Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.08-045 - Hyperalimentation Update #116 & Prosthetics Update #123

Current through Register Vol. 49, No. 6, June, 2024
242.120
Enteral (Sole Source)
			 Formulas
The following pages provide 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.
Modifiers in this section are indicated by the headings M1, M2
				and M3.
Enteral formulas are divided into several categories. Each unit
				of service equals 100 calories of formula. All supplies and equipment necessary
				to administer the nutrients in the beneficiary's place of residence, except the
				infusion pump and pump supply kit are included in the unit description.
For a non-covered prescribed formula, a review for medical
				necessity will be performed upon request. The product information, with
				assigned HCPCS code and physician documentation of the medical necessity of the
				formula for a specific beneficiary, must be submitted to Utilization Review.
View or print the Utilization Review Section contact
				information.
If approved, the formula will be added to the
				list of covered formulae and the provider will be notified. If denied, the
				provider and beneficiary will be notified.
For beneficiaries ages 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 preference will not be considered for medical necessity.
A separate prior authorization must be obtained for the enteral
				infusion pump and the pump supply kit. The enteral infusion pump and the pump
				supply kit may be billed separately.
Exceptions to Use of
				Formula
The following exceptions must be followed in order to use
				formulas listed in this section.
The exceptions are indicated by an alpha letter in parenthesis
				that precedes the product description. For
				example:(A'* Nestle Good Start Supreme with DHA
				& ARA Powder.
A. Nestle Good Start
			 Supreme with DHS & ARA - sensitive to intact protein - Enfamil Gentlease
			 Lipil must first have been tried.
B. Nestle Good Start Supreme Soy with DHA
			 & ARA - sensitive to intact protein - Enfamil Gentlease Lipil must first
			 have been tried.
C. Nutramigen
			 Lipil - sensitivity or allergy to milk and soy protein - chronic diarrhea, food
			 allergies, Gl bleeds - Enfamil Gentlease Lipil and Good Start Supreme must
			 first have been tried.
D. EleCare -
			 allergy to intact protein and casein hydrolysates - severe food allergies,
			 short bowel syndrome and/or malabsorption - Alimentum, Nutramigen and
			 Pregestimil must first have been tried.
E. Neocate - allergy to intact protein and
			 casein hydrolysates, severe food allergies, short bowel syndrome, malabsorption
			 -Alimentum, Nutramigen and Pregestimil must have been tried.
F. 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.
G. 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).
WIC (Women Infants Children Program) must be accessed before
				the Medicaid Program for children from birth to 5 years of age.
HCPCS Code
M1
M2
M3
Description
Covered Formulae
B4149
U9
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
Compleat
B4150
U9
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
See list below
Covered Formulae:
Fibersource HN IsoSource IsoSource HN Jevity 1.0 CAL
						  Nutren 1.0
Nutren 1.0 Fiber
Osmolite
Osmolite LOCAL
Portagen
Pro balance
Promote
Promote with Fiber
Boost
Boost with Benefiberand FOS
Carnation Instant Breakfast-Lactose Free
Ensure
Ensure Fiber with FOS
Ensure High Protein
Ensure Powder
Fibersource
B4152
U9
Enteral formula, 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
Boost Plus
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
U9
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
U9
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 formulae:
Impact with Fiber
IsoSourceVHN
Ketocal
Nepro with Carb
NutriHep
Pulmocare
Resource Diabetic TF Similac 60/40 Suplena with
Carb Steady Traumacal
Boost Diabetic
Glucerna
Nutren Glytrol
Hepatic Aid
Impact
B4155 U9
Bill on Paper (Indicate specific name of formula on
						  claims.)
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
U9
U1
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
Polycose Powder Scandical
B4155
U9
U2
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
Microlipid
B4155
U9
U3
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
80056
MSUD1
MSUD2
PKU 1
PKU2
PKU 3
RCF
TYR1
TYR2
B4158
U9
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
Enfamil Next Step Lipil:
(A-» Nestle Good Start
						  Supreme with DHA & ARA Powder
B4159
U9
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
Enfamil Next Step Prosobee
Lipil Enfamil Prosobee Lipil
{B)
Nestle Good Start Supreme
						  Soy-with DHA & ARA Powder
B4159
(Ages 0-4 Years)
U9
U8
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
Similac Isomil
Similac Isomil Advance Soy-Formula with
						  Iron
B4160
U9
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
(G'' Enfamil Enfacare
						  Lipil
Powder Pediasure Pediasure with Fiber
Effective 7-1-08, WIC no longer provides Enfamil
						  Kindercal products due to manufacturer ceasing production of the product. WIC
						  replaced Enfamil Kindercal products with Pediasure or Pediasure w.
						  Fiber.
B4160
(Ages 0-4 Years)
U9
U8
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
Nutren Jr.
Nutren Jr. with Fiber
Resource Just For Kids
Resource Just for Kids-with
Fiber
B4160
U9
U1
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
(R) Enfamil Premature
						  Lipil
With Iron 24 Cal 
						  (R) Enfamil Premature
						  Lipil
Low Iron 24 Cal 
						  (R) Enfamil Premature Lipil-with
						  Iron 20 Cal 
						  (R) Enfamil Premature Lipil-Low
						  Iron 20 cal
B4160
(Ages 0-4 Years)
U9
U1
U8
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
Similac Neosure
B4161
U9
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
(D-)
						  EleCare
(E-[GREATER THAN] Neocate
						  Infant
(E'* Neocate Jr.
(E-[GREATER THAN] Neocate
						  One + Powder
(C)
						  Nutramigen Lipil
Pregestimil Lipil
Similac Alimentum
B4161
Ages 5 to 99 Years
B4161
(Ages 0-4 Years)
U9 U9
U8
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
E028 Splash Peptamen Jr. Vivonex Pediatric
B4162
U9
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
See list below
Covered Formulae:
MSUD Maxamaid MSUD Maxamum MSUD Analog Periflex Advance
						  Periflex Infant
Periflex Junior Phenex-1
Phenex-2
Phenyl Free 1
Phenyl Free 2
Propimex-1
Propimex-2
XLys, XTrp Maxamaid
Xphe Maxamaid
Xphe Maxamum
XPhe.XTyr Analog
XPhe, XTyr Maxamaid
Calcilo XD
Cyclinex-1
Cyclinex-2
Hominex-1
Hominex-2
l-Valex-1
l-Valex-2
Ketonex-1
Ketonex-2
B4162
U9
U1
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
XMTVI Maxamaid
TOC not required