3.0 Policy
3.1 Medically
necessary food and medical equipment and supplies necessary to administer
such food are covered by TRICARE when prescribed for dietary management
of a covered disease or condition. Medically necessary food includes
specialized formulas, a Low Protein Modified Food (LPMF) product
or an amino acid preparation product. Medically necessary food and
medical equipment and supplies may be covered when it is:
3.1.1 Furnished
pursuant to the prescription of a TRICARE authorized individual
professional provider as described in
32 CFR 199.6 (e.g., physician, certified Nurse
Practitioner (NP), or a certified Physician Assistant (PA), etc.)
acting within the provider’s scope of license/certificate of practice
for the dietary management of a covered disease or condition as
listed in
paragraph 3.3; and
3.1.2 A specifically formulated
and processed product (as opposed to a naturally occurring foodstuff
used in its natural state) for the partial or exclusive feeding
of an individual by means of oral intake, or enteral feeding by
tube, or parenteral feeding by IV, or intraperitoneal administration;
and
3.1.3 Intended for the dietary management of an individual
who, because of therapeutic or chronic medical needs, has limited
or impaired capacity to ingest, digest, absorb, or metabolize ordinary
foodstuffs or certain nutrients, or who has other special medically
determined nutrient requirements, the dietary management of which
cannot be achieved by the modification of the normal diet alone;
and
3.1.4 Intended to be used under medical supervision,
which may include in a home setting; and
3.1.5 Intended only for an individual
receiving active and ongoing medical supervision under which the
individual requires medical care on a recurring basis for, among
other things, instructions on the use of the food.
3.2
Medically
Necessary Vitamins And Minerals
Medically
necessary vitamins and minerals, including prenatal vitamins for
prenatal care (also see
Section 9.1),
are covered when used for the management of a covered disease or
condition, as listed in
paragraph 3.3, pursuant to a prescription
or order of a TRICARE authorized individual professional provider
acting within the provider’s scope of license/certificate of practice
as described in
32 CFR 199.6.
3.3 Covered
disease or conditions include:
• Inborn Errors of Metabolism
(IEM);
• Medical
conditions of malabsorption;
• Pathologies of
the alimentary tract or the gastrointestinal tract; and,
• A neurological
or physiological condition.
3.4 Specialized
Formulas
Specialized formulas, to include
amino acid based formulas, when covered as medically necessary food
under
paragraph 3.1, will be found in the “Enteral
Nutrition Product Classification List.” The list is maintained by
Noridian Administrative Services and is currently available on line
at:
https://www.dmepdac.com/dmecsapp/do/search.
3.5 Low Protein
Modified Foods
3.5.1 Low protein modified foods, when covered as
medically necessary foods under
paragraph 3.1, are those food products that
have been modified to be low in protein for use by individuals who have
been diagnosed with IEM (e.g., phenylketonuria (PKU)), maple syrup
urine disease, etc.), and are not typically readily available in
grocery stores. Low protein modified foods are primary to the management
of IEM, as they help those diagnosed with the condition, avoid organ
damage, grow properly, and maintain or improve health status. Low
protein modified foods may be covered pursuant to a prescription,
when medically necessary and appropriate for the treatment of IEM.
3.5.2 Contractor
Responsibilities - Low Protein Modified Foods
3.5.2.1 The contractor
shall preauthorize all prescribed low protein modified medical foods
and ensure the low protein modified foods are medically necessary
and appropriate medical care for the treatment of IEM.
3.5.2.2 If preauthorization
is not obtained and the contractor finds the low protein modified
foods is medically necessary and appropriate and the care otherwise
meets the requirements of this policy, the payment reduction provision
of the TRICARE Reimbursement Manual (TRM),
Chapter 1, Section 28 applies.
3.5.2.3 If preauthorization
is not obtained by the beneficiary and the beneficiary purchases
low protein modified food directly from a vendor, and all policy
criteria are met, the appropriate out of network cost-share shall
apply.
3.5.2.4 Low protein modified food products are purchased
from vendors who specialize in the distribution of low protein modified
foods. The contractor shall include providers of low protein modified
foods in their network as medical supply firm providers.
3.6 Ketogenic
Diet
3.6.1 Inpatient ketogenic diet is covered when it
is part of a medically necessary inpatient admission for epilepsy.
Services and supplies will be reimbursed under the Diagnosis Related
Group (DRG) payment methodology.
3.6.2 Medically necessary specialized
formulas (e.g., Ketocal) for the treatment of seizures that are
refractory to standard anti-seizure medication are covered when
otherwise covered as a medically necessary food under
paragraph 3.1.
Covered items include those on the list maintained by Noridian Administrative
Services and available online at:
https://www.dmepdac.com/dmecsapp/do/search.
3.7 Medical Nutritional
Therapy/Medical Nutritional Counseling
3.7.1 Medical nutritional therapy/medical
nutritional counseling required in the administration and maintenance
of TRICARE covered medically necessary foods, to include low protein
foods, for those covered conditions listed in
paragraph 3.3, may be covered
when medically necessary and appropriate.
3.7.2 Medical nutritional therapy
must be provided by a TRICARE authorized individual professional
provider described in
32 CFR 199.6 (e.g.,
physician, nurse, nutritionist, or Registered Dietician (RD)). If
required by
32 CFR 199.6,
the authorized provider (e.g., a nutritionist or RD) must be licensed
by the state in which the care is provided and must be under the
supervision of a physician who is overseeing the episode of treatment
or the covered program of services.
4.0 Reimbursement
4.1 Medical
foods shall be reimbursed using the rate on the Durable Medical
Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule.
If there is no DMEPOS fee schedule rate, the allowable charge shall
be established in accordance with the TRM,
Chapter 3, Section 1 and
Chapter 5, Sections 1 and
3.
4.2 When reimbursement is made
in accordance with the TRM,
Chapters 3 and
5, especially when the state prevailing or
billed rate is used, the contractor shall ensure the provisions
of
32 CFR 199.9(b)(2),
(b)(7),
(c)(11) and
the TRICARE Operations Manual (TOM),
Chapter 13,
are followed to prevent fraud and abuse.
5.0 Exclusions
TRICARE covered medically necessary food and
vitamins do not include:
5.1 Food taken as part of an overall
diet designed to reduce the risk of a disease or medical condition,
or as weight-loss products, even if the food is recommended by a
physician or other health care professional.
5.2 Food marketed
as gluten-free for the management of celiac disease or non-celiac
gluten sensitivity.
5.3 Food marketed for the management
of diabetes.
5.4 Vitamins or mineral preparations, except as
provided in
paragraph 3.2.
5.5 Nutritional supplements administered
in the absence of a covered disease or a medical condition that
is listed in
paragraph 3.3.
5.6 Megavitamin psychiatric therapy,
orthomolecular psychiatric therapy.
5.7 Items used primarily for convenience
or for features which exceed that which is medically necessary (for
example, prepackaged, liquid vs. powder, etc.).
5.8 Over-the-counter
(OTC) nutritional products that are marketed for use for individuals
without medical conditions and can be purchased and readily available
in a retail supermarket, wholesale club, or pharmacy, etc.
5.9 Naturally
occurring foodstuff used in its natural state, to include those
that are naturally low in protein. Excluded items are those not
intended to be used under the direction of a physician for the dietary
treatment of an inborn error of metabolism.
5.10 Healthcare
Common Procedure Coding System (HCPCS) code B4104 is an enteral
formula additive. The enteral formula codes include all nutrient
components, including vitamins, mineral and fiber. As a result B4104
is not separately payable.
5.11 Banked breast milk.
5.12 Non-prescription
nutritional formula that does not require a prescription and is
delivered orally (e.g., Ensure, Boost, etc).