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PRIOR AUTHORIZATION / ENTERAL NUTRITION PRODUCTS ATTACHMENT (PA/ENPA)
Page 3 of 4
F-11054 (10/12)
SECTION V — CLINICAL INFORMATION (Continued)
17. Indicate the member’s medical condition. Check all that apply.
 Member is tube fed because nutrition cannot be taken orally in an adequate quantity or the member requires tube feeding to
maintain weight and strength commensurate with overall health status.
 Pathology of the gastrointestinal tract that prevents digestion, absorption, or utilization of nutrients that cannot otherwise be
medically managed.
 Metabolic disorder that cannot otherwise be medically managed.
 Renal failure with recent significant weight loss and secondary acute diagnosis. (Note: Providers are required to indicate a
three-month weight history and description of the member’s secondary acute diagnosis as it relates to the request for an
enteral nutrition product in Element 21.)
 Severe food allergies.
 Failure to thrive. (Note: Providers are required to submit growth charts with each PA request.)
 Severe swallowing disorder due to tissue injury, trauma, excoriation, or defect. (Note: Providers are required to submit
speech/swallow evaluations and feeding recommendations with each PA request.)
 Transition from tube feeding to oral diet.
 Other. If other is checked, describe the reason in the space below.
18. For the member’s medical condition checked in Element 17, indicate the specific details of the medical condition, including
treatment recommendations, as it relates to enteral nutrition in the space provided. If applicable, indicate any clinical changes
that have occurred since previously approved PAs have been submitted.
19. For enteral nutrition products administered orally, describe why a diet of regular- or altered-consistency table foods and
beverages is not nutritionally sufficient for the member and why nutritional requirements can be met using only enteral nutrition
products.
20. For specially formulated enteral nutrition products (procedure codes B4149*, B4153*, B4154*, B4161*, and B4162*), describe
why general purpose enteral nutrition products do not meet the member’s nutritional needs, are not tolerated, or are not clinically
appropriate for the member.
Continued

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