B4155 prior authorization | Blue Cross and Blue Shield of Montana
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, is on the Blue Cross and Blue Shield of Montana commercial prior authorization list. Not a coverage or referral decision.
- 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