Nutritional Diagnosis Grid - Alabama Medicaid Agency

Kindercal TF/ Kindercal
TF w/Fiber
1-10
Chronic illness with inadequate oral intake, voluntary (anorexia 783.0) and involuntary (barriers to
normal ingestion): Dysphagia (787.2); Malignancy of lip, oral cavity & pharyngeal cavity (140-149);
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); 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 30 days of surgery (579.3); Failure to thrive (784.3);
Trauma (burns 940.0-949.9); multiple fractures (828.0, 828.1, 819.0, 819.1)
Lanaflex >12 N/A Phenylketonuria (PKU): 270.1
Lipistart 1-10 N/A
Fat Malabsorption: 579.8; Long Chain Fatty Acid Oxidation Disorders: 277.85; Type 1
Hyperlipidemia: 272.0; Chylothorax: 457.8
Liquid Nutrition
(formerly Nutrition)
> 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); Pseudobulbar palsy (335.23); Encephalopathy
(348.3); Malnutrition (261); Post-op feeding, within 4 weeks of surgery (579.3), CRF (ESRD) (585,
586)
Liquid Nutrition Plus > 12 months 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); Pseudobulbar 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)
LMD All Adult Isovaleric acidemia or other disorders of leucine catabolism (270.3)
Lophlex >9 N/A Phenylketonuria (PKU): 270.1
MCT Oil All Adult
Patients with defective intraluminal hydrolysis of fat (decreased pancreatic lipase, decreased bile
salts 579.8, 577.8), mucosal fat absorption (decreased mucosal permeability, decreased absorptive
surface 535.1, 555.0, 555.9, 556.6, 558.9, 579.3), or lymphatic transport of fat (intestinal or thoracic
lymphatic obstruction 457.1)
Methionaid > 12 months Adult Vitamin B6 Non-responsive homocystinuria or hypermethioninemia (270.4)
Modulen IBD Complete
Nutrition
> 12 months Adult Crohn’s disease (555.0, 555.1, 555.2, 555.9)
MMA/PA express ≥ 8 N/A Methylmalonic acidemia and propionic acidemia (270.7)
MMA/PA gel 1-10 N/A Methylmalonic acidemia and propionic acidemia (270.7)
Monogen > 12 months N/A
MSUD 2
> 12 months
Long chain fatty acid oxidation disorders (277.85), hyperlipoproteinemia type I (272.0, 272.1, 272.2,
272.3, 272.4) chylothorax (457.8), intestinal lymphangiectasia (457.1), intractable malabsorption
with steatorrhoea (579.0, 579.3, 579.4, 579.8, 579.9), post-operative feeding in short gut syndrome,
within 4 weeks of surgery (579.3), other lipid and lymphatic disorders where a low fat, high MCT
diet is indicated
MSUD, hypervalinemia, alpha-methylacetoacetic acidura, ketotic hypoglycemia (270.3),
hyperprolinemia type II (270.8)
9 10/1/11