Medicare Coverage Guidelines for Enteral Therapy
- Diagnosis: Enteral nutrition therapy must be ordered by a physician.
The patient must have:
- Permanent non-function or disease of the structures that normally permit food to reach or be absorbed from the small bowel, and
- Require tube feedings to provide sufficient nutrients to maintain weight and strength. These questions are #7 and #8 on the Certificate of Medical Necessity (CMN) and must be answered Yes for Medicare to cover.
- Calorie Justifications: Calories must fall in the range of 20-35 kcals/kg/BW unless appropriately justified and documented by ordering physician.
- Product Justifications: Specialized products must be accompanied with an appropriate diagnosis.
- Test of Permanence: Physician must feel patient’s condition will warrant tube feeding for at least 90 days. It is not appropriate to order tube feeding for 1-2 week period with plans to remove tube.
- Pump Justification: Use of an enteral pump requires a secondary diagnosis to support the medical necessity.
Examples of Appropriate Pump Diagnosis Include:
Home tube feeding is an excellent alternative to hospitalization or long-term care. Reeves-Sain has a registered dietitian on staff that clinically monitors each enteral patient. Calls are made monthly by the dietitian to assess the patient's weight and tolerance of the feeding. From this assessment our staff will determine the appropriate monthly supplies to be delivered.
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Please note: Medicare Guidelines do not always apply to Private Insurance Companies.
Information needed for Enteral Referral:
- Patient Demographics
- Ht, Wt, Diagnosis, History, Physical
- Feeding plan including formula, method of feeding (bolus, gravity, or pump), rate, and type of tube
- Signed Physician’s Order
- Primary Care Physician
- Primary and secondary insurance with policy number and name of insurer if other than patient.
