Nutritional Supplement Guideline Change

Effective 10/1/2018, Texas Children’s Health Plan will no longer require prior authorization for nutritional products for members 20 years and younger who:

• receive all or part of their nutritional intake through a tube as documented by ICD-10 codes (z43.1; z93.1, z93.4), OR
• have a metabolic disorder that has been documented with one of the diagnosis codes listed in the current TMPPM Section 2.2.17.2.2.

Providers will retain the responsibility of maintaining appropriate documentation for the nutritional products supplied. A retrospective review may be performed to ensure that the documentation included in the client’s medical record supports the medical necessity of the requested service. Documentation should include:

• Accurate diagnostic information pertaining to the underlying diagnosis or condition that resulted in the requirement for a nutritional product, as well as any other medical diagnoses or conditions, including:
  • The client’s overall health status.
  • Height and weight.
  • Growth history and growth charts.
  • Why the client cannot be maintained on an age-appropriate diet.
  • Other formulas tried and why they did not meet the client’s needs.
  • Diagnosis or condition.
  • The goals and timelines on the medical plan of care.
  • Total caloric intake prescribed by the physician.
  • Acknowledgement that the client has a feeding tube in place when applicable.

Prior authorization will be required for all members who are 21 and over and for any member who does not meet the criteria stated above. As a reminder:

• Texas Children’s Health Plan and the Comprehensive Children’s Program does not cover nutritional products that are traditionally used for infant feeding, including infant formula.
• Nutritional products for the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth are not considered medically necessary. The underlying cause of failure to thrive, gain weight, and lack of growth must be identified and documentation provided to certify that adequate nutrition is not possible by dietary adjustment using age appropriate foods.