Today’s Dietitian
Vol. 28 No. 1 P. 6
Dietitians are well-versed in the foundational principles of the Dietary Guidelines for Americans, which emphasize a “food-first” approach to nutrition: “Nutritional needs should be met primarily from foods and beverages—specifically, nutrient-dense foods and beverages. In some cases, when meeting nutrient needs is not otherwise possible, fortified foods and nutrient-containing dietary supplements are useful.”1
This hierarchy of nutrition care helps practitioners prioritize and maximize the benefits of food—fruits, vegetables, whole grains, and lean proteins—before turning to supplementation. Yet, this guidance often diverges sharply from real-world practice in enteral nutrition (EN), where the reimbursement model largely overlooks the food-first approach.
Reimbursement Policy vs Nutritional Guidelines
While the CMS long term care guidelines as well as the Dietary Guidelines prioritize a food-first approach, federal and state reimbursement policies for EN often require patients to demonstrate failure on a standard commercial formula—typically composed of synthetic or highly processed ingredients—before coverage for a real-food-based formula (coded B4149) is considered.1,2 This disconnect places both patients and clinicians in a difficult position.
“My daughter was born at just 25 weeks and has had a feeding tube since birth,” recalls Allyson Barnes, a North Carolina-based mother of a medically complex daughter. “She was doing okay on pumped breast milk, but everything changed when she transitioned to a standard pediatric formula. Her reflux worsened, she was vomiting constantly, and feeding therapy progress reversed. We tried at least five different formulas before we finally got a real-food option approved months later.”
Her story is, unfortunately, all too common for patients desiring to forego highly processed enteral formulas for those made from whole foods.
The Inverted Hierarchy of Coverage
Under current reimbursement guidelines, the burden of proof often falls on the patient and care team to demonstrate failure on a standard formula composed of highly processed ingredients before access to an alternative composed of blenderized whole foods is granted. This approach stands in stark contrast to oral diet guidelines, where oral supplements with synthetic additives are utilized after dietary intake cannot be optimized through food.1,2
“Medicare and many state Medicaid plans require patients to fail first,” says Lana Clark, RD, LD, a pediatric nutrition support dietitian through Pediatric Home Service. “Yet, we already know food is what the body is designed for. Why is it surprising that patients improve when we give them real food—even through a tube?”
Real-food-based formulas offer the potential to align convenient EN options with the same evidence-based guidance used for oral intake. Studies abound on the benefits of a diet which minimizes more highly processed carbohydrates and focuses on a variety of whole foods, yet studies focusing solely on the same effects of this type of diet via EN are more limited. Still, it stands to reason that the same nutrition that is healthy for a person who eats by mouth is healthy when delivered to the gastrointestinal system via a tube.
The existing library of evidence supports improvements often seen in blenderized tube feeding (BTF) over standard formulas, including reductions in gagging/retching,3-5 nausea/vomiting,4-8 abdominal pain,6,7 bloating,6-8 diarrhea,6-9 and constipation.6-8 Research has also shown improved growth and weight gain.5,8,10,11 A 2018 study found improved biodiversity in stool samples of pediatric patients transitioned from commercial to BTF, suggesting the role of BTF in development and maintenance of a diverse microbiome.4 BTF may also lead to reduced health care costs, as shown in a 2019 study from Boston Children’s Hospital. The authors found that children fed BTF products had 53% fewer hospital admissions than children fed commercial formula.7
Systemic Barriers to Access
According to Vicki Emch, MS, RD, area vice president of clinical operations at Aveanna Healthcare, coverage of B4149 formulas varies widely. “Blenderized formulas can be a covered benefit by insurance, but this depends on the type of policy. For Medicaid, it will vary by state, as each state has a different reimbursement rate or fee schedule. For Medicare, they do cover B4149 but there has to be plenty of good documentation by the attending practitioner, meaning an MD, PA, or NP, on why the patient needs a blenderized formula and not a standard one. That is tough!” she says.
“The DME [durable medical equipment] RD must have knowledge regarding what insurance will or will not cover and they may not be able to recommend what they would in a hospital setting,” Emch says.
Clark says, “Even if insurance ‘covers’ the product, DME companies sometimes have to make really difficult decisions on what can and cannot be provided because of the gap created by reimbursement.” By this, Clark means that just because a formula is covered does not mean the coverage provides a reimbursement rate that is sustainable for the DME to offer the product to the patient. She explains her home state of Minnesota’s relatively generous Medicaid reimbursement practices, noting, “I am really lucky. I can, as of right now, pretty much do what’s best for the patient.” She acknowledges this isn’t the case in many states. “I hear of plenty of patients who actually move to Minnesota to get access to the medical supplies they need,” alluding to the inability of many DMEs in poor-reimbursement states to provide a product, even if covered, that is not reimbursed at a rate that approaches its cost to obtain.
One such state is Michigan, whose current reimbursement model requires patients to fail to tolerate a standard formula before gaining coverage for BTF, and then provides minimal reimbursement for the product even when coverage is granted. This leaves many patients in the state of Michigan without access to BTF whether because of difficulty qualifying for it or because of inability to obtain it through a DME who cannot sustainably provide it with the reimbursement gap.
Parent-caregiver, Christina Karin, a resident of Michigan, recently shared to an online BTF support group, “I’ve not seen my daughter do so well since the trial of [BTF]. So sad that apparently my DME can’t provide it because of poor state Medicaid coverage.”
The Dietitian’s Dilemma
As DME RDs Clark and Emch outline, outpatient providers can find themselves in a frustrating bind. Do they recommend the product that aligns with evidence-based guidelines and clinical judgement? Or do they recommend the one that insurance will cover and the DME can provide? This is an ethical dilemma.
Leslie Bienz, a parent of a child who relied on blenderized food via gastrostomy following premature birth and a long road of feeding difficulties, urges transparency. “I’d rather hear the truth—that the product the dietitian feels is best isn’t covered—than have a provider try to convince me that the covered product is best. It breaks trust. No one would tell an orally fed person to live on standard oral supplement shakes alone and skip whole foods. Why do we treat tube-fed people any differently?”
Conclusion
The food-first philosophy that guides oral nutrition through CMS and Dietary Guidelines for oral intake should not be abandoned when a patient receives nutrition via a tube. As clinicians, caregivers, and advocates, RDs have an opportunity to challenge a system that forces patients to fail a standard commercial product before they can access a product that aligns with evidence-based care.
Improving access to real-food enteral options is not just a matter of clinical practice—it’s a matter of health equity, patient dignity, and professional integrity.
— Brittany Buchholz, MFA, RDN, CNSC, is an enteral nutrition advocate who serves as director of nutrition and head of sales at Whole Story Meals. She brings more than a decade of experience in enteral nutrition reimbursement and direct patient care and is passionate about making real-food diets accessible to everyone who depends on a feeding tube.
Advocacy in Action
Dietitians, as trusted health care professionals and nutrition experts, are uniquely positioned to drive change—both through patient education and policy advocacy.
- Know your state policies. While Medicare reimbursement policies are consistent nationally, Medicaid policies vary by state. Stay current with your state’s reimbursement policies and any private payors you encounter most frequently to be able to guide patients through decisions about EN regimens.
- Document thoughtfully. Collaborate closely with physicians to ensure medical necessity is documented clearly in the official medical record—not just in a letter of medical necessity or RD note. Often, the key to coverage lies in an RD’s careful documentation of improved tolerance to food-containing formulas over standard, synthetic formulas. Improved tolerance may include improvements in symptoms such as nausea/vomiting, stool regularity, fullness/bloating, reflux, or diarrhea/constipation.
- Be transparent with patients and caregivers. Explain the clinical rationale for blenderized formulas and the reimbursement realities. Patients deserve transparency and partnership in care planning.
- Connect with advocacy groups. Leverage collective voices. Partner with BTF consumer groups, professional organizations, and policymakers to advocate for equitable access. Reimbursement reform doesn’t happen overnight, but the first step is educating policymakers—and that starts with stories, clinical evidence, and consistent messaging from RDs who see the need every day.
- Support research. Research drives policy. More studies are needed in the area of real-food EN. RDs can encourage and contribute to studies exploring outcomes associated with real-food-based EN. The evidence base is growing—and powerful.
References
1. US Department of Agriculture; Health and Human Services. Dietary Guidelines for Americans, 2020–2025. 9th ed. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf. Published December 2020.
2. Centers for Medicare & Medicaid Services, US Department of Health & Human Services. S&C-08-28: Nursing Homes—Issuance of Revised Nutrition and Sanitary Conditions (Tags F325 and F371). Published June 20, 2008.
3. Pentiuk S, O’Flaherty T, Santoro K, Willging P, Kaul A. Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication. JPEN J Parenter Enteral Nutr. 2011;35(3):375-379.
4. Gallagher K, Flint A, Mouzaki M, et al. Blenderized enteral nutrition diet study: feasibility, clinical, and microbiome outcomes of providing blenderized feeds through a gastric tube in a medically complex pediatric population. JPEN J Parenter Enteral Nutr. 2018;42(6):1046-1060.
5. Batsis ID, Davis L, Prichett L, et al. Efficacy and tolerance of blended diets in children receiving gastrostomy feeds. Nutr Clin Pract. 2020;35(2):282-288.
6. Hurt RT, Edakkanambeth Varayil J, Epp LM, et al. Blenderized tube feeding use in adult home enteral nutrition patients: a cross-sectional study. Nutr Clin Pract. 2015;30(6):824-829.
7. Hron B, Fishman E, Lurie M, et al. Health outcomes and quality of life indices of children receiving blenderized feeds via enteral tube. J Pediatr. 2019;211:139-145.
8. Spurlock AY, Johnson TW, Pritchett A, et al. Blenderized food tube feeding in patients with head and neck cancer. Nutr Clin Pract. 2022;37(3):615-624.
9. Schmidt SB, Kulig W, Winter R, Vasold AS, Knoll AE, Rollnik JD. The effect of a natural food-based tube feeding in minimizing diarrhea in critically ill neurological patients. Clin Nutr. 2019;38(1):332-340.
10. Johnson TW, Spurlock AL, Epp L, Hurt RT, Mundi MS. Reemergence of blended tube feeding and parents’ reported experiences in their tube-fed children. J Altern Complement Med. 2018;24(4):369-373.
11. Johnson TW, Spurlock AL, Pierce L. Survey study assessing attitudes and experiences of pediatric registered dietitians regarding blended food by gastrostomy tube feeding. Nutr Clin Pract. 2015;30(3):402-405.