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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that enteral nutrition is considered reasonable and necessary for a patient with a functioning 
gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to 
reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition. 
Some patients require supplementation of their daily protein and caloric intake. Nutritional supplements are 
often given as a medicine between meals to boost protein-caloric intake or the mainstay of a daily nutritional 
plan. Nutritional supplementation is not covered under Medicare Part B. You can find this rule in the Medicare 
National Coverage Determination Manual, Chapter 1, Section 180.2. 
 
The rules say that in order to cover intradialytic parenteral nutrition (IDPN), documentation must be clear and 
precise to verify that the beneficiary suffers from a permanently impaired gastrointestinal tract and that there is 
insufficient absorption of nutrients to maintain adequate strength and weight. Records should document that the 
beneficiary cannot be maintained on oral or enteral feedings and that due to severe pathology of the alimentary 
tract, the beneficiary must be intravenously infused with nutrients. Infusions must be vital to the nutritional 
stability of the beneficiary and not supplemental to a deficient diet or deficiencies caused by dialysis. Physical 
signs, symptoms and test results indicating severe pathology of the alimentary tract must be clearly evident in 
any documentation submitted. Beneficiaries receiving IDPN must meet the parenteral nutrition coverage 
criteria listed below. Parenteral nutrition is covered in any of the following situations: 
A. The beneficiary has undergone recent (within the past 3 months) massive small bowel resection leaving 
less than or equal to 5 feet of small bowel beyond the ligament of Treitz, or 
B. The beneficiary has a short bowel syndrome that is severe enough that the beneficiary has net 
gastrointestinal fluid and electrolyte malabsorption such that on an oral intake of 2.5-3 liters/day the 
enteral losses exceed 50% of the oral/enteral intake and the urine output is less than 1 liter/day, or 
C. The beneficiary requires bowel rest for at least 3 months and is receiving intravenously 20-35 
cal/kg/day for treatment of symptomatic pancreatitis with/without pancreatic pseudocyst, severe 
exacerbation of regional enteritis, or a proximal enterocutaneous fistula where tube feeding distal to the 
fistula isn't possible, or 
D. The beneficiary has complete mechanical small bowel obstruction where surgery is not an option, or 
E. The beneficiary is significantly malnourished (10% weight loss over 3 months or less and serum 
albumin less than or equal to 3.4 gm/dl) and has very severe fat malabsorption (fecal fat exceeds 50% of 
oral/enteral intake on a diet of at least 50 gm of fat/day as measured by a standard 72-hour fecal fat 
test), or 
F. The beneficiary is significantly malnourished (10% weight loss over 3 months or less and serum 
albumin less than or equal to 3.4 gm/dl) and has a severe motility disturbance of the small intestine 
and/or stomach which is unresponsive to prokinetic medication and is demonstrated either:  
1. Scintigraphically (solid meal gastric emptying study demonstrates that the isotope fails to reach 
the right colon by 6 hours following ingestion), or 
2. Radiographically (barium or radiopaque pellets fail to reach the right colon by 6 hours following 
administration). These studies must be performed when the beneficiary is not acutely ill and is 
not on any medication which would decrease bowel motility. 
You can find this rule in the Local Coverage Article for Parenteral Nutrition, A52515 (eff 01/01/20). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.