Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.07-010 - Hyperalimentation Provider Manual Update Transmittal # 89

Current through Register Vol. 49, No. 6, June, 2024
Section II
Hyperalimentation
242.120
Enteral (Sole Source) Formulas
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.
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.
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.
WIC (Women Infants Children Program) must be accessed before
				the Medicaid Program for children from birth to 5 years of age.
Modifiers in this section are indicated by the headings M1 and
				M2.
HCPCS Code
M1
M2
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:
Boost
Fibersource HN
Nutren 1.0 with Fiber
Boost with Benefiber and FOS
Fortison
Osmolite
Carnation Instant Breakfast -
Intraolite
Osmolite 1.0 CAL
Lactose Free
Isocal
Osmolite HN
Ensure
Isocal HN
Portagen
Ensure Fiber with FOS
IsoSource
Probalance
Ensure High Protein
IsoSource HN
Promote
Ensure HN
Jevity 1.0 CAL
Promote with Fiber
Ensure Powder
Nutrapack
Ultracal
Fibersource
Nutren 1.0
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 Comply Ensure Plus Novasource 2.0
						  Nutren 1.5 Nutren 2.0 Osmolite 1.5 Cal 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
Alitraq
Criticare HN
Isotein HN
Peptamen
Peptamen 1.5
Peptamen VHP
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
B4155
U9
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
Casec Powder Fructose Powder MCT Oil Polycose Liquid
						  Procel Protein Power Provimin Sumacal
Bill on Paper (Indicate specific name of formula on
						  claims.)
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
Dextrose
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
Microlipids
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
Product 80056
PKU 1, 2 and 3
RCF
Try 1 and 2
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
Enfamil AR Lipil Enfamil Lactofree Enfamil Lactofree
						  Lipil Enfamil Lipil Low Iron Enfamil Lipil with Iron Enfamil Next Step Lipil
						  Nutren Jr.
Nutren JR with Fiber Resource for Kids Resource Just
						  for Kids with Fiber
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 Isomil
Isomil Advance Soy with Iron Prosobee
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
Enfamil Enfacare Lipil
Powder Kindercal
Kindercal with Fiber Pediasure Pediasure 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
Enfamil Premature Lipil
24 Cal Low Iron Enfamil Premature Lipil
24 Cal with Iron Similac Neosure Similac Neosure
						  Advance Special Care Advance 20 Special Care Advance 20
with Iron Special Care Advance 24 Special Care Advance
						  24
with Iron
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
Alimentum
ELECARE
Enfamil Nutramigen Lipil
Enfamil Pregestimil
Neocate Infant Formula
Neocate Jr
Neocate One + (Pediatric
E028) Liquid Neocate One + Powder Nutramigen Peptamen
						  Jr Pregestimil Similac Alimentum Advance with Iron 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 Fo
Calcilo XD
Cyclinex-1
Cyclinex-2
Hominex-1
Hominex-2
I-Valex-1
I-Valex-2
Ketonex-1
Ketonex-2
rmulae:
Low Phe Try Diet Powder Maxamaid MSUD
Maxamum MSUD
MSUD Analog MSUD 1 and 2
Periflex Advanced
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
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 Maximaid
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.
				Add utilization review link here.
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.