Blue Cross Blue Shield Oklahoma prior authorization B4155

Blue Cross Blue Shield Oklahoma 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 Outpatient Medical Surgical ASO Prior Authorization Codes, Pg 199 Original policy

Blue Cross Blue Shield Oklahoma prior authorization

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