Reimbursement Details

At Nutricia, we understand how complex the reimbursement landscape can be.  Nutricia’s Pro-Stat line of products may be reimbursed by Medicare if given via tube feeding. 

Medicare categories for adult enteral formulas (B4149 and B4153-B4155) require written justification of their medical necessity before they will be covered. This justification must be maintained in the patient’s medical record. If the medical necessity for specialty nutrients is not met, the formula will be denied as not reasonable and necessary. Medicare does not cover foods that are or can be blenderized and given via an enteral feeding tube.

B4155 —Modular Nutrients (such as Pro-Stat® Sugar Free): This category includes modular formula nutrients that are added to an existing formula. These components are designed to supply additional nutrition in the form of carbohydrate or protein.  It is billed/reimbursed in units.  Each Unit = 100 kcal increment.  Pro-Stat Sugar Free & Pro-Stat© AWC are each 100 kcals per fluid ounce. 

Are modular nutrients covered by Medicare Part B in my zip code?To determine if modular nutrients are covered by Medicare Part B reimbursement based on your zip code, please visit http://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home. To find a supplier in your area, visit http://www.medicare.gov/SupplierDirectory/?AspxAutoDetectCookieSupport=1.

 If reimbursement is available in my zip code, how much will Medicare Part B reimburse for B4155? The supplier that bills for Part B covers 80% of the cost and the beneficiary's responsibility is the remaining 20%.  Please visit http://dmecompetitivebid.com/palmetto/cbicrd2.nsf/DocsCat/94ETC90234 for more information.

If you have private insurance, please consult your insurance provider on whether Nutricia’s line of specialized adult nutrition products can be reimbursed.

Note: As of October 1, 2014, Medi-Cal in California will reimburse home care patients given Pro-Stat Sugar Free. This reimbursement applies to Pro-Stat Sugar Free bottles that are consumed orally or via tube feeding. For reimbursement, all enteral nutrition products require the beneficiary’s pharmacy provider to submit either a Treatment Authorization Request (TAR) or a Service Authorization Request (SAR) for authorization.

Reimbursement Codes:

Product
Name

Item #

Flavor

Case Pack

Reimbursement Code

Pro-Stat® Sugar Free

10064

Wild Cherry Punch

6 x 30 fl oz

26974-0410-07

 

10464-U

Wild Cherry Punch

96 x 1 fl oz

26974-0410-17

 

30064

Citrus Splash

6 x 30 fl oz

26974-0300-64

 

30464-U

Citrus Splash

96 x 1 fl oz

26974-0304-64

 

40064

Vanilla

6 x 30 fl oz

26974-0410-40

 

40464-U

Vanilla

96 x 1 fl oz

26974-0410-42

 

50064

Grape

6 x 30 fl oz

26974-0410-50

 

50464-U

Grape

96 x 1 fl oz

26974-0410-52

Pro-Stat® Sugar Free AWC

40130

Wild Cherry Punch

4 x 30 fl oz

26974-0410-30

 

40130-U

Wild Cherry Punch

96 x 1 fl oz

26974-0410-31

 

40230

Citrus Splash

4 x 30 fl oz

26974-0410-23

 

40230-U

Citrus Splash

96 x 1 fl oz

26974-0410-24

Pro-Stat® Max

90001

Grape

4 x 30 fl oz

26974-0900-01

 

90001-U

Grape

96 x 1 fl oz

26974-1900-01

Pro-Stat® Renal Care

60064

Tangerine

6 x 30 fl oz

26974-0410-64

 

60064-U

Tangerine

96 x 1 fl oz

26974-0410-65

Fiber-Stat®

70001

Prune

6 x 30 fl oz

26974-0410-70

 

70400-U

Prune

96 x 1 fl oz

26974-0410-71

UTI-Stat®

60001

Cranberry

4 x 30 fl oz

26974-0410-66

 

60001-U

Cranberry

96 x 1 fl oz

26974-0410-67

Diff-Stat®

80001

Unflavored

6 x 60 capsules

26974-0410-80

 

80001-U

Unflavored Powder

96 x 2g packs

26974-0410-81