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Medical Policy Revision: Medical Nutritional Therapy for Inherited Metabolic Disease

Effective January 4, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for medical nutritional therapy used to treat metabolic diseases.

According to the guidelines of our medical policy, Medical Nutritional Therapy for Inherited Metabolic Disease:

  • Foods and food products must meet all of the following criteria to be eligible for reimbursement:

    Must be used under the direction of a physician for the nutritional therapeutic management of these congenital diseases or conditions: Hypothyroidism (currently, there is no medical food for this condition); Galactosemia; Phenylketonuria; Sickle cell anemia and other hemoglobinopathis; Maple syrup urine disease; Congenital adrenal hyperplasia; Biotinidase deficiency; Cystic fibrosis; Medium chain acyl-CoA dehydrogenase (MCAD) deficiency; Short chain acyl-CoA dehydrogenase (SCAD) deficiency; Long chain acyl-CoA dehydrogenase (LCAD) deficiency; Very long chain acyl-CoA dehydrogenase (VLCAD) deficiency; Citrullinemia; Argininosuccinic academia.

    Must be a "medical food" or "low protein modified food product."

    Please note that even if a member is diagnosed with an inherited metabolic disease, a food or food product which either (a) does not fall under the statutory definition of "medical food" or "low protein modified food product", or (b) is not specifically formulated as a dietary treatment of the inherited metabolic disease for which it is being given but is merely supplying calories and nutrients, is NOT eligible for reimbursement under the mandate.
  • Other nutritional therapeutic items (including those that do not require prescription by a physician, i.e., in phenylketonuria, phenylalanin-free or low protein baking mix, flour, and pasta) are considered eligible when used under the direction of a physician for specific nutritional or dietary needs caused by an inherited metabolic disease.

Based on the guidelines included in our revised medical policy, Medical Nutritional Therapy for Inherited Metabolic Disease, AND the submitted diagnosis or diagnoses code(s), claims for services provided to members enrolled in coverage through self-insured employer groups on and after January 4, 2015 that include HCPCS codes B4157, B4158, B4160, B4161, B4162, S9433, S9434 or S9435 may pend while information required to determine medical necessity is requested and reviewed.

Review this revised policy in our online Medical Policy Manual.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after January 4, 2015.

Published on: October 2, 2015, 12:39 p.m. ET
Last updated on: November 24, 2020, 23:45 p.m. ET