Patient’s Name:
Medicaid ID # / Date of Birth:
Medical Diagnoses:
Method of feeds:  oral  NG  NJ-tube  G tube  GJ tube
(need to qualify oral feeds)
Is patient unable to reach or maintain weight and height at the 10th percentile for age and sex without supplemental feeding? /  Yes
Please provide growth chart
 No
Does patient have a disease or dysfunction of the digestive tract, including dysphagia, which causes nutritional deficiency with insufficient nutrients to maintain body weight by impaired delivery of nutrients to the small bowel? /  Yes
Describe:
 No
Formula Name:
HCPC Code: ( on back) / Total Volume for 30 days:
Amount required to meet 100% of daily estimated needs for one day, total Kcal/day______
Anticipated length of time needed: _____months
Method of Administration:
Syringe
Gravity
Pump* type:______
Describe how feeds are administered:
Continuous
Intermittent
Bolus
ombination(explain)______/ *Must document reason of necessity for pump. Check all that apply (attach medical/clinical documentation)
Severe diarrhea
Dumping syndrome
Reflux
Aspiration
Blood glucose fluctuations
Nissen
Jejunal feeds
Ventilated and/or trached
Feeding difficulties (oral aversions)
______Date: ______Time: ______
signature
Statement of Medical Necessity:
______MD/LIP Contact #:______Date: ______

Enteral Nutrition Documentation

Jan 09

DRUG DESCRIPTION /

HCPCS CODE

/ DRUG DESCRIPTION /

HCPCS CODE

FORMULA ALIMENTUM ADV BTL 32 OZ / B4161 / FORMULA NUTREN 1 VAN 1 CAL/ML / B4150
FORMULA ALIMENTUM POWER / B4161 / FORMULA NUTREN 1.0 W/FIBER / B4150
FORMULA BENEPROTEIN 8 OZ PWD / B4155 / FORMULA NUTREN 1.5 VAN 1.5 CAL/ / B4152
FORMULA BOOST CHOCOLATE / B4150 / FORMULA NUTREN 2 VAN 2 CAL/ML / B4152
FORMULA BOOST HI PROTEIN VANIL / B4150 / FORMULA NUTREN JR W/FIBER VAN / B4160
FORMULA BOOST KID ESS 1.5 FBR / B4160 / FORMULA NUTREN JR. VANILLA / B4160
FORMULA BOOST KID ESS 1.5 VAN / B4160 / FORMULA OPTIMENTAL VANILLA 8 OZ / B4153
FORMULA BOOST PLUS CHOCOLATE / B4152 / FORMULA OSMOLITE 1.5 CAL 1L RTH / B4152
FORMULA BOOST PLUS VANILLA 237 / B4152 / FORMULA OSMOLITE 1.5 CAL 240ML / B4152
FORMULA BOOST VANILLA / B4150 / FORMULA OSMOLITE HN 1.06 CAL/ML / B4150
FORMULA BOOST W/FIBER VANILLA / B4150 / FORMULA OSMOLITE HN RTH 1000 ML / B4150
FORMULA BRIGHT BEGINNINGS SOY / B4160 / FORMULA OXEPA VANILLA 8 OZ / B4154
FORMULA CARN G/START SUPR DHA / B4158 / FORMULA PEDIALYTE 32 OZ CHLD 12 / B4103
FORMULA CARNA G/START SUPR PWD / B4158 / FORMULA PEDIASURE BANANA CREAM / B4160
FORMULA CARNATION LF VANIL VHC / B4152 / FORMULA PEDIASURE CHOCOLATE / B4160
FORMULA CERALYTE 90 LEMON 50 / B4103 / FORMULA PEDIASURE STRAWBERRY 8 / B4160
FORMULA COMPLEAT 1.07 CAL/ML / B4149 / FORMULA PEDIASURE VAN 8 OZ 1 / B4160
FORMULA COMPLEAT PED 1 CAL/ML / B4149 / FORMULA PEDIASURE W/FIBER VAN / B4160
FORMULA DIABETISOURCE AC / B4154 / FORMULA PEDIATRIC EO28 GRAPE / B4161
FORMULA DUOCAL UNFLVD POWDER / B4155 / FORMULA PEDIATRIC E028 ORG/PIN / B4161
FORMULA ELECARE POWDER 14.1 OZ / B4161 / FORMULA PEDIATRIC 3028 TROPICA / B4161
FORMULA ELECARE VAN PWD 14.1 / B4161 / FORMULA PEPDITE JR UNFLV PKT / B4161
FORMULA ENF LF W/LIPIL 13 OZ / B4158 / FORMULA PEPTAMEN 1.5 UNFLVD / B4153
FORMULA ENFACARE LIPIL 14 OZ PW / B4160 / FORMULA PEPTAMEN AF UNFLAV 250 / B4153
FORMULA ENFAMIL AR W/LIPIL PWD / B4158 / FORMULA PEPTAMEN JR PREBIO VAN / B4161
FORMULA ENFAMIL GENTLEASE PWD / B4158 / FORMULA PEPTAMEN JR UNFLAV 1 / B4161
FORMULA ENFAMIL LIPIL W/FE PWD / B4158 / FORMULA PEPTAMEN JR VAN 1 CAL / B4161
FORMULA ENSURE CHOC 1.06 CAL/ML / B4150 / FORMULA PEPTAMEN JR W/FIBER VA / B4161
FORMULA ENSURE PLUS CHOC / B4152 / FORMULA PEPTAMEN UNFLV 250 ML / B4153
FORMULA ENSURE PLUS STRAWBERRY / B4152 / FORMULA PEPTAMEN VANILLA / B4153
FORMULA ENSURE PLUS VAN 8 OZ 50 / B4152 / FORMULA PEPTAMEN W/PREBIO VANI / B4153
FORMULA ENSURE STRAWBERRY 1.06 / B4150 / FORMULA PEPTINEX 1.5 VANILLA / B4153
FORMULA ENSURE VAN 1.06 CAL/ML / B4150 / FORMULA PEPTINEX DT PED 250 ML / B4161
FORMULA ENSURE W/FIBER VAN 1 / B4150 / FORMULA PEPTINEX DT PED/FIBER / B4161
FORMULA FIBERSOURCE HN 250ML / B4150 / FORMULA PHENEX 2 PWD (>12) / S9435
FORMULA GLUCERNA 8 OZ 1 CAL/ML / B4154 / FORMULA PHENEX 2 VAN PWD (>12) / S9435
FORMULA GLYTROL DIAB VANILLA / B4154 / FORMULA POLYCOSE POWDER 746 2. / B4155
FORMULA GOOD ST 2 S/SOY 24 OZ / B4159 / FORMULA PORTAGEN PWD 1 LB (>12) / B4150
FORMULA GOOD ST 2 SUPR SOY PWD / B4159 / FORMULA PORTAGEN PWD 1 LB <=12 / B4158
FORMULA GOOD START NATURAL CUL / B4158 / FORMULA PREGESTIMIL PWDR 1 LB 1 / B4161
FORMULA IMPACT W/FIBER / B4154 / FORMULA PRO-PHREE PWD 350 GM / B4155
FORMULA ISOMIL ADV W/FE LF PWD / B4159 / FORMULA PROMOTE 8 OZ 1 CAL/ML / B4150
FORMULA ISOMIL W/FE PWD 12.9 OZ / B4159 / FORMULA PROMOTE W/FIBER 8 OZ 1. / B4150
FORMULA ISOSOURCE 1.5 CAL / B4152 / FORMULA PROPIMEX 2 PWD (>12) / S9435
FORMULA ISOSOURCE HN VANILLA / B4150 / FORMULA PROSOBEE LIPIL PWD / B4159
FORMULA JEVITY 1 RTH 1000ML / B4150 / FORMULA PULMOCARE VAN 1.5 CAL/M / B4154
FORMULA JEVITY 1.2 1500 ML BTL / B4150 / FORMULA RCF LOW IRON SOY 81 CAL / B4155
FORMULA JEVITY 1.2 RTH 1000 ML / B4150 / FORMULA RENALCAL 2 CAL/ML / B4154
FORMULA JEVITY 1.5 RTH 1000 ML / B4152 / FORMULA REPLETE W/FIBER VAN / B4150
FORMULA JEVITY 8 OZ 1 CAL/ML / B4150 / FORMULA RESOURCE GLUTASOLVE / B4155
FORMULA JEVITY 8 OZ 1.2 CAL/ML / B4150 / FORMULA RESOURCE JFK W/FIBER / B4160
FORMULA JEVITY 8 OZ 1.5 CAL/ML / B4152 / FORMULA RESOURCE JUST FOR KIDS / B4160
FORMULA KETOCAL 4:1 300 GM PWD / B4154 / FORMULA RESOURCE PEACH 186400 / B4150
FORMULA KINDERCAL TF W/FIBER / B4160 / FORMULA SCANDISHAKE CHOCO 3 OZ / B4152
FORMULA MCT OIL 32 OZ / B4155 / FORMULA SIMILAC ADV/FE RTF 32 / B4158
FORMULA MICROLIPID 89 ML 400 CAL / B4155 / FORMULA SIMILAC ADVANCE/FE PWD / B4158
FORMULA NEOCATE INFANT POWDER / B4161 / FORMULA SIMILAC NEOSURE ADV PW / B4160
FORMULA NEOCATE JR POWDER / B4161 / FORMULA SIMILAC PM 60/40 16 OZ / B4154
FORMULA NEOCATE JR TROP FR PWD / B4161 / FORMULA SUPLENA CARB STEADY / B4154
FORMULA NEOCATE ONE+ 60 GM PWD / B4161 / FORMULA TOLEREX 80 GM / B4153
FORMULA NEOCATE ONE+ PWD PKT / B4161 / FORMULA TWOCAL HN VAN 8 OZ 2 / B4152
FORMULA NEPRO W/CARB STEADY VA / B4154 / FORMULA VITAL HN PWDR 766 1 / B4153
FORMULA NEXT STEP LIP PWD 24 / B4158 / FORMULA VIVONEX PED PWDR / B4161
FORMULA NEXT STEP PROSOB LIP24 / B4159 / FORMULA VIVONEX RTF 1000 ML / B4153
FORMULA NOVASOURCE RENAL 8 OZ / B4154 / FORMULA VIVONEX TEN PWDR / B4153
FORMULA NUTRAMIGEN PWDR 1LB 10 / B4161