B4199 Parenteral sol > 100gm proteParenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix
16 of 16 payer prior-auth lists that name B4199 require prior authorization or set conditions: Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Texas, Blue Shield of California, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of New Mexico, Molina Healthcare of Texas, Passport by Molina Healthcare (Kentucky), Rocky Mountain Health Plans.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 | Jul 1, 2026 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| Humana | Humana Healthy Horizons | OH | prior auth required | Jan 1, 2027 | 555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Apr 1, 2025 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth required | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 | |
| Molina Healthcare of Texas | STAR | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR+PLUS | TX | prior auth required | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 | |
| Molina Healthcare of Texas | STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) | TX | prior auth required | Apr 1, 2025 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 | |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Apr 1, 2025 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 | |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth required | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 |
B4199 appears in 13 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, BlueCross BlueShield of South Carolina, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Molina Healthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Growth Hormone (GH) and Growth Hormone Antagonists (0170) | listed, no stance (range B4164-B5200) | Jun 26, 2026 | payer document |
| Aetna | Intestinal Transplantation (0605) | listed, no stance (range B4164-B5200) | Sep 3, 2026 | payer document |
| Aetna | Nutritional Support (0061) Enteral lactoferrin supplementation | covered if criteria are met (range B4102-B9999) | Jan 15, 2026 | payer document |
| Aetna | Pediatric Intensive Feeding Programs (0809) | listed, no stance (range B4164-B5200) | Dec 11, 2025 | payer document |
| Anthem | Home Parenteral Nutrition (CG-MED-89) | covered if criteria are met | May 14, 2026 | payer document |
| Anthem | Intradialytic Parenteral Nutrition (CG-MED-99) | covered if criteria are met | May 14, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Intradialytic Parenteral Nutrition (L.8.01.413) | covered if criteria are met | 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 | TPN (296) | listed, no stance | payer document | |
| BlueCross BlueShield of South Carolina | Intradialytic Parenteral Nutrition (CAM 80144) | listed, no stance (range B4164-B5200) | Sep 1, 2026 | payer document |
| Centene | Total Parenteral Nutrition and Intradialytic Parenteral Nutrition Reference Number: CP.MP.163 (CP.MP.163) | covered if criteria are met (range B4164-B5200) | Jan 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 |
| Molina Healthcare | Regulatory Status | listed, no stance | payer document |
Prior authorization required or conditional in CO, KY, OH.
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.