Blue Cross and Blue Shield of Montana prior authorization B4158

Blue Cross and Blue Shield of Montana prior authorization for B4158: Enteral Formula For Pediatrics Nutritionally Complete With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber And/Or Iron Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit

Code: B4158
Description: Enteral Formula For Pediatrics Nutritionally Complete With Intact Nutrients Includes Proteins Fats Carbohydrates Vitamins And Minerals May Include Fiber And/Or Iron 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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