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Benefit Updates for CSHCN Medical Nutritional Products Effective November 1, 2021

Last updated on 9/17/2021

Effective for dates of service on or after November 1, 2021, benefit and prior authorization criteria will change for medical nutritional products for the Children with Special Health Care Needs (CSHCN) Services Program.

New Form for Medical Nutritional Products

Effective for dates of service on or after November 1, 2021, providers must use the CSHCN Services Program Prior Authorization Request for Medical Nutritional Products Form and Instructions.

Reimbursement

In-line cartridges containing digestive enzymes for enteral feeding procedure code B4105 will be added as a benefit and may be reimbursed with prior authorization to durable medical equipment (DME) medical suppliers for services rendered in the home setting.

Rental of an enteral nutrition infusion pump, any type (procedure code B9002), may be reimbursed once per calendar month, same procedure, any provider. Custom DME providers may be reimbursed for services rendered in the home setting. The feeding pump is considered purchased after 10 months of lease within the same year, same provider.

Prior Authorization

Prior authorization is required every six months for nutritional products. Documentation must be submitted indicating that the client has a medical condition that is expected to be permanent or of indefinite duration that prevents the individual from being sustained on an age-appropriate diet and has manifested in nutritional deficiencies.

Prior authorization is not required for nutritional formulas administered via an enteral feeding tube.

Prior authorization requests must be submitted on the CSHCN Services Program Prior Authorization Request for Medical Nutritional Products Form. The form must be signed by the physician within 90 days prior to the requested start of service. All claims with dates of service prior to the prescribing provider’s signature will be denied.

The following information must be provided on the CSHCN Services Program Prior Authorization Request for Medical Nutritional Products Form:

  • The full name of the product
  • The appropriate procedure code(s)
  • The recommended total caloric intake from all sources ordered for nutritional products, except food thickeners
    • The percentage of the total caloric intake from formula or the total number of calories from formula each day
  • Identification or explanation of the medical condition resulting in the requirement for a special nutritional product. Additional documentation may be submitted to supplement the information provided on the CSHCN Services Program Prior Authorization Request for Medical Nutritional Products Form. Documentation should be current (within the past 12 months.) Documentation must include:
    • The client’s height and weight
    • The client’s growth history, growth charts, or both (for clients who are 18 years of age or older, only a weight history is required)
    • Documentation to support why the client cannot be maintained on an age-appropriate diet

Food thickener may be considered for clients with a diagnosis of dysphagia. Documentation of the findings of a swallow study indicating a recommended thickness must be submitted.

Enteral feeding pumps may be considered for prior authorization for lease or purchase with documentation that gravity or syringe feedings are not medically indicated. Requests must be submitted on the CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) Form.

Procedure code B4105 may be considered for prior authorization for clients 5 years of age or older with documentation of the following:

  • The client’s diagnoses of both exocrine pancreatic insufficiency and cystic fibrosis
  • The client’s body mass index (BMI) below 18.5 for initial requests and a BMI below 25 for renewal requests
  • The client’s use of an enteral feeding pump for overnight feedings
  • The amount of formula (mL) the client receives during overnight feedings
  • An attestation that the client uses a compatible formula

Note: One cartridge can be used with up to 500mL of formula with a maximum of two cartridges per day.

Exclusions

The CSHCN Services program will not cover nutritional products for individuals who can be sustained on an age-appropriate diet. Most oral electrolyte solutions may be reimbursed through the Texas Vendor Drug program and will not be approved as a nutritional product.

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.