Does B4216 require prior authorization?

No, B4216 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`B4216`, Parenteral nutrition; additives (vitamins, trace elements, heparin,

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

A completed Standard Written Order (SWO) must be communicated to the supplier before claim submission; for DMEPOS base items requiring WOPD, a signed WOPD must be received before delivery.
Medical records must document the clinical diagnosis, the consideration/attempt/contraindication of enteral nutrition, and permanence of the impairment (see Policy Article).
Treating practitioner evaluation within 30 days prior to initiation of parenteral nutrition must be documented, or the reason and alternate monitoring methods must be documented if not performed.

Key Coverage Criteria

Parenteral nutrition is covered when the beneficiary qualifies under the Medicare Prosthetic Device Benefit and the service is reasonable and necessary for the diagnosis or treatment of illness or injury.
Parenteral nutrition is covered only when enteral nutrition (EN) has been considered and ruled out, tried and found ineffective, or EN exacerbates gastrointestinal tract dysfunction.
Beneficiary must have either (a) a condition of the small intestine and/or its exocrine glands that significantly impairs nutrient absorption or (b) disease of the stomach and/or intestine that is a motility disorder impairing transport and absorption of nutrients.
The beneficiary must have a permanent impairment causing the need for parenteral nutrition (see LCD-related Policy Article for permanence guidance).
Related supplies, equipment, and nutrients are covered when the coverage requirements for parenteral nutritional therapy are met under the prosthetic device benefit.
A daily total caloric intake of 20–35 kcal/kg/day is considered reasonable and necessary; medical necessity must be documented if prescribing calories outside this range.

7 Active Policies

ANTHEM-CG-MED-89, Home Parenteral Nutrition

ANTHEM-CG-MED-99, Intradialytic Parenteral Nutrition

L38953, Parenteral Nutrition

BCBSIL-MED201.011, Nutritional Support

BCBSMT-MED201.011, Nutritional Support

BCBSNM-MED201.011, Nutritional Support

BCBSOK-MED201.011, Nutritional Support

`B4216`, Parenteral nutrition; additives (vitamins, trace elements, heparin,

Prior Authorization

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

B4216, Parenteral nutrition; additives (vitamins, trace elements, heparin,

Prior Authorization

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

`B4216`, Parenteral nutrition; additives (vitamins, trace elements, heparin,