Louisiana Revised Statutes Tit. 40, § 1081.13. Medicaid coverage; amino acid-based elemental formulas

(1) Immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins.

(2) Severe food protein-induced enterocolitis syndrome.

(3) Eosinophilic disorders, as evidenced by the results of a biopsy.

(4) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.

C. (1) A health maintenance organization, health insurance organization, or managed care organization that contracts with the state to provide or coordinate healthcare services to any person eligible for Medicaid shall provide coverage on a basis no less favorable than the basis on which prescription drugs and other medications and related services are covered by the organization, and to the same extent that the organization provides coverage for drugs that are available only on the orders of a physician.

(2) A utilization review agent acting on behalf of an organization listed in this Subsection may review a treating physician's determination of the medical necessity of the use of an amino acid-based elemental formula for the treatment of a covered infant or child who is diagnosed with a disease or disorder listed in Subsection A of this Section.