Appeal type: unknown
Decision: unknown

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 state that Maintenance of weight and strength commensurate with the beneficiary's overall health status must require intravenous nutrition and must not be possible utilizing all of the following approaches: Modifying the nutrient composition of the enteral diet (e.g., lactose free, gluten free, low in long chain triglycerides, substitution with medium chain triglycerides, provision of protein as peptides or amino acids, etc.), and2.Utilizing pharmacologic means to treat the etiology of the malabsorption (e.g., pancreatic enzymes or bile salts, broad spectrum antibiotics for bacterial overgrowth, prokinetic medication for reduced motility, etc.)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, orB.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, orC.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, orD.The beneficiary has complete mechanical small bowel obstruction where surgery is not an option, orE.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), orF.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), or2.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.Unresponsiveness to prokinetic medication is defined as the presence of daily symptoms of nausea and vomitingwhile taking maximal doses.For criteria A-F above, the conditions are deemed to be severe enough that the beneficiary would not be able to maintain weight and strength on only oral intake or tube enteral nutrition.Beneficiaries who do not meet criteria A-F above must meet criteria 1-2 above (modification of diet and pharmacologic intervention) plus criteria G and H below:G.The beneficiary is malnourished (10% weight loss over 3 months or less and serum albumin less than or equal to 3.4 gm/dl), andH.A disease and clinical condition has been documented as being present and it has not responded to altering the manner of delivery of appropriate nutrients (e.g., slow infusion of nutrients through a tube with the tip located in the stomach or jejunum).You can find this information in the Local Coverage Article: Parenteral Nutrition -Policy Article (A52515)