016-06-07 Ark. Code R. § 10
Enteral formulas are divided into several categories. Each unit of service equals 100 calories of formula. All supplies and equipment necessary to administer the nutrients in the beneficiary's place of residence, except the infusion pump and pump supply kit are included in the unit description.
A separate prior authorization must be obtained for the enteral infusion pump and the pump supply kit. The enteral infusion pump and the pump supply kit may be billed separately.
The following pages provide the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients.
WIC (Women Infants Children Program) must be accessed before the Medicaid Program for children from birth to 5 years of age.
Modifiers in this section are indicated by the headings M1 and M2.
HCPCS Code | M1 | M2 | Description | Covered Formulae |
B4149 | U9 | Enteral formula, blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Compleat | |
B4150 | U9 | Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | See list below |
Covered Formulae:
Boost | Fibersource HN | Nutren 1.0 with Fiber |
Boost with Benefiber and FOS | Fortison | Osmolite |
Carnation Instant Breakfast - | Intraolite | Osmolite 1.0 CAL |
Lactose Free | Isocal | Osmolite HN |
Ensure | Isocal HN | Portagen |
Ensure Fiber with FOS | IsoSource | Probalance |
Ensure High Protein | IsoSource HN | Promote |
Ensure HN | Jevity 1.0 CAL | Promote with Fiber |
Ensure Powder | Nutrapack | Ultracal |
Fibersource | Nutren 1.0 |
B4152 | U9 | Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 Kcal/ml), with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Boost Plus Carnation Instant Breakfast - Lactose Free Plus Comply Ensure Plus Novasource 2.0 Nutren 1.5 Nutren 2.0 Osmolite 1.5 Cal Scandishake Two-Cal HN | |
B4153 | U9 | Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Alitraq Criticare HN Isotein HN Peptamen Peptamen 1.5 Peptamen VHP Peptamen with Prebio 1 Perative Tolerex Vital HN Vivonex Plus Vivonex TEN | |
B4154 | U9 | Enteral formula, nutritionally complete, for special metabolic needs, includes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | See list below |
B4155 | U9 | Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit | Casec Powder Fructose Powder MCT Oil Polycose Liquid Procel Protein Power Provimin Sumacal | |
Bill on Paper (Indicate specific name of formula on claims.) | ||||
B4155 | U9 | U1 | Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit | Polycose Powder Dextrose Scandical |
B4155 | U9 | U2 | Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit | Microlipids |
B4155 | U9 | U3 | Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit | Product 80056 PKU 1, 2 and 3 RCF Try 1 and 2 |
B4158 | U9 | Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit | Enfamil Enfamil AR Lipil Enfamil Lactofree Enfamil Lactofree Lipil Enfamil Lipil Low Iron Enfamil Lipil with Iron Enfamil Next Step Lipil Nutren Jr. Nutren JR with Fiber Resource for Kids Resource Just for Kids with Fiber | |
B4159 | U9 | Enteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit | Enfamil Next Step Prosobee Lipil Enfamil Prosobee Lipil Isomil Isomil Advance Soy with Iron Prosobee | |
B4160 | U9 | Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Enfamil Enfacare Lipil Powder Kindercal Kindercal with Fiber Pediasure Pediasure with Fiber | |
B4160 | U9 | U1 | Enteral formula, for pediatrics, nutritionally calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Enfamil Premature Lipil 24 Cal Low Iron Enfamil Premature Lipil 24 Cal with Iron Similac Neosure Similac Neosure Advance Special Care Advance 20 Special Care Advance 20 with Iron Special Care Advance 24 Special Care Advance 24 with Iron |
B4161 | U9 | Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | Alimentum ELECARE Enfamil Nutramigen Lipil Enfamil Pregestimil Neocate Infant Formula Neocate Jr Neocate One + (Pediatric E028) Liquid Neocate One + Powder Nutramigen Peptamen Jr Pregestimil Similac Alimentum Advance with Iron Vivonex Pediatric | |
B4162 | U9 | Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | See list below | |
Covered Fo Calcilo XD Cyclinex-1 Cyclinex-2 Hominex-1 Hominex-2 I-Valex-1 I-Valex-2 Ketonex-1 Ketonex-2 | rmulae: | Low Phe Try Diet Powder Maxamaid MSUD Maxamum MSUD MSUD Analog MSUD 1 and 2 | Periflex Advanced Periflex Infant Periflex Junior Phenex-1 Phenex-2 Phenyl Free 1 Phenyl Free 2 Propimex-1 Propimex-2 XLys, XTrp Maxamaid Xphe Maxamaid Xphe Maxamum XPhe, XTyr Analog XPhe, XTyr Maxamaid | |
B4162 | U9 | U1 | Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | XMTVI Maximaid |
For a non-covered prescribed formula a review for medical necessity will be performed upon request. The product information, with assigned HCPCS code and physician documentation of the medical necessity of the formula for a specific beneficiary, must be submitted to Utilization Review. Add utilization review link here. View or print the Utilization Review Section contact
information.If approved, the formula will be added to the list of covered formulae and the provider will be notified. If denied, the provider and beneficiary will be notified.
016.06.07 Ark. Code R. § 010