§ 40-6-3.12 - Enteral nutrition products.
SECTION 40-6-3.12
§ 40-6-3.12 Enteral nutrition products.– (a) As used in this section:
(1) "Enteral nutrition" means a supplemental feeding that isprovided via the gastrointestinal tract by mouth (orally), or through a tube,catheter, or stoma that delivers nutrients distal to the oral cavity.
(2) "Nutritional risk" means actual or potential fordeveloping malnutrition, as evidenced by clinical indicators, the presence ofchronic disease, or increased metabolic requirements due to impaired ability toingest or absorb food adequately.
(b) The department shall provide for vendor payment ofenteral nutrition products in accordance with rules and regulations of thedepartment, when determined to be medically necessary on an individual,case-by-case basis and ordered by a physician in accordance with Rhode Islanddepartment of health form(s) on enteral nutrition products. Provided, however,that coverage shall not exceed an amount of two thousand five hundred dollars($2,500) per individual per year.
(c) The determination of medical necessity for enteralnutrition products shall be based upon a combination of clinical data and thepresence of indicators that would affect the relative risks and benefits of theproducts including, but not limited to:
(1) Enteral nutrition, whether orally or by tube feeding, isused as a therapeutic regimen to prevent serious disability or death in aperson with a medically diagnosed condition that precludes the full use ofregular food.
(2) The person presents clinical signs and symptoms ofimpaired digestion malabsorption, or nutritional risk, as indicated by thefollowing anthropometric measures:
(i) Weight loss that presents actual or potential fordeveloping, malnutrition as follows:
(A) In adults, showing involuntary or acute weight loss ofgreater than or equal to ten percent (10%) of usual body weight during a three(3) to six (6) month period, or body mass index (bmi) below 18.5 kg/m2;
(B) In neonates, infants and children, showing:
(I) Very low birth weight (lbw) even in the absence ofgastrointestinal, pulmonary or cardiac disorders;
(II) A lack of weight gain, or weight gain less than two (2)standard deviations below the age appropriate mean in a one month period forchildren under six (6) months, or two (2) month period for children aged six(6) to twelve (12) months;
(III) No weight gain or abnormally slow rate of gain forthree (3) months for children older than one year, or documented weight lossthat does not reverse promptly with instruction in appropriate diet for age; or
(IV) Weight for height less than the tenth (10th) percentile;and
(ii) Abnormal laboratory test pertinent to the diagnosis.
(3) The risk factors for actual or potential malnutritionhave been identified and documented. Such risk factors include, but are notlimited to, the following:
(i) Anatomic structures of the gastrointestinal tract thatimpair digestion and absorption;
(ii) Neurological disorders that impair swallowing or chewing;
(iii) Diagnosis of inborn errors of metabolism that requiremedically necessary formula used for specific metabolic conditions and foodproducts modified low in protein (for example, phenylketonuria (pku)tyrosinemia, homocystinuria, maple syrup urine disease, propionic aciduria andmethylmalonic aciduria);
(iv) Prolonged nutrient losses due to malabsorption syndromesor short-bowel syndromes, diabetes, celiac disease, chronic pancreatitis, renaldialysis, draining abscess or wounds, etc.;
(v) Treatment with anti-nutrient or catabolic properties (forexample, anti-tumor treatments, corticosteroids, immunosuppressant, etc.);
(vi) Increased metabolic and/or caloric needs due toexcessive burns, infection, trauma, prolonged fever, hyperthyroidism, orillnesses that impair caloric intake and/or retention; or
(vii) A failure-to-thrive diagnosis that increases caloricneeds while impairing caloric intake and/or retention.
(4) A comprehensive medical history and a physicalexamination have been conducted to detect factors contributing to nutritionalrisk.
(5) Enteral nutrition is indicated as the primary source ofnutritional support essential for the management of risk factors that impairdigestion or malabsorption, and for the management of surgical preparation orpostoperative care.
(6) A written plan of care has been developed for regularmonitoring of signs and symptoms to detect improvement in the person'scondition. Nutritional status should be monitored regularly;
(i) For improvements in anthropometric measures;
(ii) For improvements in laboratory test indicators; and
(iii) In children, to assess growth and weight for height.
(d) Enteral nutrition products shall not be consideredmedically necessary under certain circumstances including, but not limited to,the following:
(1) A medical history and physical examination have beenperformed and other possible alternatives have been identified to minimizenutritional risk.
(2) The person is underweight, but has the ability to meetnutritional needs through the use of regular food consumption.
(3) Enteral products are used as supplements to a normal orregular diet in a person showing no clinical indicators of nutritional risk.
(4) The person has food allergies, lactose intolerance ordental problems, but has the ability to meet his or her nutritionalrequirements through an alternative food source.
(5) Enteral products are to be used for dieting or aweight-loss program.
(6) No medical history or physical examination has been takenand there is no documentation that supports the need for enteral nutritionproducts.