|
24.5.29 Nutritional (Enteral) Products, Supplies, and Equipment
24.5.29.1 Nutritional Products and Supplies
Enternal nutritional products are those food products that are included in an enteral treatment protocol. They serve as a therapeutic agent for health maintenance and are required to treat an identified medical condition. Nutritional products, supplies, and equipment may be provided in the home under Home Health Services.
Enteral products, including nutritional formulas, food thickener, and related supplies and equipment, are a benefit under Home Health Services for clients 21 years of age and older who require tube feeding as their sole source of nutrition. Prior authorization is required for all enteral products, supplies, related DME, and services provided through Home Health Services. The prior authorization also includes all related accessories and/or supplies. Requests are reviewed for medically necessary amounts based on caloric needs as indicated by the client's physician. Enteral products for clients who can take nutrition by mouth and/or that are used as a supplement will not be prior authorized.
Nutritional products and supplies will not be reimbursed for clients receiving TPN. Any nutritional products and/or supplies are included as part of the reimbursement for TPN. Requests are reviewed for reasonable amounts. Enteral products for clients who can take nutrition by mouth and/or that are used as a supplement will not be prior authorized.
To avoid unnecessary denials, the physician must provide correct and complete, signed, and dated information, including documentation of the medical necessity of the equipment and/or supplies requested. The physician must maintain documentation of medical necessity in the clients medical record. The requesting provider may be asked for additional information to clarify or complete a request for the nutritional products, supplies, or equipment.
To be reimbursed as a home health benefit:
• The client must be eligible for home health benefits.
•The criteria listed in this policy for the requested supplies/equipment must be met.
•The supplies/equipment requested must be medically necessary.
•Federal financial participation must be available.
•The client's nutritional status would be compromised without the requested enteral nutritional products/supplies/equipment.
Note: For clients under 21 years of age who do not meet criteria through Home Health Services, products, supplies, and equipment may be considered through CCP.
The completed, signed, and dated DME Certification and Receipt Form is required before reimbursement can be made for any DME delivered to a client. The certification form must include the name of the item, the date the client received the DME/products/supplies, and the signatures of the provider and the client or primary caregiver. This form must be maintained by the DME provider in the client's medical record.
To request prior authorization for nutritional formula/supplies/equipment, the following documentation must be provided:
•Accurate diagnostic information pertaining to the underlying diagnosis/condition as well as any other medical diagnoses/conditions, including the client's overall health status.
•Diagnosis/condition (including the appropriate ICD-9-CM code).
•A statement from the ordering physician noting that enteral nutritional products are the client's sole source of nutrition.
•Total caloric intake prescribed by the physician.
•Acknowledgement that the client has a gastrostomy or nasogastric tube.
•Necessary product information.
The DME may be considered for prior authorization when criteria for nutritional products are met.
Prior authorization may be given for up to twelve months. Prior authorization may be recertified with documentation supporting ongoing medical necessity for the nutritional products requested.
Comparability will be determined from information provided by the manufacturer of the nutritional products. Documentation must include both the diagnosis indicating the metabolic disorder and the nutritional product which must be for use in metabolic disorders.
|
