Medicare Coverage Guidelines
Medicare patients can receive coverage for Real Food Blends, but the proof of medical necessity needs to be well documented. Please read below and if you believe you fit the criteria for coverage, call your current DME or home infusion provider. You can also fill out the form below for assistance finding a DME/home infusion provider in your state who accepts Medicare. Email us at firstname.lastname@example.org if you have questions or concerns.
In order for Medicare to cover Enteral Tube Feeding Products in your home, you must meet the following criteria:
1) Permanence of condition, as defined by anticipated Length of Need greater than 90 days.
2) A permanent (ordinarily at least 3 months) non-function or disease of the structures that normally permit food to reach the small bowel or a disease of the small bowel which impairs digestion and absorption of an oral diet, either condition must require tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with your overall health status. The condition could be either anatomic (obstruction due to head and neck cancer or reconstructive surgery) or due to a motility disorder (severe dysphagia following a stroke).
Medicare considers Real Food Blends a special enteral formula (B4149), so medical necessity must be justified in each beneficiary. If a special enteral nutrition formula is provided and the medical record does not document why that item is medically necessary, it will be denied as not reasonable and necessary.
In order to receive Medicare coverage for Real Food Blends, you must have proof of trial and failure of standard formula.
Documents must be submitted that show which formula(s) were trialed, when they were trialed, and evidence of your intolerance response to formula.
If you believe you meet these requirements, work with your doctor to have a prescription and applicable medical records sent to your DME/home infusion provider. Your DME/home infusion provider will handle sending the claim to Medicare and then billing Medicare once the claim is approved.
If you are an RD or other medical professional who is prescribing Real Food Blends for your patient with Medicare, get more information and tips here.
If Medicare or your primary insurance will not cover your tube feeding products, but your secondary insurance will, what should you do?
This instance depends on your DME supplier. Some DME suppliers are able to bill for a denial with your primary insurance. The DME suppliers can then submit your charges to your secondary insurance for billing.
Sometimes this is done through utilizing an ABN (Advanced Beneficiary Notice).
Can I bill Medicare directly if a DME supplier is unwilling to bill on my behalf?
Yes, Medicare has a very helpful website to help with this process.
As always, we are here to help! Please contact us at email@example.com for insurance-related questions.