B4161 prior authorization | Blue Cross and Blue Shield of Montana

B4161, Enteral Formula For Pediatrics Hydrolyzed/Amino Acids And Peptide Chain Proteins Includes Fats Carbohydrates Vitamins And Minerals May Include Fiber 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: B4161
Description: Enteral Formula For Pediatrics Hydrolyzed/Amino Acids And Peptide Chain Proteins Includes Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit
Source: 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 250 Original policy

Blue Cross and Blue Shield of Montana prior authorization

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