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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 02|01|2026 POLICY LAST REVIEWED: 10|15|2025 OVERVIEW This policy provides the criteria for coverage for non-prescription nutritional formulas for home use (i.e., Ensure, Boost, etc.) delivered orally, low protein foods, or special medical formulas as prescribed by a physician for treatment of malabsorption caused by Crohn’s Disease, Ulcerative Colitis, Gastroesophageal Reflux, Chronic Intestinal Pseudo Obstruction, and Inherited Diseases of Amino Acids and Organic Acids. This policy is applicable to Commercial products only. This policy does not describe coverage or reimbursement of donor breast milk therapy which is not a covered service under Blue Cross & Blue Shield of Rhode Island plans.
This policy does not address enteral nutrition therapy as the sole source of nutrition delivered through a feeding tube. See Related Policies section for Enteral/Parenteral Nutrition Therapy policy. This policy is to address the language in the mandate and the claims submission process. Prior authorization is handled via our online authorization tool. Please refer to the Related Policies section. MEDICAL CRITERIA
Commercial Products Treatment with low protein food products is covered when ordered by a physician for individuals with Inherited Diseases of Amino Acids and Organic Acids caused by the following conditions such as, but not limited to: • Phenylketonuria (PKU) • Tyrosinemia • Homocystinuria • Maple Syrup Urine Disease • Propionic Aciduria and Methylmalonic Aciduria Treatment with oral nutritional formulas or special medical formulas (i.e., Neocate, Boost, Ensure) for home use is covered when ordered by a physician for individuals with malabsorption caused by: • Crohn’s Disease; or • Ulcerative Colitis; or • Gastroesophageal Reflux; or • Chronic Intestinal Pseudo Obstruction; or • Inherited Diseases of Amino Acids and Organic Acids; or, • Milk/soy protein allergy for infant (0 – 12 months) with failure to thrive AND blood in the stools. Low protein food products, oral nutritional formulas, and special medical formulas are non-covered and a contractual exclusion for all Commercial Products when the criteria above are not met.
PRIOR AUTHORIZATION Commercial Products Prior authorization is recommended for Commercial Products only and is obtained via the online tool for participating providers. See the Related Policies section. Medical Coverage Policy | Oral Nutrition Mandate

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

The following prior authorization form is for use by non-participating providers.

Preauthorization Form for Oral Nutrition *Refer to “Preauthorization Form for Oral Nutrition” listed under section, “Coordination of Care”

POLICY STATEMENT Commercial Products Treatment with low protein food products, oral nutritional formulas, or special medical formulas are covered for all Commercial products when the criteria above is met. Those services not meeting the criteria are not covered and are a contract exclusion.

Process for Member submitted reimbursement requests:

Following preauthorization approval, the member can be reimbursed for the food products. The member must submit itemized receipt(s) highlighting or circling the special foods purchased, together with the reimbursement form listing the special foods purchased within one year from the date of purchase to:

Attention: Claims Department
Blue Cross & Blue Shield of Rhode Island
500 Exchange Street Providence, RI 02903-2699

Oral Enteral Food Products Reimbursement Form *Refer to “Oral Enteral Food Products Reimbursement Form” listed under section, “Coordination of Care”

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable “Medical Equipment, Enteral Formula or Food, Medical Supplies, and Prosthetic Devices” benefits/coverage.

BACKGROUND Rhode Island General Law (RIGL) 27-20-56 mandates coverage for nutrition products:

§ 27-20-56 Enteral nutrition products – (a) Every individual or group health insurance contract, or every individual or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery, or renewed in this state on or after January 1, 2009, shall provide coverage for nonprescription enteral formulas for home use for which a physician has issued a written order and that are medically necessary for the treatment of malabsorption caused by Crohn's disease, ulcerative colitis, gastroesophageal reflux, chronic intestinal pseudo-obstruction, and inherited diseases of amino acids and organic acids. Coverage for inherited diseases of amino acids and organic acids shall include food products modified to be low protein and shall extend to all recipients regardless of age.

Definition of Oral Nutrition:
• Non-prescription nutritional formulas for home use consist of nutritional liquids (i.e., Ensure, Boost, etc.) delivered orally.

• Low protein food products are defined as food products that have been modified to be low in protein for individuals who have been diagnosed with phenylketonuria (PKU) and other inherited diseases of amino acids and organic acids.

• Special medical formulas (i.e., Neocate) are formulas labeled for use by infants and children who have inborn errors of metabolism. These infant formulas are not typically found in retail stores for general consumer purchase, they must be prescribed by a physician and requested from a pharmacy.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM Effective January 1, 2014, Qualified Health Plans (QHPs) are required to cover Essential Health Benefits (EHBs), as defined in Section 1302(b) of the Patient Protection and Affordable Care Act. As groups renewed in 2014, most benefit plans were updated to include these EHBs (some exceptions may apply to certain large groups; consult your Subscriber Agreement or Benefit Booklet for details).
Coverage for oral nutritional is included in the Rhode Island Benchmark Plan that defines the EHBs for RI QHPs. Federal mandates regarding EHBs supersede RI state mandates with regards to removing any annual and lifetime dollar limits. Blue Cross Blue Sheild of Rhode Island covers oral nutritional formulas or special medical formulas (i.e. Neocate, PurAmino, Elecare, Similac Alimentum, Nutramigen, Gerber Extensive HA) for home use when ordered by a physician for milk/soy protein allergy for infants (0 – 12 months) with failure to thrive AND blood in the stools.
CODING Commercial Products The following HCPCS code(s) are covered for low protein food products when the medical criteria above is met: S9433 Medical food nutritionally complete, administered orally, providing 100% of nutritional intake
S9434 Modified solid food supplements for inborn errors of metabolism
S9435 Medical foods for inborn errors of metabolism RELATED POLICIES Enteral/Parenteral Nutrition Therapy
Prior Authorization for Durable Medical Equipment (DME) PUBLISHED Provider Update, April/December 2025 Provider Update, April 2024 Provider Update, April 2023 Provider Update, January/May 2022 Provider Update, November 2019 REFERENCES Rhode Island General Law (RIGL) 27-20-55: http://webserver.rilin.state.ri.us/Statutes/TITLE27/27-20/27- 20-56.HTM i This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS