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TRICARE Policy Manual 6010.60-M, April 1, 2015
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.
4.2  Vitamins or mineral preparations, except as provided in paragraph 3.0 or by Section 9.1.
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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