`B4103` Ef ped fluid and electrolyte

Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 0 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy
DME supplier: max 0 units per day (clinical), rationale: Published Contractor Policy

Payer policies and prior authorization for B4103

34 of 34 payer prior-auth lists that name B4103 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Texas, Blue Shield of California, Molina Complete Care (Virginia), Molina Healthcare of Iowa, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	State of Arizona employee group (SYD, S3Z)	AZ	prior auth required		Sep 1, 2026	State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
Blue Shield of California	Blue Shield commercial	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield
Blue Cross and Blue Shield of New Mexico	Turquoise Care (New Mexico Medicaid)	NM	prior auth required		Oct 1, 2026	New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jan 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
Molina Complete Care (Virginia)	Virginia state exceptions to the national Medicaid grid (exceptions only)	VA	prior auth required	State exception	Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required	State exception	Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
UnitedHealthcare Community Plan	ALTCS Long Term Care	AZ	prior auth required		Oct 1, 2026	Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026
UnitedHealthcare Community Plan	District of Columbia LTSS	DC	prior auth required		Oct 1, 2026	Prior Authorization Requirements for District of Columbia LTSS Effective October 1, 2026
UnitedHealthcare Community Plan	Indiana Hoosier Care Connect	IN	prior auth required		Oct 1, 2026	Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026
UnitedHealthcare Community Plan	Louisiana Medicaid (Healthy Louisiana)	LA	prior auth required		Jan 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Massachusetts OneCare	MA	prior auth required		Nov 1, 2025	Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO)	MA	prior auth required		Nov 1, 2025	CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO) and OneCare	MA	prior auth required		Oct 1, 2026	Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth required		Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth under conditions	Age 5+; Age under 5	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth required		Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth required		May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community Plan	TennCare	TN	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth required		May 1, 2019	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth required		May 1, 2019	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth required		May 1, 2019	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth required		May 1, 2019	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth under conditions	Cost over $500	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Connected (Texas MMP)	TX	prior auth required		Jan 1, 2015	Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U
UnitedHealthcare Community Plan	Washington Apple Health	WA	prior auth required		Oct 1, 2026	Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community Plan	Wisconsin BadgerCare Plus and Medicaid SSI	WI	prior auth required		Sep 1, 2026	Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community

Payer coverage policies that name B4103

B4103 appears in 22 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, BlueCross BlueShield of South Carolina, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Eating Disorders (0511)	covered if criteria are met (range B4102-B4103)	Aug 4, 2026	payer document
Aetna	Nutritional Support (0061) Enteral lactoferrin supplementation	covered if criteria are met (range B4102-B9999)	Jan 15, 2026	payer document
Aetna	Nutritional Support (0061) Enteral lactoferrin supplementation	covered if criteria are met	Jan 15, 2026	payer document
Aetna	Pediatric Intensive Feeding Programs (0809)	listed, no stance (range B4034-B4162)	Dec 11, 2025	payer document
Anthem	Home Enteral Nutrition (CG-MED-08)	covered if criteria are met	Aug 13, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Parenteral Pen And Enteral En Nutrition Support In The Home (L.1.01.404)	covered if criteria are met		payer document
Blue Cross Blue Shield of Massachusetts	Special Foods (304)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Total Parenteral Nutrition and Enteral Nutrition in the Home (CAM 10201) 997.40 \| Digestive system complication (*this code should be accompanied by a code to identify the specific condition)	listed, no stance (range B4102-B4162)	Jun 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Nutritional Support (MED201.011) HCPCS Codes B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4102,	listed, no stance	Jan 1, 2026	payer document
Premera Blue Cross	Home Nutritional Support	listed, no stance	May 1, 2026	payer document
Regence	Enteral and Oral Nutrition Therapy in the Home Setting (Allied Health 05)	listed, no stance	Mar 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (MP.027.14)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (CS136.R)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (for Idaho Only) (CS136ID.D)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (for Kansas Only) (CS136KS.03)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (for Kentucky Only) (CS136KY.13)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (for Nebraska Only) (CS136NE.O)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (for New Jersey Only) (CS136NJ.P)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (for New Mexico Only) (CS136NM.D)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (for North Carolina Only) (CSNC.MP.104.06)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (for Ohio Only) (CS136OH.F)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (for Pennsylvania Only) (CS136PA.R)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Enteral Nutrition (Oral and Tube Feeding) (for Tennessee Only) (CS136TN.P)	listed, no stance	Jun 1, 2026	payer document

Recent prior-auth changes

Apr 1, 2026: PA added, Blue Cross and Blue Shield of Texas
Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Feb 19, 2025: PA removed, Molina Healthcare of Texas
Feb 19, 2025: PA removed, Molina Healthcare of Texas
Jan 1, 2025: PA removed, Molina Healthcare of Texas

Medicaid fee-for-service

Prior authorization required or conditional in CO, IN, KY, LA, MA, OH, VA, WA.

IN: $5.04 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
LA: $1.06 (dme), effective Jan 1, 2023
MD: $3.33 (dme), effective Apr 1, 2026
OH: $0.60 (dme), effective Jun 1, 2014
OK: $5.33 (dme), effective Aug 1, 2020
TX: $3.33 (dmepos_tos_9_e_j_l_and_r, Home Health Dme, non-facility), effective Mar 1, 2023
VA: $5.36 (dme), effective Dec 1, 2026
VT: $10.23 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $1.75 (enteral_nutrition), effective Jul 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

B4103 Ef ped fluid and electrolyte