			 infant for increased calories.
Procedure codes found in this section must be billed either
				electronically or on paper with modifier
EP
for 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
B4149 B4149
B4149 B4149
Ages 0 - 4 Years requires PA
M1
EP EP
EP EP
M2
BO
U7 U7
M3
BO
M4 Description
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
Covered Formulae
Compleat
B4150 B4150
B4150 B4150
Ages 0 - 4 Years requires PA
Covered For
Boost
Carnation Ins Lactose Fr Ensure Ensure Fiber Ensure
						  High Ensure Powd
EP EP
EP EP
mulae
tant Br ee with F
Protein er
BO
U7 U7
:
eakfas
OS
BO t -
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
Fibersource HN IsoSource HN Jevity 1.0 CAL Nutren
						  1.0
See list below
Nutren 1.0 Fiber Osmolite 1.0 CAL Promote Promote with
						  Fiber
B4150
B4150
Ages 0 - 4 Years requires PA
EP EP
U1 U1
BO U7
Enteral formula, nutritionally complete with intact
						  nutrients, includes BO proteins, fats,
carbohydrates, vitamins and minerals, may include
						  fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
Boost Pudding Ensure Pudding
B4152
EP
Enteral formula,
Boost Plus
B4152
B4152 B4152
Ages 0 - 4 Years requires PA
EP
EP EP
BO
U7
U7 BO
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
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
Vivonex TEN
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 for
Boost Gluco Glucerna 1.0 Nutren Glytr Hepatic Aid I
						  Impact
mulae:
se Cont cal ol
I
rol
Impact with Fiber
Ketocal 4:1
Ketocal 3:1
Nepro with Carb Steady
NutriHep
Pulmocare Similac 60/40 Suplena with Carb Steady
B4155 B4155
Bill on paper specific nam formula on c
EP EP
(Indica e of laims.)
BO te
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 B4155
Ages 0 - 4 Years requires PA
Bill on paper specific nam formula on c
EP EP
(Indica e of laims.)
U7 te
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
B4155 B4155
B4155 B4155
Ages 0 - 4 Years requires PA
EP EP
EP EP
U1 U1
U1 U1
BO
U7 U7
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates BO (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
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates BO (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
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates BO (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
MSUD 1 MSUD 2 PKU 1 PKU 2 PKU 3 RCF TYR 1 TYR 2
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
Enfagrow Premium
Next Step
Enfamil Premium with
Triple Health Guard
Portagen
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
Enfagrow Soy Next
Step
Enfamil Prosobee Lipil
Enfamil Soy Lipil
B4159 B4159
B4159 B4159
Ages 0 - 4 Years requires PA
EP EP
EP EP
BO
U8 U8
U7 U7
Enteral formula, for pediatrics, nutritionally complete
						  soy base with intact nutrients, includes proteins, fats, BO carbohydrates,
						  vitamins and minerals, may include fiber and/or iron, administered through an
						  enteral feeding tube, 100 calories = 1 unit
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 Pediasure Pediasure with Fiber
B4160 B4160
B4160 B4160
Ages 0 - 4 Years requires PA
EP EP
EP EP
BO
U8 U8
U7 U7
Enteral formula, for pediatrics, nutritionally
						  calorically dense (equal to or greater than 0.7 Kcal/ml) with intact BO
						  nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may
						  include fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
Boost Kids Essentials
Nutren Jr
Nutren Jr with Fiber
B4160 B4160
B4160 B4160
Ages 0 - 4 Years requires PA
EP EP
EP EP
U1 U1
U1 U1
BO
U7 U7
Enteral formula, for pediatrics, nutritionally
						  calorically dense (equal to or greater than 0.7 Kcal/ml) with intact BO
						  nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may
						  include fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
Enfamil Premature Lipil With Iron 24 Cal Enfamil
						  Premature Lipil Low Iron 24 Cal Enfamil Premature Lipil-with Iron 20 Cal
						  Enfamil Premature Lipil-Low Iron 20 Cal
B4160 B4160
Ages 0 - 4 Years requires PA
EP EP
U1 U1
U8 U8
Enteral formula, for BO pediatrics, nutritionally
						  calorically dense (equal to or gre0ater 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
EleCare Neocate Infant Neocate Jr Neocate One +
						  Powder
Nutramigen AA Lipil Nutramigen Enflora LGG
Nutramigen Lipil Pregestimil Lipil Similac
						  Alimentum
B4161 B4161
B4161 B4161
Ages 0 - 4 Years requires PA
EP EP
EP EP
BO
U7 U7
U8 U8
Enteral formula, for pediatrics,
hydrolyzed/amino acids and peptide chain BO 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
Covered For
Calcilo XD
Cyclinex-1
Cyclinex-2
Hominex-1
Hominex-2
I-Valex-1
I-Valex-2
Ketonex-1
Ketonex-2
EP EP
EP EP
mulae
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
MSUD Maxamaid MSUD Maxamum MSUD Analog Periflex Advance
						  Periflex Infant Periflex Junior Phenex-1 Phenex-2
See list below
Phenyl Free 1 Phenyl Free 2 Propimex-1 Propimex-2 XLys,
						  XTrp Maxamaid Xphe Maxamaid Xphe Maxamum Xphe, XTyr Maxamaid
B4162 B4162
B4162 B4162
Ages 0 - 4 Years requires PA
EP EP
EP EP
U1 U1
U1 U1
BO
U7 U7
Enteral formula, for pediatrics, special metabolic
						  needs for inherited disease of metabolism, includes fats, BO 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.