Enteral Nutrition Products: Specialized (enteral spec) by JYT808qI

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									                                                                                                                                                              enteral spec
Enteral Nutrition Products: Specialized                                                                                                                                  1
This section includes the criteria for specialized enteral nutrition products for multiple disease states; the products contain intact macronutrients (protein,
carbohydrate or fat). Products include, but are not limited to products for diabetes (DM), renal disease (CKF, ESRF), chronic obstructive pulmonary disease
(COPD), acute respiratory distress syndrome (ARDS), hepatic disease and immune enhancing products for critical illness. This section also includes
macronutrient modules (protein, carbohydrate or fat).



Documentation Requirements                    To receive authorization for products listed in this section, specific information as documented in the beneficiary’s medical
                                              record must be supplied clearly on the authorization request or as an attachment to the request. Refer to specifics
                                              outlined in this section and in the Enteral Nutrition Products: An Overview section in this manual.



Authorization                                 A Treatment Authorization Request (TAR) or Service Authorization Request (SAR) is required for all enteral nutrition
                                              products.



Medical Criteria                              In addition to the prescription requirement, medical criteria and documentation requirements listed in the Enteral
                                              Nutrition: An Overview section of this manual, the following medical criteria must be met and documented clearly
                                              on, or attached to, the authorization request to receive authorization for Medi-Cal reimbursement.

                                                   Beneficiaries under age 21
                                                    – May be oral or tube-fed
                                                   Beneficiaries 21 years of age or older
                                                    – Tube fed only
                                                     Note: Products listed in this section are not a benefit for oral-fed beneficiaries 21 years of age or older. (See
                                                           Cystic Fibrosis beneficiary exception in the Enteral Nutrition Products: Metabolic section of this
                                                           manual.)




2 – Enteral Nutrition Products: Specialized
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Product Criteria                              The following product criteria must be met for each product type and documented clearly on, or attached to, the
                                              authorization request to receive authorization for Medi-Cal reimbursement.

                                              For diabetes mellitus, only products listed in this section of the manual are available for authorization.

                                              For all other product types in this section (CKF, ESRF, COPD, ARDS, modules, etc.), products are considered for
                                              authorization on a case by case basis.

                                              Note: All eligible tube-fed beneficiaries may be eligible for products listed in any of the enteral nutrition product
                                                    sections of this manual.




2 – Enteral Nutrition Products: Specialized
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SPECIALIZED ENTERAL NUTRITION PRODUCT LIST—DIABETIC PRODUCTS (DM)

    Abbott: 1-800-558-7677
                                                 Caloric
                                                 density
                                                 (kcal/g               Medi-Cal Billing   UPC Number     UPC Number     MAC per          EAC per
    Product Label Name                           or ml)                Number             (Item)         (Case)           g or ml         g or ml
    Glucerna 1.0 (237ml) van                     1.00                  70074050241        070074502410   070074502403    0.0065           0.0065
    Glucerna 1.0 (1000ml)                        1.00                  70074051207        070074512075   070074512068    0.0080           0.0080
    Glucerna 1.0 (1500ml)                        1.00                  70074052603        070074526034   070074526027    0.0080           0.0080
    Glucerna 1.2 (237ml) van                     1.20                  70074050905        070074509051   070074509044    0.0100           0.0100
    Glucerna 1.2 (1000ml)                        1.20                  70074050907        070074509075   070074509068    0.0100           0.0100
    Glucerna 1.2 (1500ml)                        1.20                  70074050903        070074509037   070074509020    0.0100           0.0100
    Glucerna 1.5 (237ml) van                     1.50                  70074053535        070074535357   070074535340    0.0110            0.0110
    Glucerna 1.5 (1000ml)                        1.50                  70074053537        070074535371   070074535364    0.0110            0.0110
    Glucerna Select (237ml) van                  1.00                  70074057702        070074577029   070074577012    0.0090            0.0090
    Glucerna Select (1000ml)                     1.00                  70074057704        070074577043   070074577036    0.0100            0.0100
    Glucerna Select (1500ml)                     1.00                  70074057706        070074577067   070074577050    0.0100            0.0100




†      Dagger indicates new product or change to an entire table row
*      Asterisk(s) indicate a change to individual table cell(s)


2 – Enteral Nutrition Products: Specialized
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    Nestle: 1-800-422-ASK2
                                                 Caloric
                                                 density
                                                 (kcal/g               Medi-Cal Billing   UPC Number     UPC Number       MAC per       EAC per
    Product Label Name                           or ml)                Number             (Item)         (Case)            g or ml       g or ml
    Nutren Glytrol Tet Prsm                      1.00                  00065908570        798716062756   00798716162753    0.0065        0.0065
    (250ml) van
    Glytrol Tet Prsm (250ml)                     1.00                  00065908570        798716062756   00798716162753    0.0065         0.0065
    van
    Nutren Glytrol UltraPak                      1.00                  98716016376        798716163767   10798716223901    0.0080         0.0080
    SpikeRight (1000ml)
    Nutren Glytrol UltraPak                      1.00                  98716016377        798716163774   00798716323918    0.0080         0.0080
    SpikeRight (1500ml)
    Boost Glucose Control                        1.06                  00212360162        043900360119   10043900360109    0.0065         0.0065
    (237ml) van
    Boost Glucose Control                        1.06                  00212360262        043900360218   10043900360208    0.0065         0.0065
    (237ml) choc
    Boost Glucose Control                        1.06                  00212360362        043900360317   10043900360307    0.0065         0.0065
    (237ml) str
    Diabetisource AC Tet Prsm                    1.20                  00212365051        043900365008   10043900365005    0.0100         0.0100
    (250ml) unflav
    Diabetisource AC (1000ml)                    1.20                  00212365142        043900365015   10043900365012    0.0100       0.0100 †
    Diabetisource AC (1500ml)                    1.20                  00212365244        043900365022   10043900365029    0.0100       0.0100 †
    Diabetisource AC SpikeRight                  1.20                  43900036508        043900365084   10043900365081    0.0100         0.0100
    (1000ml)
    Diabetisource AC SpikeRight                  1.20                  43900036582        043900365824   10043900365821    0.0100         0.0100
    (1500ml)
    Diabetisource AC                             1.20                  43900036582        043900365824   10043900365838    0.0100       0.0100 †
    SpikeRight (1500ml)
†          Effective September 1, 2012

†      Dagger indicates new product or change to an entire table row
*      Asterisk(s) indicate a change to individual table cell(s)


2 – Enteral Nutrition Products: Specialized
                                                                                                                                     July 2012

								
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