Blue Cross and Blue Shield of Montana prior authorization B4155

Blue Cross and Blue Shield of Montana prior authorization for B4155: Enteral Formula Nutritionally Incomplete/Modular Nutrients Includes Specific Nutrients Carbohydrates (E. G. Glucose Polymers) Proteins/Amino Acids (E. G. Glutamine Arginine) Fat (E. G. Medium Chain Triglycerides) Or Combination Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit

Code: B4155
Description: Enteral Formula Nutritionally Incomplete/Modular Nutrients Includes Specific Nutrients Carbohydrates (E. G. Glucose Polymers) Proteins/Amino Acids (E. G. Glutamine Arginine) Fat (E. G. Medium Chain Triglycerides) Or Combination Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit
Source: 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 249 Original policy

Blue Cross and Blue Shield of Montana prior authorization

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