B4159 prior authorization | Blue Cross and Blue Shield of Montana

B4159, Enteral Formula For Pediatrics Nutritionally Complete Soy Based 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, is on the Blue Cross and Blue Shield of Montana commercial prior authorization list. Not a coverage or referral decision.

Code: B4159
Description: Enteral Formula For Pediatrics Nutritionally Complete Soy Based 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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