Nutritional Diagnosis Grid - Alabama Medicaid Agency

Ensure High Protein > 2 Adult
For patients unable to maintain their nutrition from normal foods: Dysphagia (787.2); Malignancy
of lip, oral cavity & pharyngeal cavity (140.0-149.9); Jakob-Creutzfeldt disease (046.1); Other
demyelinating disease of CNS (341.8, 341.9); Pick’s disease (331.0); Profound mental retardation
(318.2); Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0);
Cerebral Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome)
(330.8); Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code);
Cerebral degeneration of childhood in other diseases classified elsewhere (330.3, with underlying
disease code); Supranuclear Palsy (333.0); Motor neuron disease (335.2); Progressive muscular
atrophy (335.21); Progressive bulbar palsy (335.22); Psuedobulbar palsy (335.23); Encephalopathy
(348.3); Malnutrition (261); Post-op feeding, within 4 weeks of surgery (579.3), CRF (ESRD) (585,
586); Post-op feeding, within 4 weeks of surgery (579.3); Burns (940-949); Wounds (707.0, 879.8,
998.83)
Ensure Plus > 2 Adult
For children unable to maintain their nutrition from normal foods: Dysphagia (787.2); Malignancy
of lip, oral cavity & pharyngeal cavity (140.0-149.9); Jakob-Creutzfeldt disease (046.1); Other
demyelinating disease of CNS (341.8, 341.9); Pick’s disease (331.0); Profound mental retardation
(318.2); Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0);
Cerebral Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome)
(330.8); Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code);
Cerebral degeneration of childhood in other diseases classified elsewhere (330.3, with underlying
disease code); Supranuclear Palsy (333.0); Motor neuron disease (335.2); Progressive muscular
atrophy (335.21);Progressive bulbar palsy (335.22); Psuedobulbar palsy (335.23); Encephalopathy
(348.3); Malnutrition (261); Post-op feeding, within 4 weeks of surgery (579.3); Fluid restriction
(CHF 428.9, Neurosurgery/Cerebral edema 348.5, Cirrhosis/Liver disease 571.3, 571.4, 571.5, 571.9,
573.3, 573.9, 751.3 CRF (ESRD) (585, 586)
Ensure Powder > 2 Adult
EO28 Splash ≥12 months N/A
For children unable to maintain their nutrition from normal foods: Dysphagia (787.2); Malignancy
of lip, oral cavity & pharyngeal cavity (140.0-149.9); Jakob-Creutzfeldt disease (046.1); Other
demyelinating disease of CNS (341.8, 341.9); Pick’s disease (331.0); Profound mental retardation
(318.2); Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0);
Cerebral Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome)
(330.8); Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code);
Cerebral degeneration of childhood in other diseases classified elsewhere (330.3, with underlying
disease code); Supranuclear Palsy (333.0); Motor neuron disease (335.2); Progressive muscular
atrophy (335.21); Progressive bulbar palsy (335.22); Psuedobulbar palsy (335.23); Encephalopathy
(348.3); Malnutrition (261); Post-op feeding, within 4 weeks of surgery (579.3); Renal failure (586);
Pressure sores (707.0); Burns (940-949); HIV or AIDS (042); COPD (492.8); Cardiomyopathy
(425.4)
GI Tract Impairment: IBD 564.1; Crohn’s Disease: 555.0, 555.1, 555.2, 555.9; Cow & Soy Milk
Allergy: 477.1; Multiple Food Protein Intolerance:579.8, 558.2, 536.9, 535.4, 558.9; Eosinophilic
Esophagitis: 530.19; GERD: 530.81; Short Bowel Syndrome: 579.3
F.A.A. (Free Amino
Acid Diet)
Adult
Patients with severely impaired GI function: Intractable Diarrhea (787.91); Inflammatory Bowel
Disease (558.9); GI surgery, within 4 weeks pre- or post-op (564.2); Malabsorption (579.9); Short
Bowel Syndrome (579.3); Chronic pancreatitis (577.1); Crohn’s disease (555.0, 555.1, 555.2, 555.9);
Radiation enteritis (558.1); Ulcerative colitis (556.9)
Fibersource Standard > 12 months Adult
Conditions preventing oral intake of adequate nutrition; for total enteral nutrition: Dysphagia
(787.2); Malignancy of lip, oral cavity & pharyngeal cavity (140.0-149.9); Alzheimer’s disease
(331.0); Huntington’s chorea (334.0); Jakob-Creutzfeldt disease (046.1); MS (340); Other
demyelinating disease of CNS (341.9); Pick’s disease (331.0); Profound mental retardation (318.2);
Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0); Cerebral
Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome) (330.8);
Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code); Cerebral
degeneration of childhood in other diseases classified elsewhere (330.3, with underlying disease
code); Parkinson’s disease (332.0, 332.1); Supranuclear Palsy (333.0); ALS (335.20); Motor neuron
disease (335.2); Progressive muscular atrophy (335.21); Progressive bulbar palsy (335.22);
Psuedobulbar palsy (335.23); Encephalopathy (348.3); Senile dementia (290.0)
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