Other Services
Chapter 8
Section 7.1
Nutritional Therapy -
For Dates Of Service On or Before December 22, 2017
Issue Date: April 19, 1983
Revision: C-8, August 28, 2017
1.0 HCPCS
PROCEDURE CODES
B4034 - B9999
2.0
DESCRIPTION
Nutritional therapy provides medically necessary
nutrient intake for individuals with:
• Inborn Errors
of Metabolism (IEM);
• Medical conditions
of malabsorption;
• Pathologies of
the alimentary or gastrointestinal tract; and/or
• Neurological or
physiological conditions which require enteral tube feedings.
3.0
POLICY
3.1 When
used as the primary source of calories or as the primary source
or a required macronutrient (i.e., protein), TRICARE may cost-share
medically necessary supplies and nutritional products for:
3.1.1 Enteral
nutritional therapy.
3.1.2 Parenteral nutritional therapy.
3.1.3 Oral nutritional
therapy.
3.1.4 Medically necessary vitamins and minerals added
to the nutritional solution.
3.1.5 Intraperitoneal Nutrition
(IPN) therapy when determined to be medically necessary treatment
for individuals suffering from malnutrition as a result of end stage
renal disease.
3.1.6 Ketogenic
diet if it is part of a medically necessary admission for epilepsy.
Services and supplies will be reimbursed under the Diagnosis Related
Group (DRG) payment methodology.
3.2 Medically necessary nutritional
products which are provided under
paragraph 3.1 and which are on the “Enteral
Nutrition Product Classification List” are eligible for TRICARE
cost-sharing. The list is maintained by Noridian Administrative
Services and is currently available online at:
http://www.dmepdac.com/dmecsapp/do/search.
3.3 Medical
supplies and equipment required to provide the therapy are covered.
3.4 Nutritional
therapy may be provided in the inpatient or outpatient setting.
4.0 EXCLUSIONS
4.1 Food and
food substitutes.
4.3 Nutritional
supplements administered solely to boost protein or caloric intake
or in the absence of a medical condition for which the accepted
treatment consists of or includes administration of nutritional
supplements.
4.4 The above exclusions apply also to prenatal
care.
4.5 For children less than one year of age who
require enteral nutritional therapy, formulas that are readily available
in a retail environment and are marketed for use by infants without
medical conditions as described in
paragraph 2.0 are excluded
from coverage.
4.6 Except as provided in
paragraph 3.1.6, services
and supplies related to a ketogenic diet, including nutritional
counseling, calculation of a ketogenic formula, and food substitutes.
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