Total Parenteral Nutrition and Intradialytic Parenteral Nutrition
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Medical necessity criteria, indications, and coding implications for provision of total parenteral nutrition and intradialytic parenteral nutrition for members/enrollees of Arizona Complete Health (Centene-affiliated plans). Applies to inpatient, outpatient, and home infusion settings as described.
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 prior laboratory-based criteria and removed CNS disorders from list of conditions making enteral feeding inappropriate; added conditions (I.A.2.m and n).
Medical Necessity and Coverage Criteria
Total Parenteral Nutrition (TPN)
Covered when ALL of the following are met
Initial approval: 3 months; continued approval: 6 months with documented benefit and absence of unacceptable complications.
Intradialytic Parenteral Nutrition (IDPN)
Covered when ALL of the following are met
Initial approval: 3 months; continued approval: 6 months with documented benefit and absence of unacceptable complications.
This policy identifies specific populations and scenarios where total parenteral nutrition (TPN) and intradialytic parenteral nutrition (IDPN) have been determined not to be proven safe and effective. For TPN, examples include children who were previously well nourished or only mildly malnourished who are undergoing oncologic treatments associated with low nutrition risk (for example, less advanced disease, less intense therapies, or maintenance-phase treatments), members with advanced cancer whose disease is documented as unresponsive to chemotherapy or radiation, and members for whom liver transplantation is not feasible and prognosis will not change despite TPN.
For IDPN, the policy specifies that IDPN provided in addition to regularly scheduled TPN and IDPN given to members with acute kidney injury without end‑stage renal disease (ESRD) are considered not proven safe and effective.
Coverage decisions under this policy are subject to the terms, conditions, exclusions, and limitations in the member’s coverage documents and the Health Plan’s administrative policies. For Medicaid members, when state Medicaid coverage provisions conflict with this clinical policy, state Medicaid provisions take precedence; providers should consult the applicable state Medicaid manual. For Medicare members, providers should review applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles prior to applying the criteria in this policy.
The policy lists specific scenarios that are considered not proven safe and effective and therefore are non‑covered or may be deemed not medically necessary: children previously well nourished or only mildly malnourished undergoing low nutrition‑risk oncology treatment; members with advanced cancer whose malignancy is unresponsive to chemotherapy or radiation; members for whom liver transplant is not feasible and TPN will not alter prognosis; IDPN administered in addition to regularly scheduled TPN; and IDPN for patients with acute kidney injury who do not have ESRD.
Coding and Billing References
| B4164 | Parenteral nutrition solutions and supplies. |
| 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 (do not use with home infusion codes S9365 through S9368 using daily volume scales). |
| 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. |
| No codes listed |
Prior Authorization, Documentation, and Provider Responsibilities
Reference HCPCS/home infusion codes and obtain prior authorization
Prior authorization is required for TPN/IDPN services and associated HCPCS/home infusion codes; providers should reference current CPT/HCPCS coding guidance prior to claim submission.
Follow plan administrative policies and member coverage documents for PA and coverage
Prior authorization requirements and final coverage decisions are governed by the Health Plan’s administrative policies and the member’s coverage documents; providers should also review applicable Medicare NCDs/LCDs for Medicare members.
- Coverage and benefits are subject to terms, conditions, exclusions and limitations of the member’s coverage documents
- State Medicaid provisions take precedence when they conflict with this policy; review state Medicaid manual as needed
Use IDPN only when oral/enteral nutrition are inadequate or not tolerated
Consider IDPN only after oral supplements and enteral nutrition are inadequate or not tolerated; societies recommend reserving IDPN for patients unable to meet needs orally and who are not candidates for enteral nutrition or standard TPN.
- IDPN indicated for dialysis patients who continue to lose weight or have very low serum albumin (< 3.4 g/dL) despite oral supplements
- IDPN delivers nutrients during dialysis and avoids additional venous access but provides approximately 70% of nutrient needs due to loss into dialysate
Step therapy: no specifics in this policy
No step therapy requirements or sequencing specifics are provided in this policy.
Provide documentation demonstrating nutritional insufficiency and nonfunctional GI tract
Document medical necessity by demonstrating nutritional insufficiency and evidence that the GI tract is non‑functioning or contraindicates enteral feeding.
- Adults: involuntary weight loss of 10% in 6 months or 5% in 1 month
- Children: weight-for-length/height or sex <10th percentile, inadequate weight gain, or significant decrease in growth percentile
- Neonates: extremely low birth weight <1000 g
- Evidence of structural or functional bowel disease (e.g., Crohn's disease, short bowel syndrome, enteric fistulae, obstructing stricture, motility disorder, neonatal GI anomalies, paralytic ileus, radiation enteritis, select liver failure and acute necrotizing pancreatitis scenarios)
Document per accepted standards and defer to state Medicaid when applicable
Rely on generally accepted standards of medical practice and document medical necessity according to the plan criteria; when state Medicaid coverage conflicts with this policy, state Medicaid provisions take precedence.
- This policy is a guide to medical necessity and does not guarantee payment; follow applicable legal/regulatory requirements
- Review state Medicaid manual for Medicaid members when conflicts exist
Denial risk: not-proven safe/effective indications (pediatric oncology, advanced cancer, certain IDPN/AKI scenarios)
Requests for TPN in children previously well nourished or mildly malnourished undergoing low-nutrition-risk oncology treatment, for patients with advanced cancer unresponsive to therapy, or when liver transplantation is not feasible and prognosis will not change, are considered not proven safe/effective and may be denied.
- IDPN given in addition to regularly scheduled TPN or provided for acute kidney injury without ESRD is also considered not proven safe/effective and may be denied
Denial risk: benefit or contract limitations may affect coverage
Coverage is subject to the member’s contract terms, exclusions, and limitations; inconsistencies with state Medicaid provisions defer to the state Medicaid manual and applicable law.
- Coverage decisions and benefit administration are subject to all terms and limitations of the member’s coverage documents
- Health Plan may change or withdraw this policy; providers should confirm current plan-level administrative policies
Definitions and Terminology
Clinical Background
Parenteral nutrition (PN) delivers macro‑ and micronutrients intravenously when the gastrointestinal tract cannot be used. Total parenteral nutrition (TPN) provides complete nutrient requirements for patients with a nonfunctioning or contraindicated GI tract and may be administered short‑term via peripheral access or long‑term via central venous access. Intradialytic parenteral nutrition (IDPN) is administered during hemodialysis sessions for selected patients (typically those with stage 5 chronic kidney disease) who cannot meet nutritional needs orally and for whom enteral nutrition or standard TPN is not appropriate. This policy’s coverage criteria require documented nutritional insufficiency and clinical evidence of structural or functional gastrointestinal dysfunction for TPN, and additionally require stage 5 CKD and hemodialysis for IDPN. Initial approvals are 3 months with continued approvals up to 6 months when clinical benefit is demonstrated without unacceptable complications.
Policy Revisions and Updates
Annual review with updates: criteria I.A.1.a expanded to include age-specific low body weight details (I.A.1.a–c); removed prior laboratory-based criteria (total protein and serum albumin); removed CNS disorders from list making enteral feeding inappropriate; updated I.A.2.h to include children with paralytic ileus and added I.A.2.m and I.A.2.n; references reviewed and updated.
Corrected 01/25 revision log entries to clarify removed and added criteria numbering (removed previous I.A.2.d; added I.A.2.m and I.A.2.n) and corrected a typographical reference to I.A.2.h; references reviewed and updated.
Annual review: background updated and minor wording/formatting changes (revision of header labels, spelling corrections in criteria I.A.2.c, minor rewording to HCPCS codes) with no impact to clinical criteria; references reviewed and updated.
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