Blue Cross and Blue Shield of Montana prior authorization B4153

Blue Cross and Blue Shield of Montana prior authorization for B4153: Enteral Formula Nutritionally Complete Hydrolyzed Proteins (Amino Acids And Peptide Chain) Includes Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit

Code: B4153
Description: Enteral Formula Nutritionally Complete Hydrolyzed Proteins (Amino Acids And Peptide Chain) Includes Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit
Source: 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 248 Original policy

Blue Cross and Blue Shield of Montana prior authorization

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