|Highmark Commercial Medical Policy - Pennsylvania|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Mandated Enteral Nutrition
Effective June 20, 1997, enteral feeding solutions administered by any method are eligible when necessary for the therapeutic treatment of the following hereditary genetic disorders as defined in Act 191 - 1996. Under this Act, benefits for medically necessary enteral formulas, such as PKU 1 or 2, Lofenalac, or Ketonex 1 or 2, administered under the direction of a physician for these specified conditions are exempt from any contract deductibles:
Effective April 20, 2015, coverage for amino acid-based elemental medical formulas is determined according to individual or group customer benefits.
Amino acid-based elemental medical formulas, made of 100% free amino acids as the protein source, are eligible when ordered by a physician as medically necessary for oral or enteral administration in infants and children and are exempt from any contract deductibles as set forth in Act 158-2014, for the following conditions:
Non-mandated Enteral Nutrition
Infant formulas, administered either by mouth or through a tube, may be considered medically necessary based on the content of the formula and the reason for use of a special formula as noted above.
Infant formulas administered either by mouth or through a tube for lactose intolerance, milk protein intolerance, or other milk allergies are not indications for coverage and therefore considered not medically necessary. However, any hemorrhagic colitis secondary to these conditions is medically necessary. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.
Enteral feeding via nasogastric, jejunostomy, or gastrostomy tubes is an alternative to parenteral nutrition for the patient with a functioning gastrointestinal tract but for whom regular, oral feeding is impossible. Indications for enteral feeding solutions via tube feeding include but are not limited to:
Enteral Accessories and Supplies
Accessories and/or supplies that are used directly with enteral systems to achieve therapeutic benefit or assure proper functioning of the feeding system are eligible durable medical equipment (DME). They include:
No more than one month's supply of enteral nutrients, equipment or supplies may be dispensed at one time.
The codes for feeding supply kits are specific to the route of administration. Claims for more than one type of kit code delivered on the same date or provided on an ongoing basis will be denied as not medically necessary. The feeding supply kit must correspond to the method of administration.
More than three nasogastric tubes, or one gastrostomy/jejunostomy tube every three months is not medically necessary.
The codes for the enteral feeding supplies include all supplies, other than the feeding tube itself, required for the administration of enteral nutrients to the patient for one day. Some items are changed daily; others may be used for multiple days. Items included in these codes are not limited to pre-packaged "kits" bundled by manufacturers or distributors. These supplies include, but are not limited to, feeding bag/container, flushing solution bag/container, administration set tubing, extension tubing, feeding/flushing syringes, gastrostomy tube holder, dressings (any type) used for gastrostomy tube site, tape (to secure tube or dressings), Y connector, adapter, gastric pressure relief valve, declogging device, etc. These items must not be separately billed using the miscellaneous code or using specific codes for dressings or tape. The use of individual items may differ from patient to patient and from day to day. Only one unit of service may be billed for any one day. Units of service in excess of one per day will be denied as not separately payable.
Reasons for Noncoverage for Non-mandated Enteral Nutrition
Basic milk or soy formulas are not eligible.
Food thickener, blenderized baby food or regular shelf food used with an enteral system, and nutritional supplements, other than "nutritional supplements" described in Act 158 of 2014, are not covered.
Prosthetic devices which are dispensed to a patient prior to performance of the procedure that will necessitate use of the device are not covered. Dispensing a prosthetic device in this manner would not be considered medically necessary for the treatment of the patient's condition.
See attachment for information on Expanded Benefit.
Enteral feeding via nasogastric, jejunostomy, or gastrostomy tubes is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
A network provider can bill the member for the non-covered service.
04/2015, Additional Criteria Established for Enteral Nutrition
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.