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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

October 2016

Update to Formulas and Enteral Nutrition Prior Authorization Policy


This month, Harvard Pilgrim is updating our Formulas and Enteral Nutrition Prior Authorization Policy. Harvard Pilgrim offers coverage of medically necessary special medical formulas and enteral nutrition to ensure that at-risk patients receive the nutritional support needed to prevent clinical deterioration.

Effective for dates of service beginning October 28, 2016, Harvard Pilgrim is also covering the following code with prior authorization:

    B4149 – Enteral formula, manufactured 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

When requesting authorization, providers should complete the Pedi/Adult Formula Prior Authorization Request Form and include the following clinical documentation:

  • For infants and pediatric patients: weight for age, weight for height growth charts, and Body Mass Index (BMI) charts (if applicable);
  • For adults, documentation of BMI and/or weight measured over time.

For more information, please refer to the updated Formulas and Enteral Nutrition Medical Review Criteria.

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