Parenteral Nutrition

Parenteral nutrition (also called hyperalimentation or total parenteral nutrition) is considered reasonable and necessary for the patient whose alimentary tract does not adequately function to permit normal oral feeding.  It is provided by means of a catheter which is inserted usually into the superior vena cava and through which the patient receives nutritional solutions.

      Indications for parenteral nutrition include, but are not limited to:

• Inflammatory bowel syndrome
• Intestinal obstruction from carcinomatosis
• Massive bowel resection
• Mesenteric infarction
• Motility disorder (pseudo-obstruction)
• Radiation enteritis
• Short bowel syndrome

Parenteral nutrition systems are eligible under the prosthetic benefit.  Prosthetic devices, which are dispensed to a patient prior to performance of the procedure that will necessitate use of the device, are not covered.  Dispensing a prosthetic device in this manner would not be considered reasonable and necessary for the treatment of the patient's condition. 

Parenteral Accessories and Supplies

Payment may be made for accessories and/or supplies that are used directly with parenteral systems to achieve therapeutic benefit or assure proper functioning of the feeding system and are eligible durable medical equipment.  They include:

• Catheters
• Concentrated nutrients
• Dressings
• Extension tubing
• Filters
• Heparin sodium (parenteral only)
• Infusion bottles
• IV pole
• Liquid diet (for catheter administration)
• Needles 
• Pumps (food or infusion)
• Tape
• Volumetric monitors (parenteral only)

Coverage for DME/Prosthetics is determined according to individual or group customer benefits.

Parenteral services performed by a physician or surgeon

Payment can be made for the eligible services provided by the surgeon or other physician in carrying out this treatment, e.g., introduction of the catheter (36555, 36556, 36568, 36569, 36580 and 36584), as well as the reported medical care.

Hyperalimentation performed pre and /or postoperatively is not routine pre and/or postoperative care.  If, however, several doctors are involved in the patient’s care, reimbursement should be made according to the concurrent care guidelines set forth in Medical Policy Bulletin V-2.  Also, see Medical Policy Bulletin V-28 (Preoperative Care).

Intradialytic (IDPN) and Intraperitoneal Parenteral (IPN)  Nutrition

IDPN and IPN are alternative ways of delivering parenteral nutrition during dialysis.  The difference between parenteral, IDPN and IPN is the manner in which the parenteral nutrition is administered.  Because malnutrition is a common problem in patients with end-stage renal disease, parenteral nutrition is often given during dialysis treatment.

Intradialytic parenteral nutrition means intravenous nutrition administered during hemodialysis. Intradialytic parenteral nutrition is the infusion of parenteral/hyperalimentation fluids during dialysis, through the vascular shunt.  Additional vascular access is not needed.  IDPN is administered through an infusion pump that can overcome venous pressure in the dialysis bloodlines.  The fluid is then mixed with the patient's venous blood and returned to the body through the venous access.

Intraperitoneal parenteral nutrition is parenteral nutrition administered during peritoneal dialysis.  IPN solution is administered in the same manner as regular dialysate.

Although there are different accesses for IDPN and IPN, they are both ways of delivering parenteral nutrition during dialysis; therefore, both of these procedures will be referred to as intradialytic parenteral nutrition, IDPN.

Protein calorie malnutrition, typically assessed by measurements of serum albumin, occurs in an estimated 25%-40% of those undergoing dialysis and is associated with increased morbidity and mortality.  Intradialytic parenteral nutrition (IDPN) is a technique to treat protein calorie malnutrition in an effort to decrease the associated morbidity and mortality.  Patients often receive IDPN three times a week.

Intradialytic parenteral nutrition may be considered medically necessary when offered as an alternative to a regularly scheduled regimen of total parenteral nutrition only in those patients who would be considered candidates for total parenteral nutrition (TPN).

Intradialytic parenteral nutrition is considered not medically necessary in those patients who would be considered a candidate for TPN, but for whom the intradialytic parenteral nutrition is not offered as an alternative to TPN, but in addition to regularly scheduled infusions of TPN.  A participating, preferred, or network provider cannot bill the member for the denied services.

Intradialytic parenteral nutrition is considered not medically necessary in those patients who would not otherwise be considered candidates for TPN.  A participating, preferred, or network provider cannot bill the member for the denied services.

Patients with poor nutritional status should be expected first to receive nutritional supplements sufficient to insure that the diet provides at least 1.2 g/kg/day high biologic value protein, and 32 kcalories/kg/day, including calories from peritoneal dialysate glucose.

A physician attestation that the patient cannot tolerate or has failed a reasonable trial of oral and enteral nutritional supplementation (two months for each) would justify moving to parenteral nutrition (TPN).  If a patient's nutritional status or other related conditions are deteriorating during a trial of such enteral feeding, the time requirement should be waived.

The dialysis patients should meet the following criteria for poor nutritional status:

• Weight loss >7% of body weight over 3 months or >10% over 6 months; or
• Weight <90% of usual weight or "standard body weight" as determined from the NHANES data base
• Serum albumin <3.5 gm/dl
• Body mass index (BMI) <20
• Total protein <6 gm/dl
• Transferrin < 200 mg/dl
  

Coverage is determined by individual and group customer benefits.

Lab Parameters Monitored During the Course of IDPN

The following labs should be performed during the course of  IDPN:

• Blood sugars before, during and after each dialysis
• Albumin monthly
• Triglycerides monthly

Most laboratory tests needed to monitor dialysis are already routinely obtained monthly for all dialysis patients.  At times, magnesium, lipid profile, WBC differential, pre-albumin, lipase, ionized calcium, prothrombin time and certain specific nutrient levels (e.g., carotene, vitamins, zinc, carnitine, etc.) would need to be added to the routine testing. In addition, some routine testing, particularly of electrolytes, BUN, glucose, calcium phosphorus, magnesium, and albumin may be needed.

Length of Time for IDPN

The patient's nutritional status should be evaluated at 6 months.  If the nutritional abnormalities resolve, IDPN may be discontinued.  Many patients who need parenteral nutrition may need it for life, although survival is generally very limited under such circumstances.  

Description

Parenteral nutrition (hyperalimentation/TPN) is the provision of nutritional requirements intravenously.

Intradialytic parenteral nutrition is infusing hyperalimentation fluids at the time of either hemodialysis or peritoneal dialysis

Dialysis is a therapy which eliminates the toxic wastes from the body when the kidney fails and cannot do its job of eliminating these toxic wastes.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

FEP covers medical food and nutritional supplements when administered by catheter or nasogastric tubes.

BCBSA Medical Policy Reference Manual 8.01.44

CMS On-Line Manual Pub. 100-3, Chapter 1, Section 180.2