March 19, 2008 - Revised: 06.10.10
Specialty Nutrients - Documentation
According to the local coverage decision (LCD) for Enteral Nutrition, coverage of special formulas (HCPCS Codes B4149, B4153-B4157, B4161, and B4162) must be justified in each patient because they are produced to meet unique nutrient needs for specific disease conditions. The patient's medical record must adequately document the specific condition and the need for the special nutrient. Failure to substantiate the medical necessity of the special formula will result in the claim being denied as not medically necessary.
The documentation necessary to justify special formulas includes:
- Medical records documenting the medical condition requiring a HCPCS Code B4149, B4153-B4157, B4161, or B4162 formula as opposed to a B4150 formula and the severity of that condition as shown by history, physical exam and diagnostic/laboratory studies.
- The response of the medical condition to a B4150 formula as compared to the response to the prescribed B4149, B4153-B4157, B4161, or B4162 formula. If this comparison has not been made, the medical reason for its absence should be documented in the patient's medical record. The reason(s) should be individualized for the patient and not a generalized statement such as the diagnosis.
The most common request in Jurisdiction C is for specialty diabetic (B4154) formulas such as Glucerna® and Diabetisource®. If the DME MAC sends an additional documentation request (ADR) letter in regards to a claim for one of these formulas, the following documentation should be provided:
- How long was the patient on a B4150 formula?
- Were different B4150 formulas tried? What were they?
- Were adjustments made in medications in an attempt to control blood sugars while on the B4150 formula?
- Is there documentation in the form of serial blood sugars, preferably one month prior to and after beginning usage of a B4154 diabetic formula, demonstrating improvement in glycemic control?
Providing this additional information will assist Medical Review staff in their review of these claims and help insure that proper claims payment is made.