PDFWAC 182-554-500
Covered orally administered enteral nutrition products, equipment and related supplies—Clients age twenty and younger only.
(1) Subject to the prior authorization requirements and limitations in this section, and in the Enteral Nutrition Program Billing Guide, the agency covers orally administered enteral nutrition products for clients age twenty and younger.
(2) The agency's enteral nutrition program is not a food benefit. All clients under age five who qualify for supplemental nutrition from the women, infants, and children (WIC) nutrition program must receive products and formulas directly from that program. The agency may cover orally administered enteral nutrition products for a client under age five if the client has a WIC information form that verifies:
(a) The client is not eligible for the WIC program;
(b) The client is eligible for the WIC program, but the client's need for an oral enteral nutrition product or formula exceeds the amount allowed by WIC rules; or
(c) The client is eligible for the WIC program, but a medically necessary product or formula is not available through the WIC program.
(3) With expedited prior authorization, the agency covers orally administered enteral nutrition products for a one-time, initial one-month supply if the client:
(a) Has or is at risk of growth or nutrient deficits due to a condition that prevents the client from meeting their needs using food, over-the-counter nutrition products, standard infant formula, or standard toddler formula; and
(b) Has completed the agency's enteral nutrition products prescription form (HCA 13-961).
(4) With prior authorization (PA), the agency covers a monthly supply of orally administered enteral nutrition products if the client:
(a) Has or is at risk of growth or nutrient deficits due to a condition that prevents the client from meeting their needs using food, over-the-counter nutrition products, standard infant formula, or standard toddler formula;
(b) Has a valid prescription that states the product is medically necessary as defined in WAC 182-500-0070; and
(c) Has a nutrition assessment from a registered dietitian (RD) that includes all of the following:
(i) Evaluation of the client's nutritional status, including growth and nutrient analysis;
(ii) An explanation about why the product is medically necessary as defined in WAC 182-500-0070;
(iii) A nutrition care plan that monitors the client's nutrition status, and includes plans for transitioning the client to food or food products, if possible; and
(iv) Recommendations, as necessary, for the primary care provider to refer the client to other health care providers (for example, gastrointestinal specialists, allergists, speech therapists, occupational therapists, applied behavioral analysis providers, and mental health providers) who will address the client's growth or nutrient deficits as described in (a) of this subsection, and facilitate the client's transition to food or food products.
(5) If a client requires orally administered enteral nutrition products for longer than one month, the client must continue to meet criteria in subsection (4) of this section and receive periodic reevaluations from an RD. Periodic reevaluations:
(a) Must be performed at least three times a year for a client age three or younger;
(b) Must be performed at least two times a year for a client older than age three; and
(c) May be performed face-to-face, or by medical record and growth data review and phone contact with the client or the client's caregiver.
(6) If a client requires orally administered enteral nutrition products for longer than one month, the DME or pharmacy provider must obtain PA from the agency. The request for PA must include all of the following:
(a) Documentation of the client's diagnosis that supports the client's need for the orally administered enteral nutrition product;
(b) The client's nutrition care plan, which must monitor the client's nutrition status, and transition the client to food or food products, if possible, or document why the client cannot transition to food or food products;
(c) Updates to the client's nutrition care plan resulting from subsequent reevaluations;
(d) Updates to the client's growth chart;
(e) Documentation that shows through regular follow up and weight checks how the prescribed product is treating the client's growth or nutrient deficits, or is necessary to maintain the client's growth or nutrient status;
(f) Referrals, if necessary, to other health care providers (for example, gastrointestinal specialists, allergists, speech therapists, occupational therapists, applied behavioral analysis providers, and mental health providers) and show communication of recommendations and treatment plans for the client; and
(g) Documentation of any communication the treating provider has had with other providers, such as those in subsection (4)(c)(iv) of this section, directly or indirectly treating the client's growth or nutrient deficits while the client is receiving orally administered enteral nutrition products.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-500, filed 3/24/17, effective 5/1/17. WSR 11-14-075, recodified as § 182-554-500, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-500, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-554-500, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-500, filed 1/28/05, effective 3/1/05.]