PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Policy/Procedure Number: MPRP4056
Lead Department: Health Services
External Policy
Policy/Procedure Title: Pediatric Enteral Nutrition
Internal Policy
Next Review Date: 10/1/2016
Original Date: 01/05/2012
Last Review Date: 10/1/2015
Applies to:
Medi-Cal
Healthy Kids
Employees
Reviewing
Entities:
IQI
P&T
QUAC
OPERATIONS
EXECUTIVE
COMPLIANCE
DEPARTMENT
Approving
Entities:
BOARD
COMPLIANCE
FINANCE
PAC
CEO
COO
Approval Signature: Robert Moore, MD, MPH
CREDENTIALING
DEPT. DIRECTOR/OFFICER
Approval Date: 10/1/2015
I.
RELATED POLICIES: N/A
II.
IMPACTED DEPTS.:
III.
DEFINITIONS: N/A
IV.
ATTACHMENTS:
A. Medical Conditions Requiring Dietary Interventions
1. Conditions Requiring Specific Dietary Components
2. Conditions Requiring the Alteration of Specific Dietary Components
3. Conditions Impairing Adequate Oral Intake
B. Metabolic Disorders
1. Disorders of Carbohydrate Metabolism
2. Disorders of Lipid Metabolism
3. Disorders of Vitamin Metabolism
4. Disorders of Amino Acid or Nitrogen Metabolism
C. Role of the WIC Dietician in Processing Formula Requests (From WIC)
1. Role of WIC/Referrals to WIC
2. Role of RD
D. Miscellaneous
1. Examples of WIC Contract Formulas
2. Examples of WIC Medically Indicated Formulas
3. Specialty Infant Enteral Nutrition
4. Elemental and Semi-Elemental Product Age Limitations
V.
PURPOSE:
This policy will define criteria for coverage of enteral nutrition products in children under 21 years of age
served by Partnership HealthPlan.
VI.
POLICY / PROCEDURE:
A. Special Notes
1. Special Note related to children on CCS program. If the child has a CCS eligible condition that
relates to the nutritional needs with enteral supplements, provider must obtain an approved service
authorization request (SAR).
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Policy/Procedure Number: MPRP4056
Lead Department: Health Services
☒External Policy
☐Internal Policy
Next Review Date: 10/1/2016
Last Review Date: 10/1/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Pediatric Enteral Nutrition
Original Date: 01/05/2012
Applies to:
☒ Medi-Cal
2. No treatment authorization request (TAR) is required for the “carved in” counties, provider bills
PHC Claims department directly with the approved SAR. For the “carved out” counties provider
bills state Medi-Cal with the approved SAR.
B. Infants under Age 12 months: Women, Infants, and Children Program (WIC) provide their contract
formula up to 12 months. See Attachment J for the current contract formulas.
1. WIC will cover a variety of other medically indicated formulas (must have a health care provider
prescription for a qualifying medical condition) temporarily (up to 2 months) pending Medi-Cal,
Medi-Cal Managed Care authorization, or eligibility for CCS or Regional Center. See Attachment K
for a list of WIC medically indicated formulas.
2. WIC will not cover contracted low-iron formulas even with a physician prescription.
3. If/once the client has Medi-Cal, WIC refers to Partnership Contracted Pharmacy to provide the
formula. (no contracts involved, merely convenient for client) Maximum covered usually 15
cans/month (depends upon the formula and composition—powder, liquid, RTF), but more may be
covered if calculated needs are higher.
C. Toddlers over age 12 months, but under 3 years. In general, maximum covered is 3 cans (240ml/can)
per day. Larger quantities may be authorized if totally dependent on formulas for nutrition, based on
Registered Dietician (RD) recommendation of exact feeding quantity
1. Enteral formulas will be covered by PHC in the following medically necessary conditions:
a. G-tube dependent (or other tube feeding; need documentation of type of tube and the indication
for the tube), 12 months if long-term; 3 months if temporary
b. Metabolic Disorders (See Attachments D – G)
c. Some malabsorption syndromes: (See Attachment B)
d. Insufficient caloric intake, resulting in mild to severe malnutrition (Toddlers over age 12
months, but under 24 months with weight below 2 percentile of the mean weight for height at
time of diagnosis to initiate treatment; goal: treat until at least to 2 percentile of the mean weight
for height; decrease formula if over 50 percentile of mean weight for age), (Toddlers over 24
months, but under 3 years of age with weight below 5 percentile of the mean weight for height
at time of diagnosis to initiate treatment; goal: treat until at least to 5 percentile of the mean
weight for height; decrease formula if over 50 percentile of mean weight for age) due to:
1) Attachment A “Condition requiring specific Dietary Components” and Attachment C
“Conditions Impairing adequate oral intake” (cover for up to 1 year)
2) Undiagnosed condition being worked up by specialist (often Pediatric Gastroenterologist),
and/or by a behavioral health specialist (often social worker) and/or R D with experience in
young children. Cover 3 months while workup in progress; may renew if weight not yet to
target weight and documentation of workup has been completed. If no workup completed
in 3 months, deny. (Note that WIC will cover enteral formulas for children up to age 5 if
prescribed by a physician, but denied by PHC for lack of medical necessity).as per above—
see medically indicated formulas.
a) The WIC definition of a Qualifying medical condition is a condition determined by a
health care provider that impair ingestion, digestion, absorption or utilization of
nutrients that could adversely affect the participant’s nutrition status, such as
prematurity, low birth weight, failure to thrive, gastrointestinal disorders, malabsorption
syndromes, immune system disorders, inborn errors of metabolism, severe food
allergies that require an elemental formula, etc.
b) WIC would not be able to cover a formula requested by an RD, only by someone who
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Policy/Procedure Number: MPRP4056
Lead Department: Health Services
☒External Policy
☐Internal Policy
Next Review Date: 10/1/2016
Last Review Date: 10/1/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Pediatric Enteral Nutrition
Original Date: 01/05/2012
Applies to:
☒ Medi-Cal
is licensed by the State to write prescriptions, such as a physician, physician’s assistant,
osteopath, or nurse practitioner.
D. Children age 3 years to 12 years: Quantity determined by age/height/caloric requirements. Height,
weight, growth charts and estimated caloric requirements should be submitted; recommendation of a
sub-specialist (often Pediatric Gastroenterologist), or Registered Dietician with experience in children
required. May cover for up to 3 months if consultation is pending. Role of WIC noted in age 12 months
to 3 years applies up to age 5 (see above).
1. Enteral formulas will be covered by PHC in the following medically necessary conditions:
a. G-tube dependent (or other tube feeding; need documentation of type of tube and the indication
for the tube), 12 months if long-term; 3 months if temporary
b. Metabolic Disorders (See Attachments D – G)
c. tion syndromes: (See Attachment B)
d. Insufficient caloric intake, resulting in mild to severe malnutrition (BMI percentile for age
below 5 percentile at time of diagnosis to initiate treatment; goal: treat to maintain at least to 5
percentile of the BMI percentile for age; decrease formula if above 50% of mean weight for
height), due to:
1) Attachment A “Condition requiring specific Dietary Components” and Attachment C
“Conditions Impairing Adequate Oral Intake” (cover for up to 1 year)
2) Undiagnosed condition (cover for 3 months at a time)
e. Re-evaluation criteria for maintenance treatment: for conditions 1, 2, 3 and 4, request Medical
Nutrition Therapy-RD notes (may cover for 1 month if no recent RD visit). Medical Nutrition
Therapy-RD notes evaluated to see if trial of food supplements was attempted or contraindicated.
E. Children age 12 years to 21 years: Quantity determined by age/height/caloric requirements. Height,
weight, growth charts and estimated caloric requirements should be submitted; recommendation of a
sub-specialist (often Pediatric Gastroenterologist), or Registered Dietician with experience in children
required.
1. Enteral formulas will be covered by PHC in the following medically necessary conditions:
a. G-tube dependent (or other tube feeding; need documentation of type of tube and the indication
for the tube), 12 months if long-term; 3 months if temporary
b. Metabolic Disorders (See Attachment D – G)
c. Some malabsorption syndromes: (See Attachment B)
d. Insufficient caloric intake, resulting in mild to severe malnutrition (BMI percentile for age
below 5 percentile at time of diagnosis to initiate treatment; goal: treat to maintain at least to 5
percentile of the BMI percentile for age; decrease formula if above 50% of mean weight for
height), due to:
1) Due to Attachment A “Condition Requiring Specific Dietary Components” and Attachment
C “Conditions Impairing Adequate Oral Intake” (cover for up to 1 year)
2) Due to undiagnosed condition. (cover for 3 months at a time)
e. Re-evaluation criteria for maintenance treatment: for conditions 1, 2, 3 and 4a, request Medical
Nutrition Therapy-RD notes (may cover for 1 month if no recent RD visit). Medical Nutrition
Therapy-RD notes evaluated to see if trial of food supplements was attempted or contraindicated. For condition 4b, evaluation for anorexia nervosa required. If anorexia nervosa
diagnosed, formula supplementation only permitted for 1 month at a time, for a maximum of 3
months while under supervised re-feeding program (documentation required).
F. Specialty Infant Nutrition
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Policy/Procedure Number: MPRP4056
Lead Department: Health Services
☒External Policy
☐Internal Policy
Next Review Date: 10/1/2016
Last Review Date: 10/1/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Pediatric Enteral Nutrition
Original Date: 01/05/2012
Applies to:
☒ Medi-Cal
1. Products covered under this section are for patients meeting the following medical conditions
Prematurity and low birth weight cow’s milk protein allergy fat malabsorption renal disorder
chylothorax or long chain 3 hydroxylacyl-CoA dehydrogenase deficiency (LCHAD).
2. Authorizations for Specialty Infant Products are limited to a maximum 2 month term (see
Attachment L)
G. Elemental and Semi-Elemental Nutrition Product Age Limitations
1. Specific pediatric elemental or semi-elemental products are designed for children 1 through 13 years
of age and are limited for use to that age group (See Attachment M)
VII.
REFERENCES:
A. Pediatric Nutrition Handbook, American Academy of Pediatrics, Sixth Edition 1/1/2009
B. AAP Policy Statement: Reimbursement for Foods for Special Dietary Use (reaffirmed May 1, 2006)
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/5/1117
C. AAP Clinical Report regarding Failure to Thrive (reaffirmed May 1, 2009)
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/5/1234
D. Morbidity and Mortality Weekly Reports ( MMWR) September 10, 2010/59(rr09);1-15. Use of World
Health Organization and CDC Growth charts for Children Aged 0—59 Months in the United States.
E. Medi-Cal Update ( Pharmacy/October 2011/Bulletin 761)
http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/ph201110.asp
F. Department of Health Care Services: July 13,2012 MMCD Policy Letter 12-005 Subject: Enteral
Nutrition Products.
G. Department of Health Care Services: April 11, 2014 MMCD Policy Letter 14-003 Subject: Enteral
Nutrition Products.
VIII.
DISTRIBUTION:
A. Provider & Practitioner Manuals
B. PHC Department Directors
C. SharePoint
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:
A. Pharmacy Services Director
X.
REVISION DATES:
Medi-Cal
01/16/14; 08/14/14; 10/1/15
Healthy Kids
01/16/14; 08/14/14; 10/1/15
PREVIOUSLY APPLIED TO:
XI.
POLICY DISCLAIMER:
A. In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed
with involvement from actively practicing health care providers and meets these provisions:
1. Consistent with sound clinical principles and processes;
2. Evaluated and updated at least annually;
3. If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will
be disclosed to the provider and/or enrollee upon request.
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Policy/Procedure Number: MPRP4056
Lead Department: Health Services
☒External Policy
☐Internal Policy
Next Review Date: 10/1/2016
Last Review Date: 10/1/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Pediatric Enteral Nutrition
Original Date: 01/05/2012
Applies to:
☒ Medi-Cal
B. The materials provided are guidelines used by PHC to authorize, modify or deny services for persons
with similar illnesses or conditions. Specific care and treatment may vary depending on individual need
and the benefits covered under PHC.
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