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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 state 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 information 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.