B4153 prior authorization | Blue Cross Blue Shield Oklahoma

B4153, Enteral Formula Nutritionally Complete Hydrolyzed Proteins (Amino Acids And Peptide Chain) Includes Fats Carbohydrates Vitamins And Minerals May Include Fiber Administered Through An Enteral Feeding Tube 100 Calories = 1 Unit, is on the Blue Cross Blue Shield Oklahoma commercial prior authorization list. Not a coverage or referral decision.

Code: B4153
Description: Enteral Formula Nutritionally Complete Hydrolyzed Proteins (Amino Acids And Peptide Chain) Includes Fats Carbohydrates Vitamins And Minerals May Include Fiber 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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