BlueCross BlueShield of Tennessee Medical Policy Manual

Nutritional

• Air Displacement Plethysmography for the Measurement of Body Composition

• Bariatric Surgery for Morbid Obesity

• Gastric Electrical Stimulation for the Treatment of Gastroparesis and Obesity

• Home Hyperalimentation/Enteral Nutrition

• Intradialytic Parenteral Nutrition

• Ketogenic Diet Counseling for Refractory Seizure Control

• Medical Nutrition Therapy for Dietary Counseling

• Nutritional Treatment of Inborn Errors of Metabolism

• Phenylketonuria (PKU) Formula

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