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 say that 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. 
 
A total caloric daily intake of 20-35 cal/kg/day is considered reasonable and necessary to achieve or maintain 
appropriate body weight. The treating practitioner must document the medical necessity for a caloric intake 
outside this range in an individual beneficiary. 
 
The treating practitioner must document the medical necessity for protein orders outside of the range of 0.8-2.0 
gm/kg/day (B4168, B4172, B4176, B4178), dextrose concentration less than 10% (B4164, B4180), or lipid use 
per month in excess of the product-specific, FDA-approved dosing recommendations (B4185, B4187). 
 
Parenteral nutrition (PN) is a type of medical nutrition therapy provided through the intravenous administration 
of nutrients such as amino acids, glucose, lipids, electrolytes, vitamins, and trace elements. PN can be central 
through a central venous line, or peripheral through a peripheral intravenous line. 
 
When PN is used outside the hospital, it is often referred to in the literature as home parenteral nutrition (HPN). 
HPN is often used for patients with chronic intestinal failure for either benign or malignant diseases or 
provided as palliative nutrition to patients in late phases of end-stage diseases.4 
 
A review of the available literature reveals that there is no reliable measure of nutritional status or marker to 
diagnose clinically significant intestinal malabsorption. Serum albumin and other laboratory tests are no longer 
used as a measure of nutritional status due to research indicating their link to inflammation and lack of 
response to nutrition therapy.1-3 Although promising, the available evidence is insufficient to recommend 
plasma citrulline levels as a marker of small bowel absorption capacity.3,5-9 
 
Coverage of PN has been established in the Medicare National Coverage Determinations Manual (CMS Pub. 
100-03), Chapter 1, Part 3, Section 180.2. Based on review of the best available evidence, parenteral nutrition 
is considered reasonable and necessary for a beneficiary with 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. You can find these rules in the Local Coverage Determination (LCD) 
Parenteral Nutrition L38953. 
 
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.