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Enteral Therapy

Patient's must meet the below criteria for coverage:

1. Enteral nutrition is covered for a patient who has a permanent impairment, (Permanence does not require a determination that there is no possibility that the patient's condition may improve sometime in the future. If the judgment of the attending physician, substantiated in the medical record, is that the condition is of long and indefinite duration - ordinarily at least 3 months - the test of permanence is considered met).
2. The patient must require a feeding tube.
3. Total daily caloric intake is 20-35 cal/kg/day.
4. Adequate nutrition must not be possible by dietary adjustment and/or oral supplements.

Patient's must meet one of the following criteria for coverage of enteral formula:

1. The patient has a disease or anatomic defect of the of the alimentary tract that normally permits food to reach the small bowel. Such conditions may include:
   1. anatomic obstructions such as head and neck cancers
   2. reconstructive surgery
2. The patient has a disease of the small bowel which impairs digestion and absorption of an oral diet. Such conditions may include:
   1. motility disorders such as dysphagia following a stroke
   2. gastroparesis

3. The patient has a partial impairment which requires prolonged infusion of enteral nutrients to maintain nutritional status. Such conditions may include:

   1. dysphagia that allows the patient to swallow small amounts of food
   2. absorption disorders such as Crohn's disease.

ADDITIONAL REQUIREMENTS:

• If the patient requires a pump for administration of enteral therapy, there must be documentation included to justify pump use (e.g., gravity feeding is not satisfactory due to reflux and/or aspiration, severe diarrhea, dumping syndrome, administration rate less than 100ml/hr, blood glucose fluctuation, circulatory overload).
• Enteral formulas consisting of semi-synthetic intact protein/protein isolates are appropriate for the majority of patients requiring enteral nutrition. Formulas consisting of natural intact protein/protein isolates are covered for patients with an allergy or intolerance to semi-synthetic formulas. Calorically dense formulas are covered if they are ordered and are medically necessary. The medical necessity for special enteral formulas will need to be justified in each patient.

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