TMPPM 2011 > Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook > Texas Medicaid (Title XIX) Home Health Services > Services, Benefits, Limitations and Prior Authorization > Nutritional (Enteral) Products, Supplies, and Equipment > Prior Authorization Requirements Enteral Formulas

Enteral formulas require prior authorization. Requests for prior authorization must include the necessary product information.

Enteral formulas consisting of semi-synthetic intact protein or protein isolates (procedure codes B4150 and B4152) are appropriate for the majority of clients requiring enteral nutrition.

Special enteral formulas or additives (procedure code B4104) may be considered for prior authorization with supporting documentation submitted by the client's physician indicating the client's medical needs for these special enteral formulas. Special enteral formula may be reimbursed with the following procedure codes:

Procedure Codes








Pediatric nutritional products (procedure codes B4103, B4158, B4159, B4160, B4161, and B4162) are restricted to clients who are 20 years of age and younger.

Food thickener may be considered for clients with a swallowing disorder.

Texas Medicaid & Healthcare Partnership
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