Covered without prior authorization (high confidence)
Documentation Required
Documentation of infant age (≤ 12 months) when requesting coverage under the infant nutritional formula indication.
Documentation that the formula is specifically formulated for the treatment of an inborn error of metabolism and medical necessity for that IEM.
Use of appropriate ICD-10-CM diagnosis code(s) from the policy's listed IEM diagnoses to support the claim.
Use of appropriate HCPCS/CPT codes as listed in the policy (examples: B4154, B4155, B4157, B4162, S9435) and submission with the covered code(s) in order to be considered for reimbursement.
Key Coverage Criteria
Infant (i.e., ≤ 12 months of age) nutritional formula is considered medically necessary when specifically formulated for the treatment of an inborn error of metabolism (e.g., disorder of amino acid or organic acid metabolism).
Individuals with malabsorption syndromes may benefit from enteral nutritional support. Enteral nutritional support may be indicated when the formula comprises the primary source of nutrition (i.e., 60% or more of caloric nutritional intake).
D81.810 - Biotinidase deficiency
D81.818 - Other biotin-dependent carboxylase deficiency
When enteral nutritional support is claimed for malabsorption syndromes, documentation that the formula comprises ≥60% of caloric intake (primary source of nutrition).
For malabsorption-related claims (example given: ulcerative colitis), documentation of objective signs and symptoms of malabsorption such as serum albumin levels.