Prior Authorization : General Information

Covered Enteral Nutrition Formula

PA is not required for enteral nutrition products administered through a tube, per Wis. Admin Code § DHS 107.10(2)(c).

Prior Authorization Requests for Enteral Nutrition Administered Orally

PA requests for enteral nutrition formula administered orally will be approved when all of the following criteria are true:

• The member has a documented medical condition that prevents adequate nutrition or requires enteral nutrition formula and/or food thickener when medically indicated to thrive and develop normally.
• Documentation shows that one of the following is true for the member:
  • Sufficient caloric and protein intake are not obtainable through any regular, liquefied, or pureed foods
  • A swallowing impairment precludes them from oral administration of regular thin liquids or foods
• The member has had an assessment by a registered dietitian within the last 12 months that includes:
  • A clinical history indicating that oral intake is inadequate
  • A description of the impairment that prevents adequate nutrition by conventional means
  • Lab values to support nutritional deficiency, when applicable
  • The member's recommended daily caloric intake
  • Weight trends over the past six months (for example, weight-for-length, progression along a growth chart, or BMI, as appropriate)
• The nutrition formula and/or food thickener will be used under the supervision of a certified health provider in conjunction with a registered dietitian.

Covered Medical Conditions

Enteral nutrition formula and/or food thickener may be covered when a member is diagnosed with one of the medical conditions listed below by a qualified health care provider:

• Swallowing and/or feeding difficulties (for example, dysphagia, oral motor/oral sensory dysfunction/disorder)
• Open wounds (for example, diabetic wounds, surgical wounds, pressure ulcers, burns)
• Inborn errors of metabolism (for example, histidinemia, homocystinuria, phenylketonuria, hyperlysinemia, maple syrup urine disease, tyrosinemia, or methylmalonic acidemia)
• More than 50 percent of the member's caloric need is required to be met orally by specially formulated nutrition due to a medical condition (for example, ketogenic diet, food protein-induced enterocolitis, severe allergy, eosinophilic esophagitis, or eosinophilic gastritis)
• Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length, or motility of the gastrointestinal tract (for example, short-gut syndrome, fistula, cystic fibrosis, inflammatory bowel disease, ischemic bowel disease)
• CNS disease leading to interference with neuromuscular mechanisms of ingestion of such severity that the member cannot be maintained with regular oral feeding
• Nutritional deficiency (for example, failure to thrive or malnutrition)
• Chronic disease (for example, advanced AIDS or ESRD with or without renal dialysis)
• Ongoing cancer treatment or specific cancers (for example, gastrointestinal or head/neck)

Documentation Requirements

The following must be submitted for PA requests for enteral nutrition formula:

• A completed and signed PA/RF
• A completed and signed PA/ENFA
• A prescription from a certified health provider that includes:
  • Member name
  • Prescription or order date
  • Enteral nutrition formula(s) and/or food thickener(s) prescribed or ordered
  • Calories, ounces, or milliliters per day prescribed or ordered
  • Prescriber's name, signature, and professional credentials
  • Documentation identified under the coverage policy

PA Requests Submitted via the Portal Considered for Immediate Approval

PA requests may be submitted through the Portal to allow for real-time review of clinical information and immediate adjudication. PA requests will be considered for immediate adjudication for members under age 21 who receive partial or total nutrition orally and who have one of the medical conditions listed in the Covered Medical Conditions section above.

PA requests for enteral nutrition formula consumed orally may be reviewed by a clinical consultant.

Providers are required to complete the PA/ENFA on the Portal and upload a copy of the original prescription or order and all supporting clinical documentation with the initial submission of the PA request.