Article Detail - JD DME

Original Effective Date: 06/16/2003
Revision Effective Date: 11/01/2013

According to the local medical review policy (LMRP) for Enteral Nutrition, coverage of special formulas (HCPCS Codes B4151, B4153-B4156) must be justified in each patient. Failure to substantiate the medical necessity of the special formula will result in payment according to the least costly alternative, B4150. The most common request in Region D is for specialty diabetic formulas such as Glucernaâ and Diabetisourceâ. The documentation necessary to justify these special formulas was outlined in a December 1996 DMERC Dialogue article entitled "Category IV, V and VI Enteral Nutrients" (page 7):

• Medical records documenting the medical condition requiring the Category IV/V/VI nutrient and the severity of that condition as shown by history, physical exam and diagnostic/laboratory studies.
• The response of the medical condition to Category I or II nutrients as compared to the response to the prescribed Category IV/V/VI nutrient. If this comparison has not been made, the medical reason for its absence should be documented in the patient's medical record. The reason(s) should be individualized for the patient, not be a generalized statement such as the diagnosis.

In response to numerous questions on the coverage of these specialty nutrients, especially the diabetic formulas, the following additional specific documentation guidance is provided:

• How long was the patient on a Category I nutrient?
• Were different Category I formulas tried? What were they?
• Were adjustments made in medications in an attempt to control blood sugars while on the Category I nutrient?
• Is there documentation in the form of serial blood sugars, preferably one month prior to and after beginning usage of a Category IV diabetic formula, demonstrating improvement in glycemic control?

Providing this additional information will assist Medical Review staff in their review of these claims and help insure that proper claims payment is made.