016.06.08 Ark. Code R. 017

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.08-017 - Prosthetics Update #117 & Hyperalimentation Update #110

Section II Hyperalimentation

221.000 Prior Authorization

Hyperalimentation fluids, equipment and supplies must be prior authorized by the Arkansas Foundation for Medical Care, Inc. (AFMC).

242.120 Enteral (Sole Source) Formulas

The following pages provide the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients.

Modifiers in this section are indicated by the headings M1, M2 and M3.

Enteral formulas are divided into several categories. Each unit of service equals 100 calories of formula. All supplies and equipment necessary to administer the nutrients in the beneficiary's place of residence, except the infusion pump and pump supply kit are included in the unit description.

For a non-covered prescribed formula a review for medical necessity will be performed upon request. The product information, with assigned HCPCS code and physician documentation of the medical necessity of the formula for a specific beneficiary, must be submitted to Utilization Review. View or print the Utilization Review Section contact information. If approved, the formula will be added to the list of covered formulae and the provider will be notified. If denied, the provider and beneficiary will be notified.

For beneficiaries ages birth through four years of age, the use of modifier U8, as well as additional documentation will be required when a non-WIC formula is prescribed or WIC guidelines are not followed when prescribing special formula.

An EPSDT screening, which documents the PCP's medical rationale for prescribing a formula, as well as medical records documenting the beneficiary's failed trials of WIC formula, must be submitted for review. Flavor preference will not be considered for medical necessity.

A separate prior authorization must be obtained for the enteral infusion pump and the pump supply kit. The enteral infusion pump and the pump supply kit may be billed separately.

Exceptions to Use of Formula

The following exceptions must be followed in order to use formulas listed in this section.

The exceptions are indicated by an alpha letter in parenthesis that precedes the product description. For example:^(A-) Nestle Good Start Supreme with DHA & ARA Powder.

A. Nestle Good Start Supreme with DHS & ARA - sensitive to intact protein - Enfamil Gentlease Lipil must first have been tried.

B. Nestle Good Start Supreme Soy with DHA & ARA, - sensitive to intact protein - Enfamil Gentlease Lipil must first have been tried.

C. Nutramigen Lipil - sensitivity or allergy to milk and soy protein - chronic diarrhea, food allergies, Gl bleeds - Enfamil Gentlease Lipil and Good Start Supreme must first have been tried.

D. EleCare - allergy to intact protein and casein hydrolysates - severe food allergies, short bowel syndrome and/or malabsorption - Alimentum, Nutramigen and Pregestimil must first have been tried.

E. Neocate - allergy to intact protein and casein hydrolysates, severe food allergies, short bowel syndrome, malabsorption, -Alimentum, Nutramigen and Pregestimil must have been tried.

HCPCS Code	M1	M2	M3	Description	Covered Formulae
B4153	U9	Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Peptamen Peptamen 1.5 Peptamen with Prebio 1 Perative Tolerex Vital HN Vivonex Plus Vivonex TEN
B4154	U9	Enteral formula, nutritionally complete, for special metabolic needs, includes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	See list below
Covered formulae:
Boost Diab Glucerna Nutren Glyl Hepatic Aic Impact	etic trol i	Impact with Fiber IsoSource VHN Ketocal Nepro with Carb NutriHep	Pulmocare Resource Diabetic TF Similac 60/40 Suplena with Carb Steady Traumacal
B4155	U9 3r (Indie ne of claims.;	:ate I		Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit	MCT Oil
Bill on Pap[LESS THAN] specific nar formula on	U9 3r (Indie ne of claims.;	:ate I			Procel Protein Supplement Provimin

B4159	U9	Enteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit	Enfamil Next Step Prosobee Lipil Enfamil Prosobee Lipil ^(B)Nestle Good Start Supreme Soy-with DHA & ARA Powder
B4159 (Ages 0-4 Years)	U9	U8	Enteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit	Similac Isomil Similac Isomil Advance Soy-Formula with Iron
B4160	U9	Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	^(G-) Enfamil Enfacare Lipil Powder Enfamil Kindercal Enfamil Kindercal with Fiber
B4160 (Ages 0-4 Years)	U9	.0.8	Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Nutren Jr. Nutren Jr. with Fiber Pediasure Pediasure with Fiber Resource Just For Kids Resource Just for Kids-with Fiber

B4162	U9	Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	See list below
Covered Formulae:
Calcilo XD	MSUD Maxamaid	Phenex-2
Cyclinex-1	MSUD Maxamum	Phenyl Free 1
Cyclinex-2	MSUD Analog	Phenyl Free 2
Hominex-1	Periflex Advance	Propimex-1
Hominex-2	Periflex Infant	Propimex-2
l-Valex-1	Periflex Junior	XLys, XTrp Maxamaid
l-Valex-2	Phenex-1	Xphe Maxamaid
Ketonex-1	Xphe Maxamum
Ketonex-2	XPhe, XTyr Analog
XPhe, XTyr Maxamaid
B4162	U9	U1	Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	XMTVI Maxamaid

Section II

Prosthetics_______

242.150 Nutritional Formulae for Child Health Services (EPSDT)

Beneficiaries Under 21 Years of Age

The following list provide the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients.

The coverage listed is payable only if the service is prescribed as a result of a Child Health Services (EPSDT) screening/referral.

There is no prior authorization required for nutritional formulas for EPSDT beneficiaries from age five years through twenty years.

Prior authorization is required for beneficiaries from birth through four years. Use of modifier U7 in the following list will be necessary, as indicated.

To request prior authorization, providers should complete the Arkansas Foundation for Medical Care, Inc. Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components (AFMC-103), attaching a copy of the EPSDT screening/referral as well as a prescription signed by the beneficiary's PCP. View or print form AFMC-103.

NOTE: The Women, Infant and Children program (WIC) must be accessed first for children from birth through their fifth birthday.

For beneficiaries from birth through four years of age, the use of modifier U8, as well as additional documentation will be required when a non-WIC formula is prescribed or WIC guidelines are not followed when prescribing special formula.

Exceptions to Use of Formulas

The following exceptions must be followed in order to use formulas listed in this section.

The exceptions are indicated by an alpha letter in parenthesis that precedes the product description. For example:^(A-) Nestle Good Start Supreme with DHA & ARA Powder.

A. Nestle Good Start Supreme with DHA & ARA - sensitive to intact protein - Enfamil Gentlease Lipil must first have been tried.

B. Nestle Good Start Supreme Soy with DHA & ARA, - sensitive to intact protein - Enfamil Gentlease Lipil must first have been tried.

C. Nutramigen Lipil - sensitivity or allergy to milk and soy protein - chronic diarrhea, food allergies, Gl bleeds - Enfamil Gentlease Lipil and Good Start Supreme must first have been tried.

D. EleCare - allergy to intact protein and casein hydrolysates - severe food allergies, short bowel syndrome and/or malabsorption - Alimentum, Nutramigen and Pregestimil must first have been tried.

Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under 21 Years of Age (section 242.150)

Procedure Code	M1	M2	M3	M4	Description	Covered Formulae
Covered For	mulae	;
Boost	Fibersource HN	Nutren 1.0 Fiber
Boost with B[LESS THAN]	snefibe	rand F	^:OS	IsoSource	Osmolite
Carnation Ins	»tant Br	eakfas	;t-	IsoSource HN	Osmoiite 1.0 CAL
Lactose Fr(	3e	Jevity 1.0 CAL	Portagen
Ensure	Nutren 1.0	Probalance
Ensure Fiber	with F(	DS	Promote
Ensure High	Protein	i	Promote with Fiber
Ensure Powc	ier
Fibersource
B4150	EP	U1	BO	Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Boost Pudding Ensure Pudding
B4150	EP	U1	U7			BO
Ages 0-4 Years requires PA
B4152	EP	Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 Kcal/ml), with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Boost Plus Carnation Instant Breakfast - Lactose Free Plus Ensure Plus Nutren 1.5 Nutren 2.0 Osmolite 1.5 Cal Resource 2.0 Scandishake Two-Cal HN
B4152	EP			BO
B4152	EP			U7
B4152	EP			U7	BO
Ages 0-4 Years requires PA
B4153	EP	Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Peptamen Peptamen 1.5 Peptamen with Prebio 1 Perative Tolerex Vital HN Vivonex Plus Vivonex TEN
B4153	EP			BO
B4153	EP			U7
B4153	EP			U7	BO
Ages 0-4 Years requires PA

Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under 21 Years of Age (section 242.150)

Procedure Code	M1	M2	M3	M4	Description	Covered Formulae
B4155	EP	U1	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit	Polycose Powder Scandical
B4155	EP	U1			BO
B4155	EP	Ul			U7
B4155	EP	U1			U7	BO
Ages 0-4 Years requires PA
B4155	EP	U2	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit	Microlipid
B4155	EP	U2			BO
B4155	EP	U2			U7
B4155	EP	U2			U7	BO
Ages 0-4 Years requires PA
B4155	EP	U3	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit	80056
B4155	EP	U3		BO	MSUD1
MSUD2
PKU1
B4155	EP	U3		U7	PKU2
B4155	EP	U3		U7	BO	PKU3
Ages 0-4 Years requires PA	RCF TYR1 TYP.2

B4160	EP	Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Nutren Jr
B4160	EP		BO	Nutren Jr with Fiber
Pediasure
Pediasure with Fiber
B4160	EP		U8	U7	Resource Just For
B4160	EP		U8	U7	BO	Kids
Ages 0-4 Years requires PA	Resource Just For Kids with Fiber
B4160	EP	U1	Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	^(F,) Enfamil Premature
B4160	EP	U1		BO	Lipil
With Iron 24 Cal
^(F° Enfamil Premature
B4160	EP	U1		U7	Lipil
B4160	EP	U1		U7	BO	Low Iron 24 Ca!
Ages 0-4 Years requires PA	^(F-) Enfamil Premature Lipil-with Iron 20 Cal ^(F' Enfamil Premature Lipil-Low Iron 20 Cal
B4160	EP	U.T	U8	Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Similac Neosure
B4160	EP	U1	U8		BO
Ages 0-4 Years requires PA
B4161	EP	Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4161	EP		BO	^(DJ EleCare
^(E-) Neocate Infant
^{[LESS THAN]E}° Neocate Jr
B4161	EP		U7	^(E° Neocate One +
B4161	EP		U7	BO	Powder
Ages 0-4 Years requires PA	^{C)Nutramigen Lipil Pregestimil Lipil Similac Alimentum

NOTE: Beneficiaries who require enteral nutrition as the sole source of nutrition with the formulae being administered through a nasogastric, jejunostomy or gastrostomy tube should be referred to a hyperalimentation provider enrolled in the Medicaid Program.

Each claim should reflect a "from" and "through" date of service. The claims must not be filed until after the "through" date has elapsed. Claims may be submitted on either a weekly or monthly basis.

NOTE: If a specific formula is not listed but is prescribed as the result of the EPSDT

screening of an Arkansas Medicaid beneficiary, the provider may forward a copy of the screening and prescription, along with product information, to Utilization Review for consideration.

Each claim should reflect a "from" and "through" date of service. The claims must not be filed until after the "through" date has elapsed. Claims may be submitted on either a weekly or monthly basis.

NOTE: If a specific formula is not listed but is prescribed as the result of the EPSDT

screening of an Arkansas Medicaid beneficiary, the provider may forward a copy of the screening and prescription, along with product information, to Utilization Review for consideration.

016.06.08 Ark. Code R. 017

5/1/2008