2.0 HCPCS
PROCEDURE CODES
B4034 - B9999, S9433 - S9435
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 3.2; 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 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.
3.3 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 3.2,
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.
3.4 Specialized
Formulas
3.4.1 Specialized formulas, to include amino acid
based formulas, when covered as medically necessary food under
paragraph 3.1,
are
listed in the “Enteral Nutrition Product Classification
List.” The list is maintained by Noridian Administrative Services
and
can be found at:
https://www.health.mil/rates.
3.4.2 Specialized formulas included
on the Noridian Enteral Nutrition Product Classification List are
covered for enteral and oral consumption.
3.5 Low Protein
Modified Foods
(LPMFs)3.5.1 LPMFs,
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),
or maple
syrup urine disease
), and are not typically
readily available in grocery stores.
LPMFs 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.
LPMFs may be
covered pursuant to a prescription, when medically necessary and
appropriate for the treatment of IEM.
3.5.2 Contractor Responsibilities
-
LPMFs3.5.2.1 The contractor
shall preauthorize all prescribed LPMFs and
ensure the LPMFs 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
LPMFs 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 LPMF directly
from a vendor, and all policy criteria are met, the appropriate
out of network cost-share shall apply.
3.5.2.4 LPMF products
are purchased from vendors who specialize in the distribution of LPMFs. The
contractor shall include providers of LPMFs 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 Outpatient services
and supplies for ketogenic diet are covered for the treatment of seizures
that are refractory to anti-seizure medication. Covered supplies
are included on the list maintained by Noridian Administrative Services
and can be found at: https://www.health.mil/rates.
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 3.2,
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 3.3.
5.5 Nutritional
supplements administered in the absence of a covered disease or
a medical condition that is listed in
paragraph 3.2.
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 Nutritional products
that are marketed for use for individuals without medical conditions.
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 Specialized
formulas, except those covered in paragraph 3.4.