ENTERAL FEEDING GUIDELINES:
MEDICARE:
Qualifying Diagnosis: Must be a disease of the esophagus, stomach, or small bowel that causes PERMANENT NONFUNCTION or diseases of the small bowel that impair digestion and absorption of an oral diet. (If a patient’s qualifying diagnosis is Stroke (CVA), the patient must also be diagnosed with Dysphagia and there must be swallow studies to document this.)
Criteria to be documented:
-Pt. must have a feeding tube
-TF must be the SOLE source of nutrition
-MD must anticipate PERMANENCY (Medicare defines 3 months or longer as a permanent need)
-TF must provide 20-35kcal/kg/day (For your convenience, King Drug will calculate this for you and let MD know if any alterations need to be made)
**Sole Source and Length of need can NOT be documented on the actual prescription or as an addendum. Please have MD coordinate in a progress note or in a plan of care**
Equipment:
-TF may be administered by syringe, gravity, or pump
-If a pump is ordered, TF rate cannot exceed 100cc/hr.
-Elemental formulas (B4153) require special documentation for coverage:
-Pt. has a J-tube
-Pt. has documented intolerance to standard formula.
This is not written in guidelines, but these specialized formulas are usually denied without proper documentation and pt. is left with the bill.
STANDARD MEDICAID:
-TF formula and supplies are usually covered.
-Oral supplemental nutrition is usually covered if it is the SOLE source of nutrition.
**If a pt. has Medicare and Medicaid, then Medicaid goes by Medicare’s guidelines.
MEDICAID MANAGED CARE ORGANIZATIONS (COVENTRY & WELLCARE):
-Prior authorization is required for all Enteral set ups (quoted to take 24-72 hours)
-NOTE: Coventry mandates that a dietician evaluation assessed within the last year, must be submitted with the prior auth in order to be deemed medically necessary
PRIVATE INSURANCE:
-Done on a case-by-case basis.
FOR MORE INFORMATION PLEASE CONTACT
STEVIE SMITH, INFUSION COORDINATOR
1-800-489-2609