016.06.09 Ark. Code R. 027

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

Rule 016.06.09-027 - Prosthetics Update #146 & Hyperalimentation Update #135

Section II Prosthetics

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

The following list provides 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 (DMS-679A), attaching a copy of the EPSDT screening/referral as well as a prescription signed by the beneficiary's PCP. View or print form DMS-679A.

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

The Arkansas Medicaid program mirrors coverage of approved WIC nutritional formulas. As stated in current policy, the WIC Program must be accessed first for Arkansas Medicaid beneficiaries aged 0 to five (5) years, prior to requesting supplemental amounts of WIC approved nutritional formula. The Medicaid nutritional formula list will be updated accordingly to continue compliance with the WIC Program in Arkansas. Changes will be reflected in the appropriate Medicaid provider manual.

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.

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 preferences for formulas will not be considered for medical necessity.

Exceptions to Use of Formulas

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

A. Nutramigen Lipil - sensitivity or allergy to milk and/or soy protein - chronic diarrhea, food allergies, GI bleeds - Enfamil Gentlease Lipil must first have been tried.

B. Nutramigen Enflora LGG - Sensitivity or allergy to milk and/or soy protein; chronic diarrhea, food allergies, GI bleeds - Enfamil Gentlease Lipil must first have been tried.

C. Pregestimil Lipil - Allergy to milk and/or soy protein; chronic diarrhea, short gut; cystic fibrosis; fat malabsorption due to GI or liver disease.

D. Alimentum - allergy to milk and/or soy protein; severe malnutrition; chronic diarrhea; short bowel syndrome; known or suspected corn allergy - Enfamil Gentlease Lipil must first have been tried.

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

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

G. Nutramigen AA Lipil - Allergy to intact protein and casein hydrolysates; severe food allergies; short bowel syndrome; malabsorption. Alimentum, Nutramigen Lipil or Pregestimil Lipil must first have been tried.

H. Portagen - Pancreatic insufficiency, bile acid deficiency or lymphatic anomalies; biliary atresia; liver disease; chylothorax.

I. Similac PM 60/40 - Renal, cardiac or other condition that requires lowered minerals.

J. Phenyl - Free 1 - PKU; Hyperphenylalaninemia; for infants and toddlers.

K. Phenex I - PKU; Hyperphenylalaninemia; for infants and toddlers.

L. Phenyl-Free 2 - PKU; Hyperphenylalaninemia; for children and adults.

M. Phenex II - PKU; Hyperphenylalaninemia; for children and adults.

N. Enfamil Premature Lipil - 20 or 24 calories - Preterm, low birth weight baby to 44 weeks gestational age or to a maximum weight of 8 pounds - Not approved for an infant previously on term formula or a term infant for increased calories.

O. Enfamil Enfacare Lipil Powder - Preterm infant transitional formula - for use between premature formula and term formula, the infant must have a minimum weight of 1800 grams (four pounds). Not approved for an infant previously on term formula or a term infant for increased calories.

Procedure codes found in this section must be billed either electronically or on paper with modifier EPfor beneficiaries under 21 years of age. Modifier BO is used to bill for oral usage. When a second or third modifier is listed, that modifier must be used in conjunction with EP.

For beneficiaries from birth through four years of age, the use of modifier U7, 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.

Modifiers in this section are indicated by the headings M1, M2, M3 and M4.

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

Procedure Code

B4149 B4149

Ages 0 - 4 Years requires PA

EP EP

U7 U7

M4 Description

Enteral formula, blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Covered Formulae

Compleat

B4150 B4150

Ages 0 - 4 Years requires PA

Covered For

Boost

Carnation Ins Lactose Fr Ensure Ensure Fiber Ensure High Ensure Powd

EP EP

mulae

tant Br ee with F

Protein er

U7 U7

eakfas

BO t -

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

Fibersource HN IsoSource HN Jevity 1.0 CAL Nutren 1.0

See list below

Nutren 1.0 Fiber Osmolite 1.0 CAL Promote Promote with Fiber

B4150

Ages 0 - 4 Years requires PA

EP EP

U1 U1

BO U7

Enteral formula, nutritionally complete with intact nutrients, includes BO proteins, fats,

carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Boost Pudding Ensure Pudding

B4152

Enteral formula,

Boost Plus

B4152

B4152 B4152

Ages 0 - 4 Years requires PA

EP EP

U7 BO

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

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

B4153 B4153

Ages 0 - 4 Years requires PA

EP EP

U7 BO

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

Perative

Tolerex

Vital HN

Vivonex Plus

Vivonex TEN

B4154 B4154

Ages 0 - 4 Years requires PA

EP EP

U7 BO

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 for Boost Gluco Glucerna 1.0 Nutren Glytr Hepatic Aid I Impact	mulae: se Cont cal ol I	rol	Impact with Fiber Ketocal 4:1 Ketocal 3:1 Nepro with Carb Steady NutriHep	Pulmocare Similac 60/40 Suplena with Carb Steady
B4155 B4155 Bill on paper specific nam formula on c	EP EP (Indica e of laims.)	BO te	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 Procel Protein Supplement Provimin
B4155 B4155 Ages 0 - 4 Years requires PA Bill on paper specific nam formula on c	EP EP (Indica e of laims.)	U7 te	BO	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 Procel Protein Supplement Provimin
B4155 B4155 B4155 B4155 Ages 0 - 4 Years requires PA	EP EP EP EP	U1 U1 U1 U1	BO U7 U7	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates BO (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 B4155

Ages 0 - 4 Years requires PA

EP EP

U2 U2

U7 U7

Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates BO (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 B4155

Ages 0 - 4 Years requires PA

EP EP

U3 U3

U7 U7

MSUD 1 MSUD 2 PKU 1 PKU 2 PKU 3 RCF TYR 1 TYR 2

B4158 B4158

Ages 0 - 4 Years requires PA

EP EP

U7 U7

Enteral formula, for pediatrics, nutritionally complete 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 AR Lipil

Enfamil Gentlease -

Lipil Powder

Enfamil Lactofree Lipil

Enfamil Lipil with Iron

Enfagrow Premium

Next Step

Enfamil Premium with

Triple Health Guard

Portagen

B4159 B4159

Ages 0 - 4 Years requires PA

EP EP

U7 U7

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

Enfagrow Soy Next

Step

Enfamil Prosobee Lipil

Enfamil Soy Lipil

B4159 B4159

Ages 0 - 4 Years requires PA

EP EP

U8 U8

U7 U7

Enteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, BO carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit

Similac Isomil Advance Soy with Iron

B4160 B4160

Ages 0 - 4 Years requires PA

EP EP

U7 U7

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

Enfamil Enfacare Pediasure Pediasure with Fiber

B4160 B4160

Ages 0 - 4 Years requires PA

EP EP

U8 U8

U7 U7

Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact BO nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

Boost Kids Essentials

Nutren Jr

Nutren Jr with Fiber

B4160 B4160

Ages 0 - 4 Years requires PA

EP EP

U1 U1

U7 U7

Enfamil Premature Lipil With Iron 24 Cal Enfamil Premature Lipil Low Iron 24 Cal Enfamil Premature Lipil-with Iron 20 Cal Enfamil Premature Lipil-Low Iron 20 Cal

B4160 B4160

Ages 0 - 4 Years requires PA

EP EP

U1 U1

U8 U8

Enteral formula, for BO pediatrics, nutritionally calorically dense (equal to or gre0ater 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

B4161 B4161

Ages 0 - 4 Years requires PA

EP EP

U7 U7

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

EleCare Neocate Infant Neocate Jr Neocate One + Powder

Nutramigen AA Lipil Nutramigen Enflora LGG

Nutramigen Lipil Pregestimil Lipil Similac Alimentum

B4161 B4161

Ages 0 - 4 Years requires PA

EP EP

U7 U7

U8 U8

Enteral formula, for pediatrics,

hydrolyzed/amino acids and peptide chain BO proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

E028 Splash Peptamen Jr. Vivonex Pediatric

B4162 B4162

Ages 0 - 4 Years requires PA

Covered For

Calcilo XD

Cyclinex-1

Cyclinex-2

Hominex-1

Hominex-2

I-Valex-1

I-Valex-2

Ketonex-1

Ketonex-2

EP EP

mulae

U7 U7

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

MSUD Maxamaid MSUD Maxamum MSUD Analog Periflex Advance Periflex Infant Periflex Junior Phenex-1 Phenex-2

See list below

Phenyl Free 1 Phenyl Free 2 Propimex-1 Propimex-2 XLys, XTrp Maxamaid Xphe Maxamaid Xphe Maxamum Xphe, XTyr Maxamaid

B4162 B4162

Ages 0 - 4 Years requires PA

EP EP

U1 U1

U7 U7

Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, BO carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

XMTVI Maxamaid

One unit of service equals 100 calories with a reimbursable maximum of 30 units per day. Supplies furnished by prosthetics providers in conjunction with the nutritional formula must be billed to Medicaid with the prosthetics medical supply codes. These formulae are covered as nutritional supplements rather than as the sole source of nutrition.

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 a 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.

242.120Enteral (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.

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.

A. Nutramigen Lipil - sensitivity or allergy to milk and/or soy protein - chronic diarrhea, food allergies, GI bleeds - Enfamil Gentlease Lipil must first have been tried.

B. Nutramigen Enflora LGG - Sensitivity or allergy to milk and/or soy protein; chronic diarrhea, food allergies, GI bleeds - Enfamil Gentlease Lipil must first have been tried.

C. Pregestimil Lipil - Allergy to milk and/or soy protein; chronic diarrhea, short gut; cystic fibrosis, fat malabsorption due to GI or liver disease

D. Alimentum - allergy to milk and/or soy protein; severe malnutrition; chronic diarrhea; short bowel syndrome, known or suspected corn allergy - Enfamil Gentlease Lipil must first have been tried.

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

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

H. Portagen - Pancreatic insufficiency, bile acid deficiency or lymphatic anomalies; biliary atresia; liver disease; chylothorax.

I. Similac PM 60/40 - Renal, cardiac or other condition that requires lowered minerals.

J. Phenyl - Free 1 - PKU; Hyperphenylalaninemia; for infants and toddlers.

K. Phenex I - PKU; Hyperphenylalaninemia; for infants and toddlers.

L. Phenyl-Free 2 - PKU; Hyperphenylalaninemia; for children and adults.

M. Phenex II - PKU; Hyperphenylalaninemia; for children and adults.

WIC (Women Infants Children Program) must be accessed before the Medicaid Program for children from birth to 5 years of age.

The Arkansas Medicaid program mirrors coverage of approved WIC nutritional formulas. As stated in current policy, the WIC Program must be accessed first for Arkansas Medicaid beneficiaries aged 0 to five (5) years, prior to requesting supplemental amounts of WIC approved nutritional formula. The Medicaid nutritional formula list will be updated accordingly to continue compliance with the WIC program in Arkansas. Changes will be reflected in the appropriate Medicaid provider manual.

HCPCS Code	M1	M2	M3	Description	Covered Formulae
B4149	U9	Enteral formula, blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Compleat
B4150 Covered Fo Boost Carnation In Lactose Fr Ensure Ensure Fibe Ensure High Ensure Pow	U9 rmulae: stant Break ee r with FOS Protein der	fas	t -	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 Fibersource HN IsoSource HN Jevity 1.0 CAL Nutren 1.0	See list below Nutren 1.0 Fiber Osmolite 1.0 CAL Promote Promote with Fiber
B4152	U9	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
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 Covered for Boost Glucos Glucerna 1.0 Nutren Glytro Hepatic Aid I Impact	U9 mulae e Con cal l I	: trol	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 Impact with Fiber Ketocal 4:1 Ketocal 3:1 Nepro with Carb NutriHep	See list below Pulmocare Similac 60/40 Suplena with Carb Steady
B4155 Bill on Paper specific nam formula on cl	U9 (Indic e of aims.)	ate	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 Procel Protein Supplement Provimin
B4155	U9	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	U9	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	U9	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	MSUD 1 MSUD 2 PKU 1 PKU 2 PKU 3 RCF TYR1 TYR 2
B4158	U9	Enteral formula, for pediatrics, nutritionally complete 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 AR Lipil Enfamil Gentlease Lipil Powder Enfamil Lactofree Lipil Enfamil Lipil with Iron Enfagrow Premium Next Step Enfamil Premium with Triple Health Guard Portagen
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	Enfagrow Soy Next Step Enfamil Prosobee Lipil Enfamil Soy Lipil
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 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	Enfamil Enfacare Pediasure Pediasure with Fiber
B4160 (Ages 0-4 Years)	U9	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	Boost Kids Essentials Nutren Jr. Nutren Jr. with Fiber
B4160	U9	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	Enfamil Premature Lipil With Iron 24 Cal Enfamil Premature Lipil Low Iron 24 Cal Enfamil Premature Lipil-with Iron 20 Cal Enfamil Premature Lipil-Low Iron 20 cal
B4160 (Ages 0-4 Years)	U9	U1	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
B4161	U9	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	EleCare Neocate Infant Neocate Jr. Neocate One + Powder Nutramigen AA Lipil Nutramigen Enflora LGG Nutramigen Lipil Pregestimil Lipil Similac Alimentum
B4161 Ages 5 to 99 Years B4161 (Ages 0-4 Years)	U9 U9	U8	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	E028 Splash Peptamen Jr. Vivonex Pediatric
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 Fo Calcilo XD Cyclinex-1 Cyclinex-2 Hominex-1 Hominex-2 I-Valex-1 I-Valex-2 Ketonex-1 Ketonex-2	rmulae	:	MSUD Maxamaid MSUD Maxamum MSUD Analog Periflex Advance Periflex Infant Periflex Junior Phenex-1	Phenex-2 Phenyl Free 1 Phenyl Free 2 Propimex-1 Propimex-2 XLys, XTrp Maxamaid Xphe Maxamaid Xphe Maxamum 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

016.06.09 Ark. Code R. 027

12/18/2009