B4154 prior authorization | Blue Cross Blue Shield Oklahoma

B4154, Enteral Formula Nutritionally Complete For Special Metabolic Needs Excludes Inherited Disease Of Metabolism Includes Altered Composition Of Proteins Fats Carbohydrates Vitamins And/Or 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: B4154
Description: Enteral Formula Nutritionally Complete For Special Metabolic Needs Excludes Inherited Disease Of Metabolism Includes Altered Composition Of Proteins Fats Carbohydrates Vitamins And/Or 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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