Medicare guidelines for home enteral nutrition
Medicare Part B: Covers services and supplies that are medically necessary to treat health conditions.
Enteral nutrition is covered under the prosthetic device benefit for Medicare Part B. The patient receives nutrition support through a tube placed into the stomach or small intestine. The tube may be nasoenteric, gastric, or jejunal.
Enteral nutrition is covered for a patient who has:
a) Permanent non-function or disease of the structures that normally permit food to reach the small bowel or
b) Disease of the small bowel which impairs digestion and absorption of an oral diet, either of which requires tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the patient’s overall health status.
c) The patient must have a permanent impairment (ordinarily at least 90 days).
d) Adequate nutrition must not be possible by dietary adjustment and/or oral supplements.
NOTE: Coverage may be possible for patients with partial impairments. For example: A patient with Crohn’s disease or a patient with dysphagia who can swallow small amounts of food.
The following medical conditions are often associated with patients receiving enteral nutrition. This is a partial list that includes, but is not limited to, some common enteral-related diagnoses.
The patient’s condition can be either anatomic or due to a motility disorder. These medical conditions may meet coverage criteria if they cause impairment of consuming, digesting, and/or absorbing food. When the diagnosis itself does not reflect malabsorption or a functional impairment, additional documentation may be required to qualify a patient for enteral therapy coverage.
Medicare does not cover temporary impairment. The patient must have a permanent impairment (ordinarily at least 90 days).
Adult Hypertrophic Pyloric Stenosis
Allergic Gastroenteritis and Colitis
ALS (Amyotrophic Lateral Sclerosis)
Anoxic Brain Damage
Athetoid Cerebral Palsy
Atopic Dermatitis due to Food Allergy
Carcinoma in Situ-Digestive Organs
Cow’s Milk Protein Allergy
Delayed Gastric Emptying
Failure to Thrive/Underweight
Gastroesophageal Reflux Disease
Multiple Food Protein Allergy
Persistent Vegetative State
Pyothorax with Fistula
Short Bowel Syndrome
Additional Documentation Required for Enteral Feeding Pumps and Specialty Nutrients
Documented clinical rationale to justify the use of pumps or specialty nutrients is required in addition to documentation supporting medical necessity for enteral nutrition.
Pumps may be used as a result of complications associated with the use of the gravity or syringe methods of administration. Common conditions that may satisfy coverage criteria for enteral pumps:
• Reflux or aspiration
• Severe diarrhea
• Dumping Syndrome
• Administration rate < 100 mL/hr
• Blood glucose fluctuations
• Circulatory overload
• Use of Jejunostomy or Gastrostomy tube
Documented clinical rationale to justify caloric needs ≤750 or ≥2,000 is required in addition to documentation supporting medical necessity for enteral nutrition.
For patients who are prescribed calories outside of the 750 to 2,000 per-day range, documentation must support the clinical need. A Physician’s or Registered Dietitian’s assessment of estimated nutrition needs is ideal.
Use of formulas other than B4150 or B4152 require documentation of medical necessity to justify Medicare coverage. Justification for medical necessity is not diagnosis driven and may require supportive clinical laboratory information and/or clinical chart information for reimbursement.
Enteral Nutrient HCPCS (Healthcare Common Procedure Coding System) Descriptions
||Enteral Nutrient Categories
||Blenderized natural foods with intact nutrients
||Nutritionally complete with intact nutrients
||Nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/mL) with intact nutrients
||Nutritionally complete hydrolyzed proteins (amino acids and peptide chain)
||Nutritionally complete, special metabolic needs, excludes inherited disease of metabolism
||Nutritionally incomplete/modular nutrients
||For pediatrics, nutritionally complete with intact nutrients
||For pediatrics, nutritionally complete, soy based with intact nutrients
||For pediatrics, nutritionally complete, calorically dense (equal to or greater than 0.7 kcal/mL) with intact nutrients
||For pediatrics, nutritionally complete hydrolyzed/amino acids and peptide chain proteins