Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.08-017 - Prosthetics Update #117 & Hyperalimentation Update #110

Current through Register Vol. 49, No. 6, June, 2024
Section II
			 Hyperalimentation
221.000 Prior Authorization
Hyperalimentation fluids, equipment and supplies must be prior
				authorized by the Arkansas Foundation for Medical Care, Inc. (AFMC).
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.
HCPCS Code
M1
M2
M3
Description
Covered Formulae
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:
Boost Diab Glucerna Nutren Glyl Hepatic Aic
						  Impact
etic trol i
Impact with Fiber
IsoSource VHN
Ketocal
Nepro with Carb
NutriHep
Pulmocare
Resource Diabetic TF Similac 60/40 Suplena with
Carb Steady Traumacal
B4155
U9
3r (Indie ne of claims.;
:ate
I
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
Bill on Pap[LESS THAN] specific nar formula on
Procel Protein Supplement Provimin
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 Enfamil Kindercal Enfamil Kindercal with
						  Fiber
B4160
(Ages 0-4 Years)
U9
.0.8
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
Pediasure
Pediasure with Fiber
Resource Just For Kids
Resource Just for Kids-with Fiber
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:
Calcilo XD
MSUD Maxamaid
Phenex-2
Cyclinex-1
MSUD Maxamum
Phenyl Free 1
Cyclinex-2
MSUD Analog
Phenyl Free 2
Hominex-1
Periflex Advance
Propimex-1
Hominex-2
Periflex Infant
Propimex-2
l-Valex-1
Periflex Junior
XLys, XTrp Maxamaid
l-Valex-2
Phenex-1
Xphe Maxamaid
Ketonex-1
Xphe Maxamum
Ketonex-2
XPhe, XTyr Analog
XPhe, XTyr Maxamaid
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