Baby Formula - Medical Necessity Criteria
Criteria for documenting medical necessity of infant formula (milk)
Contents:
- Does insurance cover baby formula?
- When is formula considered medically necessary?
- Which health plans cover baby formula?
- Aetna
- Cigna
- Harvard Pilgrim Health Care
- Independence Blue Cross
- Premera Blue Cross
- UnitedHealthcare
- FAQs
- How can I get formula covered by insurance?
- What states mandate formula coverage?
- What is a semi-elemental formula?
- Does UnitedHealthcare pay for formula?
- Documentation to submit
- Health plan criteria for baby formula and other references
Does insurance cover baby formula?
Most, if not all, health plans do not cover baby formula.
There are only certain cases where specialized types of formula are covered when they are medically necessary. An example is when babies who have phenylketonuria need formula that does not have phenylalanine.
When is formula considered medically necessary?
Generally speaking, formula may be considered medically necessary when it is a specialized type of formula created specifically for patients who have a particular condition.
For example, formula that does not have phenylalanine may be considered medically necessary for patients with phenylketonuria, and formula that does not have leucine, isoleucine or valine may be considered medically necessary for patients with maple syrup urine disease.
Health plans have medical necessity criteria that will guide you on what you need to show to prove that the formula you are requesting is medically necessary.
Which health plans cover baby formula?
Below is a summary of health plans’ coverage and medical necessity criteria for formula. There is a link at the end of each summary so you can take a look at the health plan’s guidance/policy and read their terms and conditions in more detail.
In all of these cases, the specific coverage and medical necessity criteria for each health plan must be met, as well as their documentation requirements. If there are differences between the general criteria of a health plan and the benefits/conditions set in the patient’s particular plan, the terms of the patient’s plan will be followed.
Aetna
Aetna does not cover infant formula given orally.
Infant formula is covered only when it is given via feeding tube to a patient who meets the medical necessity criteria for enteral nutition.
Aetna does cover special oral formulas that are designed to restrict intake of one or more amino acids in patients with inborn errors of metabolism when coverage is required by state mandates. However, when there is no state mandate or when coverage is not specifically included in the plan, specialized infant formulas will not be covered.
Cigna
Cigna generally covers infant formula when it is medically necessary for infants under 12 months of age with an inborn error of metabolism.
Cigna does not cover infant formula (whether standard or specialized) for conditions other than inborn errors of metabolism. Infant formula is NOT covered for:
- Celiac disease or gluten-sensitive enteropathy
- Fat maldigestion
- Food allergies
- Lactose intolerances
- Low birthweight
- Milk allergies
- Prematurity
- Protein intolerance/sensitivity/maldigestion
- Soy formula intolerance
Harvard Pilgrim Health Care
Harvard Pilgrim Health Care considers special medical formulas for oral feeding medically necessary for patients with medical conditions related to inborn errors of metabolism, malabsorption, or interference with nutrient absorption and assimilation.
Independence Blue Cross
Independence Blue Cross covers commercially available nutritional formulas for infants and children who need elemental formula as their sole source of nutrition because they have any of these conditions:
- Severe systemic protein hypersensitivity that is refractory to dietary and other treatments
- Anatomical disorder that impedes or obstructs passage of nutrition through the alimentary canal
Premera Blue Cross
Specialized infant formula is covered by Premera Blue Cross for patients with histidinemia, homocystinuria, maple syrup urine disease, phenylketonuria, tyrosinemia, and other inborn errors of metabolism.
UnitedHealthcare
Infant formula and standard milk-based formula are generally excluded from coverage by UnitedHealthcare, as are donor breast milk, food additives, food thickeners, or indeed food of any kind.
However, UnitedHealthcare does generally cover enteral formula — that is, amino acid-based elemental formulas, extensively hydrolyzed protein formulas, and modified nutrient content formulas — whether given orally or by feeding tube for patients who have medical conditions that require specialized nutrients or formulas. These conditions include (but are not limited to):
- Maple syrup urine disease
- Phenylketonuria (PKU)
- Other metabolic diseases
- Food allergies that, if left untreated, will result in malnourishment, disability, or death
- Gastrointestinal tract disorders that cause impaired absorption of nutrients
FAQs
How can I get formula covered by insurance?
You can get formula covered by insurance by presenting medical records that show that your baby needs a special kind of formula because of a medical condition that prevents them from getting the nutrition they need from regular formula. For example, if your baby has maple syrup urine disease, they will not be able to break down three particular amino acids called leucine, isoleucine, and valine, and so you can get insurance to cover formula that has been specially made to be without these three amino acids.
What states mandate formula coverage?
States that mandate insurance coverage for elemental formula include Arizona, Colorado, Connecticut, Florida, Illinois, Kansas, Kentucky, Maine, Maryland, Massachusetts, Missouri, Nebraska, New Hampshire, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Texas, Virginia, Washington, and West Virginia.
What is a semi-elemental formula?
Semi-elemental formulas are partially pre-digested formulas. Unlike elemental formulas, which have been broken down (pre-digested) to the very basic building blocks of food and so require little digestion inside the body, semi-elemental formulas are made of slightly bigger blocks.
Does UnitedHealthcare pay for formula?
UnitedHealthcare generally pays for formula for individuals with inborn errors of metabolism, severe food allergies, and impaired absorption of nutrients due to various digestive tract disorders. It will also matter what kind of plan you have and if you live in a state that requires coverage of formula.
Documentation to submit
These are the things you can prepare documentation of in order to support your statement that baby formula is medically necessary. Submit only those that apply.
Documentation of a medical condition that requires the use of specialized infant formula, including but not limited to the following. Keep in mind that, in the absence of state mandates, the health plan decides for which conditions they will cover formula, and so some of the conditions below might be covered by one health plan but not by another. Some conditions are listed more than once under their different names for ease of location.
Alternatives
Health plan criteria for baby formula and other references
- Aetna Clinical Policy Bulletin on Nutritional Support
- American Partnership for Eosinophilic Disorders Summary of State Insurance Mandates for Elemental Formula
- California Health & Wellness Clinical Policy on Oral and Enteral Formula
- Cigna Medical Coverage Policy on Nutritional Support
- Geisinger Health Plan Medical Benefit Policy on Nutritional Supplements
- Harvard Pilgrim Health Care Medical Policy on Formulas and Enteral Nutrition
- Independence Blue Cross Commercial Medical Policy on Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
- LifeWise Health Plan of Washington Benefit Coverage Guideline on Home Nutritional Support
- Maine Insurance Code Coverage for medically necessary infant formula
- MassHealth Guidelines for Medical Necessity Determination for Enteral Nutrition and Special Medical Formulas
- Premera Blue Cross Benefit Coverage Guideline on Home Nutritional Support
- Tufts Health Plan Medical Necessity Guidelines on Enteral Nutrition, Digestive Enzyme Cartridges and Special Medical Formulas
- UnitedHealthcare Commercial Coverage Determination Guideline on Enteral Nutrition
- UnitedHealthcare Community Plan Coverage Determination Guideline on Oral and Enteral Nutrition
- UnitedHealthcare Community Plan (Nebraska) Coverage Determination Guideline Oral and Enteral Nutrition
- UnitedHealthcare Medicare Advantage Policy Guideline on Enteral and Parenteral Nutritional Therapy
- UnitedHealthcare Oxford Administrative Policy on Formula and Specialized Food
- UnitedHealthcare West (California) Benefit Interpretation Policy on Enteral and Oral Nutritional Therapy
- UnitedHealthcare West (Oklahoma) Benefit Interpretation Policy on Enteral and Oral Nutritional Therapy
- UnitedHealthcare West (Texas) Benefit Interpretation Policy on Enteral and Oral Nutritional Therapy