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PRIOR AUTHORIZATION / ENTERAL NUTRITION PRODUCTS ATTACHMENT (PA/ENPA)
Page 2 of 4
F-11054 (10/12)
SECTION IV — DIETARY ASSESSMENT AND PLAN (Continued)
12. Does the enteral nutrition product(s) prescribed or ordered in Element 9 provide
100 percent of the member’s total daily caloric requirements indicated in Element 11?
Yes
No
If the enteral nutrition product(s) requested does not meet 100 percent of member’s total daily caloric needs, check the most
appropriate reason why:
 The requested product will supplement the member’s diet because the member can consume regular table foods and
beverages.
 The requested product will supplement the member’s diet because the member can consume altered- or regular-consistency
foods (soft or pureed foods) and beverages.
 The member receives nutrition (calories) from another source (e.g., additional enteral nutrition product, breast milk, Special
Supplemental Nutrition Program for Women, Infants, and Children). If this box is checked, describe the nutrition in the space
below.
 The member is able to consume small sips or bites for pleasure tasting.
 Other. If other is checked, describe the reason in the space below.
13. Indicate how the enteral nutrition product(s) prescribed or ordered in Element 9 will be administered.
 Feeding tube only.
 Mouth only.
 Mouth and feeding tube.
If the enteral nutrition product will be administered using both mouth and feeding tube, indicate the following:
Calories per day administered orally ________________
Calories per day administered via feeding tube ________________
SECTION V — CLINICAL INFORMATION
14. Primary Diagnosis Code and Description as It Relates to Enteral Nutrition
15. Secondary Diagnosis Code and Description as It Relates to Enteral Nutrition (A secondary diagnosis is not required.)
16. Anthropometric Measures
Current Height: ______ inches
Date Measured ___________________
Current Weight: ______ pounds
Date Measured ___________________
Continued

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