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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:

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:

Providing this additional information will assist Medical Review staff in their review of these claims and help insure that proper claims payment is made.