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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 parenteral nutrition is covered for a beneficiary with permanent, severe pathology of the
alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength
commensurate with the beneficiary's general condition.
PROSTHETIC BENEFIT REQUIREMENTS:
The beneficiary must have a permanent impairment. Permanence does not require a determination that there is
no possibility that the beneficiary's condition may improve sometime in the future. If the judgment of the
treating practitioner, substantiated in the medical record, is that the condition is of long and indefinite duration
(ordinarily at least 3 months), the test of permanence is considered met. Parenteral nutrition will be denied as
non-covered in situations involving temporary impairments.
The beneficiary must have (a) a condition involving the small intestine and/or its exocrine glands which
significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a
motility disorder and impairs the ability of nutrients to be transported through the GI system. There must be
objective evidence supporting the clinical diagnosis.
Parenteral nutrition is noncovered for the beneficiary with a functioning gastrointestinal tract whose need for
parenteral nutrition is only due to any of the following conditions:
- Swallowing disorder
- Temporary defect in gastric emptying such as a metabolic or electrolyte disorder
- Psychological disorder impairing food intake such as depression
- Metabolic disorder inducing anorexia such as cancer
- Physical disorder impairing food intake such as the dyspnea of severe pulmonary or cardiac disease
- Side effect of a medication
- Renal failure and/or dialysis
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.
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:
1. 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.), and
2. 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, 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.
Unresponsiveness to prokinetic medication is defined as the presence of daily symptoms of nausea and
vomiting while 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), and
H. 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).
The following are some examples of moderate abnormalities which would require a failed trial of tube enteral
nutrition before parenteral nutrition would be covered.
- Moderate fat malabsorption - fecal fat exceeds 25% 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
- Diagnosis of malabsorption with objective confirmation by methods other than 72-hour fecal fat test
(e.g., Sudan stain of stool, d-xylose test, etc.)
- Gastroparesis which has been demonstrated (a) radiographically or scintigraphically as described in F
above with the isotope or pellets failing to reach the jejunum in 3-6 hours, or (b) by manometric
motility studies with results consistent with an abnormal gastric emptying, and which is unresponsive to
prokinetic medication
- A small bowel motility disturbance which is unresponsive to prokinetic medication, demonstrated with
a gastric to right colon transit time between 3-6 hours
- Small bowel resection leaving greater than 5 feet of small bowel beyond the ligament of Treitz
- Short bowel syndrome which is not severe (as defined in B)
- Mild to moderate exacerbation of regional enteritis, or an enterocutaneous fistula
- Partial mechanical small bowel obstruction where surgery is not an option
Parenteral nutrition is noncovered for beneficiaries who do not meet these criteria.