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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 for any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit 
category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory 
requirements. 
The purpose of a Local Coverage Determination (LCD) is to provide information regarding reasonable and 
necessary criteria based on Social Security Act  1862(a)(1)(A) provisions. 
In addition to the reasonable and necessary criteria contained in this LCD there are other payment rules, 
which are discussed in the following documents, that must also be met prior to Medicare reimbursement: 
 The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy 
under the Related Local Coverage Documents section. 
 The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage 
Documents section. 
 Refer to the Supplier Manual for additional information on documentation requirements. 
 Refer to the DME MAC web sites for additional bulletin articles and other publications related to this 
LCD. 
For the items addressed in this LCD, the reasonable and necessary criteria, based on Social Security Act  
1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical 
necessity. 
Parenteral nutrition is the provision of nutritional requirements intravenously and is covered for beneficiaries 
who qualify under the Prosthetic Device Benefit defined in the Medicare Benefit Policy Manual (CMS Pub. 
100-02), Chapter 15, Section 120. When nutritional support other than the oral route is necessary, enteral nutrition (EN) is usually initially 
preferable to parenteral nutrition for the following reasons: (1) In a fluid restricted beneficiary, EN permits 
delivery of all necessary nutrients in a more concentrated volume than parenteral nutrition; (2) EN allows for 
safer home delivery of nutrients; and (3) EN lowers the risk of Central Line-Associated Bloodstream Infections 
(CLABSI). 
For parenteral nutrition to be considered reasonable and necessary, the treating practitioner must document that 
enteral nutrition has been considered and ruled out, tried and been found ineffective, or that EN exacerbates 
gastrointestinal tract dysfunction. 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 and absorbed 
by the gastrointestinal (GI) system. The beneficiary must have a permanent impairment. Please refer to the 
LCD-related Policy Article for further guidance regarding the test of permanence.   
The treating practitioner is required to evaluate the beneficiary within 30 days prior to initiation of parenteral 
nutrition. If the treating practitioner does not see the beneficiary within this timeframe, they must document the 
reason why and describe what other monitoring methods were used to evaluate the beneficiary's parenteral 
nutrition needs. There must be documentation in the medical record supporting the clinical diagnosis. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L38953: Parenteral Nutrition. 
The rules say that the beneficiarys medical record must contain sufficient documentation of the beneficiarys 
medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency 
of use or replacement (if applicable). The information should include the beneficiarys diagnosis and other 
pertinent information including, but not limited to, duration of the beneficiarys condition, clinical course 
(worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic 
interventions and results, past experience with related items, etc. 
Information describing the medical necessity for parenteral nutrition must be available upon request. In order to 
satisfy the test of permanence, there must be documentation to reflect that in the treating practitioners 
judgement, the impairment will be of long and indefinite duration. 
Documentation in the medical record shall reflect that the beneficiary has (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 and absorbed by the gastrointestinal (GI) system. 
You can find this rule at the Medicare Local Coverage Article (LCA) A58836: Parenteral Nutrition. 
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.