Enteral Medicare Guidelines

All Medicare Enteral referrals must include the following documentation:

  • H & P, diagnosis specific to enteral indication, progress notes including supporting documentation of the criteria listed below, and a nutritional assessment.
  • Documentation of condition and need for enteral therapy is of at least three (3) months duration.
  • Nutrients will be administered via a feeding tube.

All following criteria must be met for coverage of enteral therapy:

Documentation / Required Medicare Criteria:
  • Documentation of an anatomic impairment of the alimentary tract that prohibits food from reaching the small bowel, i.e., CT scans, x-rays, EGD, barium swallow, speech therapy consultation, OR reports (or)
  • Documentation of small bowel disease/motility disorder which impairs digestion and absorption of an oral diet, i.e., small bowel/esophageal motility studies, UGI with SBFT, small bowl biopsy, gastric emptying study, barium swallow, speech therapy consultation, OR reports (or)
  • Documentation of a partial impairment which requires prolonged infusion of enteral nutrients to maintain nutritional status, i.e., barium swallow, CT scans, x-rays, OR reports, speech therapy consultations, upper GI with small bowel follow through
  • Report of feeding tube replacement

  • Additional documentation requirements:

    • If pump administration is required, documentation from the physician justifying use of the pump is required. Justification may include feeding into the jejunum, need for controlled rate of infusion due to intolerance to bolus syringe, or gravity drip feeding. Documentation of intolerance must be provided.
    • Some enteral formulas require justification to substantiate medical necessity. Chartwell will notify you if required based on the formula ordered.
    • Detailed enteral prescription is required.
Chartwell reviews all eligible Medicare patients for infusion qualification based on the Noridian LCD found at: External Infusion Pumps LCD and PA (noridianmedicare.com). Noridian has the most current and up to date information. Please refer to the Noridian site for clarification of any content on this site.

Some therapies will have fill and total dose limitations with each qualifying diagnosis. Some therapies will require an electronic external infusion pump, while others will prohibit use of an electronic pump based on the LCD. Medicare covers home infusion under their external infusion pump coverage within the Durable Medical Equipment benefit.

For qualification, provider documentation requires diagnostic testing to support diagnosis for all therapies requiring Medicare qualification. Additionally:
  • The patient must be eligible for a defined Medicare benefit category.
  • Therapy must be reasonable and necessary for the diagnosis and supported in medical documentation.
  • The case must meet all other applicable Medicare statutory and regulatory requirements.