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Excellus BlueCross BlueShieldCommercial · Coverage · Food (Nutrition) · NY · Gastroenterology, Neurology, Pediatrics +1 moreHigh impact

Enteral Nutrition 10.01.03

Effective date
Feb 19, 2026
Identified
Jun 20, 2026

Summary

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.

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What to do

Action · 6 steps
01Already effective February 19, 2026: Billing team, for in-line digestive enzyme cartridges (B4105), the policy requires that the individual meets enteral nutrition criteria, has a diagnosis of cystic fibrosis and exocrine pancreatic insufficiency, has documented failure to achieve feeding goals with pancreatic enzyme replacement therapy in combination with enteral feedings, requires overnight enteral feedings to meet nutritional or calorie demands, and receives no more than two in-line cartridges per day.
02For enteral formulas, the provider's written order must contain the individual's diagnosis, state that the formula is medically necessary, and state that it has been proven effective as a disease-specific treatment regimen.
03Individuals with cognitive or neurological disease must have documentation in the medical record of a dysfunction of the swallowing mechanism, and swallowing assessments or evaluations are required.
04Enteral formulas administered orally without feeding tubes, and modified solid food products, are considered under the pharmacy benefit, and no benefits are provided if there is no pharmacy coverage.
05For enteral formulas given with feeding tubes, when the individual receives home care billed by a home care agency, formulas and supplies are considered under the home care benefit; otherwise the formulas are considered under the medical contract with a copayment equal to the third-tier pharmacy benefit, and necessary supplies are considered under the prosthetic benefit.
06Dietary supplements such as probiotics are considered not medically necessary.

Codes mentioned

B4034B4036B4102B4103B4104B4105B4148B4149B4150B4152B4153B4154B4155B4157B4158B4159B4160B4161B4162B9002B9998S9340S9341S9342S9343S9432S9433S9434S9435

Original notice

Enteral Nutrition 10.01.03
excellusbcbs.com · Always check the source before changing claims.
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Related policy hubs

Excellus BlueCross BlueShield policiesNY policy changesGastroenterologyNeurologyPediatricsPharmacyCode B4034Code B4036Code B4102Code B4103Code B4104Code B4105Code B4148Code B4149Code B4150Code B4152Code B4153Code B4154Code B4155Code B4157Code B4158Code B4159Code B4160Code B4161Code B4162Code B9002Code B9998Code S9340Code S9341Code S9342Code S9343Code S9432Code S9433Code S9434Code S9435

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