ModifiedAmbetter NevadaPolicy CP.MP.163

Total Parenteral Nutrition (TPN) and Intradialytic Parenteral Nutrition (IDPN)

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Medical necessity criteria and coding implications for provision of TPN and IDPN for Ambetter Nevada members/enrollees, including indications, not-proven indications, approval durations, and background clinical context.

Policy Summary

PayerAmbetter Nevada

PolicyTotal Parenteral Nutrition (TPN) and Intradialytic Parenteral Nutrition (IDPN)

Policy CodePolicy CP.MP.163

Change TypeCriteria revisions and added indications

Effective Date

Next Review Date

Key ActionObtain prior authorization and document age-specific weight loss criteria plus evidence that enteral/oral feeding is inappropriate to support TPN or stage 5 CKD and hemodialysis for IDPN.

SourceLink

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ModifiedAmbetter NevadaPolicy CP.MP.163

Total Parenteral Nutrition (TPN) and Intradialytic Parenteral Nutrition (IDPN)

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Sign up for Ambetter Nevada Policy CP.MP.163 alerts

Get alerted when Policy CP.MP.163 changes without checking for updates manually.

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Policy Summary

PayerAmbetter Nevada

PolicyTotal Parenteral Nutrition (TPN) and Intradialytic Parenteral Nutrition (IDPN)

Policy CodePolicy CP.MP.163

Change TypeCriteria revisions and added indications

Effective Date

Next Review Date

Key ActionObtain prior authorization and document age-specific weight loss criteria plus evidence that enteral/oral feeding is inappropriate to support TPN or stage 5 CKD and hemodialysis for IDPN.

SourceLink

POLICY UPDATE CHANGES

Updated criteria I.A.1.a regarding low body weight to include details by age group and expanded to I.A.1.a through c; removed previous criteria regarding total protein and serum albumin.

Replaced 'end-stage renal disease' with 'stage 5 chronic kidney disease' in IDPN criteria.

Added indications for radiation enteritis, liver failure in children, liver failure in adults, and acute necrotizing pancreatitis in adults to list of conditions making enteral feeding inappropriate.

3 moInitial approval

6 moContinued approval

Stage 5IDPN CKD stage

20-70%Malnutrition prevalence (dialysis)

Alb <3.4Example lab threshold

CenteneOwner

Coverage Criteria for TPN and IDPN

Total Parenteral Nutrition (TPN)

Total Parenteral Nutrition (TPN) — TPN is covered when ALL of the following are met:

Documentation of nutritional insufficiency in the absence of TPN, demonstrated by any of the following: (a) For adults, involuntary weight loss of 10% of usual body weight within six months or 5% within one month; (b) For children, weight for length, weight for height, or sex < 10th percentile or inadequate weight gain or a significant decrease in usual growth percentile; (c) For neonates, extremely low birth weight < 1000 g.

Evidence of structural or functional bowel disease that makes oral or tube feedings inappropriate, or a condition in which the gastrointestinal tract is non-functioning for a period of time, including but not limited to: Crohn's disease; short bowel syndrome; single or multiple enteric fistulae; obstructing stricture; motility disorder; newborn anomalies preventing or contraindicating oral feedings (e.g., tracheoesophageal fistula, gastroschisis, omphalocele, massive intestinal atresia); infants/young children who fail to thrive due to cardiac or respiratory disease, short bowel syndrome, malabsorption, or chronic idiopathic diarrhea; paralytic ileus in children or prolonged paralytic ileus following major surgery or multiple injuries; radiation enteritis; liver failure in children approved for liver transplant who fail to grow on enteral support; liver failure in adults with hepatic encephalopathy who cannot tolerate standard amino acid protein sources (including use for liver-specific amino acid mixtures); acute necrotizing pancreatitis in adults with inadequate oral intake >1 week where enteral feeding exacerbates symptoms; necrotizing enterocolitis; small bowel ischemia.

Initial approval duration for TPN: three months. Continued approval duration: six months, provided there is no evidence of unacceptable complications from treatment and documentation supports positive response to therapy.

Intradialytic Parenteral Nutrition (IDPN)

Intradialytic Parenteral Nutrition (IDPN) — IDPN is covered when ALL of the following are met:

Member meets TPN criteria in the Total Parenteral Nutrition section above.

Member has stage 5 chronic kidney disease (CKD).

Member is undergoing hemodialysis.

IDPN is offered as an alternative to regularly scheduled TPN (not in addition to regularly scheduled TPN).

Initial approval duration for IDPN: three months. Continued approval duration: six months, provided there is no evidence of unacceptable complications from treatment and documentation supports positive response to therapy.

Denial Risk

Provider action: Coverage determination constraints

Provider action — Denial risk for certain TPN and IDPN indications

TPN: Claims for the not-proven indications listed above are at risk for denial without documentation supporting a clear medical justification beyond the not-proven categories.
IDPN: IDPN administered in addition to regularly scheduled TPN, or IDPN for acute kidney injury without end-stage renal disease/ESRD (stage 5 CKD), is considered not proven and is at high risk for denial.
Prior authorization and documentation should explicitly address: nutritional insufficiency measures, structural/functional bowel disease details, CKD stage and dialysis status (for IDPN), and rationale why enteral or oral nutrition is inappropriate or insufficient.

Coding and Billing Codes

TPN and supply HCPCS codesHCPCS

B4164-B5200	Parenteral nutrition solutions and supplies
B9004	Parenteral nutrition infusion pump, portable
B9006	Parenteral nutrition infusion pump, stationary
S9364	Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula, per diem
S9365	Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula, per diem
S9366	Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula, per diem
S9367	Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula, per diem
S9368	Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula, per diem

Weight loss / growth thresholds — nutritional insufficiency

Adult weight-loss thresholdInvoluntary weight loss ≥10% of usual body weight within 6 months or ≥5% within 1 month

Pediatric growth thresholdWeight-for-length, weight-for-height, or sex-specific weight < 10th percentile, or inadequate weight gain / significant decrease in usual growth percentile

Neonatal thresholdExtremely low birth weight < 1000 g

Prior Authorization, Documentation, and Operational Requirements

Prior Authorization

Prior authorization and approval durations

Prior authorization is required and initial approvals are issued for three months; continued approvals may be granted for six months when documentation demonstrates positive response and no unacceptable complications.

Initial approval duration: 3 months
Continued approval duration: 6 months if documentation supports response and no unacceptable complications

Prior Authorization

Prior authorization governed by plan and benefit documents

Prior authorization and coverage determinations are governed by the Health Plan's administrative policies and by the member's benefit documents; review applicable state Medicaid manuals and Medicare NCDs/LCDs as required.

Follow Health Plan administrative policies and member coverage documents
For Medicaid, state Medicaid provisions take precedence if conflicting

Definitions and Terminology

TPN definition and vascular access

DefinitionTotal Parenteral Nutrition (TPN): Intravenous delivery of all necessary macronutrients and micronutrients when enteral nutrition cannot meet needs

Central vs peripheral deliveryShort-term TPN may be delivered peripherally via central venous catheter sites; long-term TPN requires a tunneled central venous catheter or implanted infusion port

Indication contextUsed when the gastrointestinal tract is incapable of digesting or absorbing nutrients via enteral (oral or tube) feeding

IDPN definition and delivery context

DefinitionIntradialytic Parenteral Nutrition (IDPN): Parenteral nutrition administered during hemodialysis sessions through the dialysis access as an alternative to regularly scheduled TPN

Delivery context

Clinical Background and Rationale

Parenteral nutrition delivers macronutrients and micronutrients intravenously when oral or enteral feeding cannot meet nutritional requirements. Total parenteral nutrition (TPN) provides complete nutrition — proteins, fats, carbohydrates, vitamins and minerals — administered via central or peripheral venous access depending on expected duration of therapy. TPN is used for patients with structural or functional gastrointestinal failure or other conditions that make enteral feeding inappropriate or impossible. Intradialytic parenteral nutrition (IDPN) is administered through the dialysis access during hemodialysis sessions to provide partial nutritional support for patients with stage 5 chronic kidney disease who remain malnourished despite oral or enteral supplementation. Both TPN and IDPN can correct macronutrient deficits but carry risks including catheter-related infections, metabolic disturbances, and hepatobiliary complications, and should be used when clinical documentation demonstrates nutritional insufficiency and an inability to use the enteral route.

Policy Revision History and Changes

2026-01-26 or as writtenannual_review

Annual review completed with minor rewording in Criteria section and updates to codes/references; external specialist reviewed.

2025-01-25criteria_update

Updated age-specific low body weight documentation by expanding I.A.1.a into I.A.1.a–c (adult, child, neonate thresholds) and removed prior total protein and serum albumin requirements; removed CNS disorders from list and added paralytic ileus in children plus new conditions I.A.2.m and I.A.2.n.

2024-04-22annual_review

Policy Summary

PayerAmbetter Nevada

PolicyTotal Parenteral Nutrition (TPN) and Intradialytic Parenteral Nutrition (IDPN)

Policy CodePolicy CP.MP.163

Change TypeCriteria revisions and added indications

Effective Date

Next Review Date

Key ActionObtain prior authorization and document age-specific weight loss criteria plus evidence that enteral/oral feeding is inappropriate to support TPN or stage 5 CKD and hemodialysis for IDPN.

SourceLink

On This Page

For Medicare, review applicable NCDs/LCDs and Medicare Coverage Articles

Step Therapy

IDPN as alternative/step before long‑term parenteral therapy

Consider IDPN for dialysis patients who remain malnourished despite oral supplements or cannot tolerate enteral nutrition; professional societies support trials of IDPN in selected hemodialysis patients as an alternative to other long‑term parenteral strategies.

Use IDPN when oral supplements and enteral nutrition are inadequate or not tolerated
Society guidelines support IDPN trials in select hemodialysis patients

Documentation Required

Required clinical documentation for TPN/IDPN

Documentation must show nutritional insufficiency by age‑specific weight/growth thresholds and evidence that the GI tract is structurally or functionally unable to support oral or enteral feeding; for IDPN, also document stage 5 CKD and ongoing hemodialysis with IDPN offered as an alternative to scheduled TPN.

Evidence of nutritional insufficiency per age‑specific thresholds (adults, children, neonates)
Evidence of structural or functional bowel disease or non‑functioning GI tract making enteral/oral feeding inappropriate
For IDPN: documentation of stage 5 CKD and that the member is undergoing hemodialysis

Documentation Required

Follow member contract terms and legal requirements

Providers must follow member contract terms and applicable state and federal requirements; this clinical policy is a guide to medical necessity and does not guarantee payment.

Adhere to the terms, conditions, exclusions and limitations in the member's coverage documents
Comply with applicable state Medicaid provisions and federal requirements

Note

Coverage decision constraints and precedence rules

Coverage determinations are subject to the terms, exclusions, limitations of the member's coverage documents and applicable Health Plan administrative policies and procedures; state Medicaid and Medicare NCD/LCD rules prevail where applicable.

Decisions limited by coverage documents (e.g., EOC, policy, contract)
State Medicaid provisions take precedence over this policy when conflicting
Review Medicare NCDs/LCDs for Medicare members

Note

Provider operational reminder — include required documentation

Operational note for providers: confirm that prior authorization requests include the specific documentation elements (age‑specific weight/growth data, GI structural/functional findings, dialysis and CKD stage for IDPN) outlined in the policy to avoid preventable denials or delays.

Include age‑specific weight/growth measures and clinical notes showing inability to tolerate enteral/oral nutrition
For IDPN, include documentation of stage 5 CKD and hemodialysis schedule
Attach prior treatment response and complication monitoring to support continued approvals

Delivered during dialysis via the patient’s dialysis access, eliminating need for additional venous catheter placement

Nutritional yieldProvides approximately 70% of nutrients to the patient due to loss into the dialysate

Terms and guideline references (ASPEN, ESPEN, society guidance)

ASPEN referenceDefinitions, terms, and conventions are guided by ASPEN board-approved documents (see ASPEN Definition of Terms)

ESPEN guidanceESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease is cited as guidance for IDPN/CKD nutrition considerations

Society guidance for IDPNMultiple society position papers and reviews (including recent IDPN implementation and review articles) are referenced for patient selection and practice considerations

Background updated with no impact to criteria; clarifying language added to Criteria I.A.1.a and minor rewording to HCPCS codes; references reviewed and updated to AMA format.

2021-04-21criteria_revision

Added indications for radiation enteritis, liver failure (children and adults), and acute necrotizing pancreatitis in adults to I.A.2.j–m and changed 'end-stage renal disease' to 'stage 5 chronic kidney disease' in IDPN criteria, with coding and references reviewed.

2016-05-16policy_approval

Policy developed and approved; added new indications and updated terminology (member to member/enrollee) with coding and references reviewed.

2026-02-24criteria_updateLatest

Updated criteria I.A.1.a to include details by age group and expanded to I.A.1.a–c; removed previous criteria referencing total protein and serum albumin and removed CNS disorders from I.A.2.d; added I.A.2.m and I.A.2.n to list of conditions making enteral/oral feeding inappropriate.