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Total Parenteral Nutrition and Intradialytic Parenteral Nutrition
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Clinical coverage criteria for medical necessity of TPN and IDPN for members/enrollees of Centene-affiliated health plans, including indications, contraindications, approval durations, and coding implications. Affects providers requesting authorization or delivering parenteral nutrition.
No material clinical or coverage changes in this revision.
Coverage Criteria for TPN and IDPN
Total Parenteral Nutrition (TPN) — Initial coverage
Covered when ALL of the following are met
TPN Criteria Group A
- Nutritional insufficiency: One of: adults — involuntary weight loss of 10% of usual body weight within six months or 5% within one month; children — weight for length/height or sex < 10th percentile OR inadequate weight gain OR significant decrease in usual growth percentile; neonates — extremely low birth weight < 1000 g
- GI disease or non-functioning tract: One or more of: Crohn's disease; short bowel syndrome; single or multiple enteric fistulae; obstructing stricture; motility disorder; newborn GI anomalies preventing or contraindicating oral feedings (e.g., tracheoesophageal fistula, gastroschisis, omphalocele, massive intestinal atresia); infants/young children failing to thrive due to cardiac/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 unable to tolerate standard amino acid/protein sources (TPN for liver-specific amino acid mixture); acute necrotizing pancreatitis in adults with inadequate intake >1 week where enteral feeding worsens symptoms; necrotizing enterocolitis; small bowel ischemia
Intradialytic Parenteral Nutrition (IDPN) — Initial coverage
Covered when ALL of the following are met
IDPN Criteria Group B
- Meets TPN criteria: Member meets the TPN criteria described in the policy (nutritional insufficiency and qualifying GI disease or non-functioning GI tract)
- Renal disease and treatment status: Member has stage 5 chronic kidney disease AND is undergoing hemodialysis
- Service role: IDPN is offered as an alternative to regularly scheduled TPN
- Approval duration: Initial approval duration: 3 months; Continued approval duration: 6 months if no unacceptable complications and documentation supports positive response to therapy.
Intradialytic parenteral nutrition (IDPN) is addressed separately from routine total parenteral nutrition (TPN). This policy specifies that IDPN is only covered when all TPN criteria are met and the member has stage 5 chronic kidney disease and is currently undergoing hemodialysis, and when IDPN is being offered as an alternative to regularly scheduled TPN. The policy also states that IDPN provided in addition to regularly scheduled infusions of TPN or for patients with acute kidney injury who do not have ESRD is not proven safe and effective and may be denied.
The policy identifies specific pediatric oncology situations where TPN is not considered proven and may be denied: children who were previously well nourished or only mildly malnourished and are receiving oncologic treatment associated with low nutrition risk. Providers should document nutritional risk status carefully when requesting coverage. The references and guideline sources cited in the policy (A.S.P.E.N., UpToDate, pediatric nutrition guidance) support detailed pediatric nutrition decision-making and should be consulted for clinical nuance when assessing oncology patients.
When state Medicaid coverage provisions differ from this clinical policy, the policy requires that state Medicaid coverage provisions take precedence. Coverage determinations must comply with applicable law and the terms, conditions, exclusions and limitations of each Health Plan's coverage documents.
Additional context for IDPN in the policy clarifies that IDPN is intended as an alternative delivery method for patients who meet TPN criteria and who are on hemodialysis for ESRD. The policy emphasizes that IDPN should not be used in addition to regularly scheduled TPN, and that when used appropriately it may avoid placement of a separate venous catheter by delivering parenteral nutrition through dialysis access. Prior authorization and documentation must show both adherence to TPN criteria and the rationale for choosing intradialytic delivery.
The policy further outlines nuanced TPN considerations for special populations: it may be considered not proven and potentially non-covered in advanced cancer patients whose malignancy is unresponsive to therapy and in cases where liver transplantation is not feasible and TPN will not change prognosis. For pediatric and other complex cases, the policy references specialty guidelines and literature to guide clinician documentation and justification.
Provider Requirements and Billing Implications
Obtain prior authorization for referenced HCPCS/home infusion and PN supply codes
Prior authorization is required for the HCPCS/HCPCS-like home infusion and parenteral nutrition supply codes listed in the policy; providers should verify and reference current coding guidance prior to claims submission.
S9368 included — follow policy criteria and PA processes
HCPCS code S9368 (home infusion therapy, TPN; more than three liters per day) is included in the policy and services billed under this code may require adherence to the policy criteria and the Health Plan's prior authorization processes.
- S9368 description: Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, per diem
Use IDPN as a trial for selected dialysis patients per society guidance
Society guidance advises reserving IDPN as a trial for dialysis patients who cannot meet nutritional needs orally and who are not candidates for enteral nutrition or TPN due to intolerance or venous access problems.
- IDPN should be reserved for patients incapable of meeting needs orally and not candidates for enteral nutrition or TPN
- Use IDPN selectively as a trial in appropriate dialysis patients
Confirm step therapy and Medicare consistency with plan procedures
Consult the clinical policy and Health Plan administrative procedures for any step therapy requirements; review applicable NCDs/LCDs for Medicare members as indicated by the plan.
- Policy emphasizes review of plan administrative procedures and Medicare NCDs/LCDs where applicable
Document nutritional insufficiency and GI dysfunction for TPN authorization
For TPN prior authorization, document nutritional insufficiency using the policy thresholds (e.g., adults: involuntary weight loss 10% in 6 months or 5% in 1 month; children: <10th percentile or inadequate gain; neonates: birth weight <1000 g) and evidence of structural or functional GI disease or non-functioning GI tract as listed in the criteria.
- Adult weight-loss thresholds: 10% in 6 months or 5% in 1 month
- Pediatric criteria: weight-for-length/height or sex <10th percentile or inadequate weight gain
- Neonates: extremely low birth weight <1000 g
- Provide evidence of listed GI structural/functional conditions (e.g., short bowel syndrome, fistulae, obstruction)
Document CKD stage, hemodialysis status, and IDPN as alternative to TPN
For IDPN prior authorization, include documentation that the member meets TPN criteria and that they have stage 5 chronic kidney disease, are undergoing hemodialysis, and that IDPN is being offered as an alternative to regularly scheduled TPN.
- Confirm TPN criteria are met
- Document CKD stage 5 and current hemodialysis
- State that IDPN is an alternative to regularly scheduled TPN
Keep documentation and administrative compliance consistent with policy and law
Maintain medical necessity documentation and administrative records consistent with this clinical policy, applicable laws/regulations, and Health Plan administrative procedures to support coverage decisions and audits.
- Follow policy medical necessity guidance
- Retain documentation consistent with coverage terms and applicable legal/regulatory requirements
Avoid IDPN when given alongside scheduled TPN or for AKI without ESRD (denial risk)
IDPN provided in addition to regularly scheduled TPN or IDPN provided for patients with acute kidney injury who do not have ESRD are identified as not proven safe and effective and may be denied.
- Do not bill or request authorization for IDPN in addition to regularly scheduled TPN
- Do not bill/request IDPN for acute kidney injury without ESRD
TPN in specified pediatric oncology and advanced cancer scenarios may be denied
TPN for certain populations — children previously well nourished or mildly malnourished undergoing low-nutrition-risk oncology treatment, members with advanced cancer unresponsive to therapy, or patients where liver transplantation is not feasible and prognosis is unchanged — is considered not proven safe and effective and may be denied.
- Do not expect coverage for TPN in low nutrition‑risk pediatric oncology patients without other indications
- TPN may be denied for advanced, treatment‑unresponsive cancer or when liver transplant is not feasible and prognosis unchanged
Coverage subject to plan terms, exclusions, and applicable laws/regulations
Coverage decisions, benefit administration, and the applicability of this policy are subject to the Health Plan's terms, conditions, exclusions, limitations, and applicable state and federal requirements; when conflicts exist, law and regulation govern.
- Policy is a guide to medical necessity and does not guarantee payment
- State Medicaid provisions take precedence where applicable
Coding and Billing Codes
| B4164 | 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 |
| 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 (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem |
Definitions
Background and Rationale
Parenteral nutrition delivers macronutrients and micronutrients intravenously when the gastrointestinal tract cannot meet nutritional needs. TPN supplies complete nutrition when enteral feeding is inadequate or impossible, and may be provided short-term via central venous catheter or long-term via tunneled catheter or port. IDPN is a form of parenteral nutrition administered during hemodialysis for patients with ESRD, intended to provide partial nutrient replacement and, in some cases, avoid separate central venous access. Evidence for IDPN benefits is limited; clinical guidance recommends reserving IDPN for selected dialysis patients who cannot meet needs orally and are not candidates for enteral nutrition or standard TPN.
References and Revision History
Selected references informing this policy include A.S.P.E.N. clinical guidelines and multiple systematic and guideline sources on parenteral nutrition and renal nutrition. Key citations listed in the policy include A.S.P.E.N. Clinical Guidelines (JPEN), KDOQI nutrition guidance for CKD, ESPEN renal nutrition guidance, multiple UpToDate topics on parenteral nutrition and pediatric practice, and Hayes Health Technology Assessment on IDPN. The policy reference list is extensive and intended to support the coverage criteria and clinical recommendations; consult the full reference list in the policy for specific citations and access details.
This clinical policy is subject to routine maintenance and review. The document history shows multiple annual reviews and minor wording or coding updates over time. The policy specifies an annual review cadence and documents prior revision notes (edits to criteria wording, code reviews, and reference updates); providers and administrators should consult the policy header for the date of last revision and the Health Plan for the effective date.
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