Enteral Nutrition 10.01.03
Excellus BlueCross BlueShield policy 10.01.03 considers in-line digestive enzyme cartridges, such as RELiZORB, medically necessary when all listed criteria are met: the individual meets enteral nutrition criteria, has cystic fibrosis with exocrine pancreatic insufficiency, has documented failure to achieve feeding goals with pancreatic enzyme replacement therapy combined with enteral feedings, requires overnight enteral feedings, and receives no more than two cartridges per day. The policy also considers enteral formulas for home use medically appropriate with a written order stating the formula is medically necessary and proven effective for a listed disease-specific condition, and considers enteral feeding tubes medically appropriate for listed functional impairments, while dietary supplements such as probiotics are considered not medically necessary. The change note for the version effective February 19, 2026 states that the in-line digestive enzyme cartridge statement was updated to medically necessary when specific criteria are met.