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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