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317:30-5-211.14.Nutritional support

[Revised 08-01-20]
(a) Enteral nutrition.  Enteral nutrition administered only via gravity, syringe, or pump is covered for children and adults at home. Refer to pharmacy policy related to coverage of food supplements at Oklahoma Administrative Code (OAC) 317:30-5-72.1. For enteral nutrition authorization guidelines, see OAC 317:30-5-211.20.

(b) Parenteral nutrition.  The member must require intravenous feedings to maintain weight and strength commensurate with the member's overall health status.  Adequate nutrition must not be possible by dietary adjustment and/or oral supplements.

(1) The member must have a permanent impairment.  Permanence does not require a determination that there is no possibility that the member's condition may improve sometime in the future.  If the judgment of the attending physician, substantiated in the medical record, is that the condition is of long and indefinite duration (ordinarily at least three (3) months), the test of permanence is met.  Parenteral nutrition will be denied as a non-covered service in situations involving temporary impairments.

(2) The member must have a condition involving the small intestine, exocrine glands, or other conditions that significantly impair the absorption of nutrients.  Coverage is also provided for a disease of the stomach and/or intestine that is a motility disorder and impairs the ability of nutrients to be transported through the GI system, and other conditions as deemed medically necessary.  There must be objective medical evidence supporting the clinical diagnosis.

(3) Re-certification of parenteral nutrition will be required as medically necessary and determined by the Oklahoma Health Care Authority (OHCA) medical staff.

(c) Long-term care facility enteral and parenteral nutrition. Enteral and parenteral nutrition products supplied to long-term care facility residents will be included in the long-term care facility per diem rate.

(d) Claim submission requirements.  A written signed and dated order must be received by the supplier before a claim is submitted to the OHCA.  If the supplier bills an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.  The ordering physician is expected to see the member within thirty (30) days prior to the initial certification or required re-certification.  If the physician does not see the member within this time frame, the physician must document the reason why and describe what other monitoring methods were used to evaluate the member's parenteral nutrition needs.

 

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.