CurrentCentenePolicy CP.MP.163

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

Defines medical necessity criteria, approved durations, and not-proven-safe indications for Total Parenteral Nutrition (TPN) and Intradialytic Parenteral Nutrition (IDPN) for members/enrollees of Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyTotal Parenteral Nutrition and Intradialytic Parenteral Nutrition

Policy CodePolicy CP.MP.163

Change TypeRevisions and clarifications (criteria updates, condition list changes, coding reviewed)

Effective Date

Next Review Date

Key ActionProviders must document nutritional insufficiency per specified thresholds (adult, child, neonate) and evidence of structural/functional bowel disease or non-functioning GI tract as described in policy when requesting TPN.

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.

Removed CNS disorders from list of conditions that make oral or tube feedings inappropriate and added paralytic ileus in children and two new conditions (I.A.2.m and I.A.2.n).

In I.B.2 changed 'end-stage renal disease' to 'stage 5 chronic kidney disease.'

HCPCS codes and S-code descriptions were reviewed and minor rewording made with no clinical significance.

2Therapies covered (TPN, IDPN)

13Qualifying GI conditions (examples)

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3Not-proven-safe exclusion categories

Coverage Summary — TPN & IDPN

This policy (Ref: CP.MP.163) addresses coverage for Total Parenteral Nutrition (TPN) and Intradialytic Parenteral Nutrition (IDPN) and is CURRENT. The coverage stance is mixed: both TPN and IDPN are covered when medical-necessity criteria are met, with explicit eligibility, approval durations, and exclusion categories defined in the policy. IDPN is described as an alternative to regularly scheduled TPN for eligible hemodialysis patients with stage 5 chronic kidney disease.

Nutritional insufficiency thresholds

Adult weight loss10% within six months OR 5% within one month

Child growth percentileWeight for length/height or sex < 10th percentile OR inadequate weight gain OR significant decrease in usual growth percentile

Neonate birth weightExtremely low birth weight < 1000 g

Serum albumin noteSerum albumin < 3.4 g/dL mentioned in background as a consideration for IDPN

A Hayes health-technology assessment found low-quality evidence that IDPN is relatively safe and is associated with improvements in laboratory measures and weight versus conventional therapies, but heterogeneity among studies, differences in IDPN formulations, and questions about patient selection and long-term benefits remain.

Medically Necessary — Total Parenteral Nutrition (TPN)

Medically Necessary - Total Parenteral Nutrition (TPN)

Covered when ALL of the following are met:

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title": "Medically Necessary - Total Parenteral Nutrition (TPN)

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title": "Medically Necessary - Total Parenteral Nutrition (TPN)"

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Medically Necessary — Intradialytic Parenteral Nutrition (IDPN)

Not Proven Safe and Effective — Exclusions

Coding — HCPCS

HCPCS - Parenteral nutrition solutions and supplies / home infusion TPN per diem codesHCPCSCovered

B4164	Parenteral nutrition solutions and supplies (listed range referenced B4164- B5200 in document)
B5200	Parenteral nutrition solutions and supplies (range end referenced)
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, per diem
S9366	Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day, per diem
S9367	Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, per diem
S9368	Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, per diem

Provider Actions & Authorization Requirements

Documentation Required

Document nutritional insufficiency and qualifying GI condition

When requesting TPN, document nutritional insufficiency using the policy's age-specific thresholds and provide evidence of a structural or functional bowel condition or a non‑functioning GI tract that makes oral or tube feeding inappropriate. Reference the TPN criteria section for required supporting evidence.

Adult weight loss threshold (10% within 6 months OR 5% within 1 month)
Child growth percentile threshold (weight for length/height or sex < 10th percentile OR inadequate weight gain OR significant decrease in usual growth percentile)
Neonate extremely low birth weight (< 1000 g)

Prior Authorization

Authorization durations and renewal documentation

Initial authorization for TPN or IDPN is for three months. Continued approval is for six months and requires documentation that the member has no unacceptable complications and that there is a positive response to therapy to support renewal. See the Authorization Duration section for details.

Background & Definitions

Parenteral nutrition (PN) is the intravenous delivery of nutrients that bypasses the gastrointestinal tract and is used when enteral nutrition cannot meet patient needs. The policy describes two forms: Total Parenteral Nutrition (TPN), which supplies all necessary macronutrients and micronutrients intravenously, and Intradialytic Parenteral Nutrition (IDPN), which is delivered during dialysis for patients with stage 5 chronic kidney disease undergoing hemodialysis.

TPN indications include documented nutritional insufficiency plus evidence of structural or functional bowel disease or a non-functioning gastrointestinal tract (examples include Crohn's disease, short bowel syndrome, enteric fistulae, obstructing stricture, motility disorders, newborn GI anomalies, radiation enteritis, liver failure in transplant candidates, acute necrotizing pancreatitis, necrotizing enterocolitis, and small bowel ischemia). Advantages of TPN include ease of administration and ability to correct fluid/electrolyte imbalances; disadvantages and complications include catheter-associated infections, thrombosis, hyperglycemia, hepatobiliary and bone disease with long-term use, fluid overload, electrolyte abnormalities, and enterocyte atrophy.

IDPN is indicated for selected undernourished hemodialysis patients (and as an alternative to scheduled TPN) and is advantageous because it uses dialysis access and avoids additional venous catheter placement; however, IDPN provides only about 70% of nutrients because of loss into the dialysate. Several societies (ASPEN, ESPEN, KDOQI) provide guidance supporting IDPN in specific situations.

TPN: Total Parenteral Nutrition — intravenous administration of all necessary macronutrients and micronutrients bypassing the gastrointestinal tract.

IDPN: Intradialytic Parenteral Nutrition — parenteral nutrition delivered during dialysis for patients with stage 5 chronic kidney disease undergoing hemodialysis as an alternative to regularly scheduled TPN.

Revision History

2026-01-26revisedLatest

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; removed CNS disorders from list of conditions that make oral or tube feedings inappropriate; updated I.A.2.h to include paralytic ileus in children and added I.A.2.m (necrotizing enterocolitis) and I.A.2.n (small bowel ischemia).

2025-01revised

Annual review: Updated criteria I.A.1.a regarding low body weight to include age-group details and expanded to I.A.1.a through c; removed prior lab-based thresholds; removed CNS disorders from list and added paralytic ileus in children and two new conditions (I.A.2.m and I.A.2.n).

Policy Summary

PayerCentene

PolicyTotal Parenteral Nutrition and Intradialytic Parenteral Nutrition

Policy CodePolicy CP.MP.163

Change TypeRevisions and clarifications (criteria updates, condition list changes, coding reviewed)

Effective Date

Next Review Date

SourceLink

On This Page

Initial approval = 3 months
Continued approval = 6 months

Denial Risk

Exclusion-based denials

Claims may be denied when TPN or IDPN is used for indications listed as not proven safe and effective. Common exclusion-based reasons include use in low‑nutrition‑risk pediatric oncology, in advanced cancer unresponsive to therapy, offering IDPN in addition to regularly scheduled TPN, or using IDPN for acute kidney injury without ESRD.

Low‑risk pediatric oncology (previously well nourished or mildly malnourished children)
Advanced cancer unresponsive to chemotherapy or radiation
IDPN in addition to regularly scheduled TPN
IDPN for acute kidney injury without ESRD

Documentation Required

IDPN specific eligibility

For IDPN requests, document that the member meets all 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. Include documentation showing the member meets TPN nutritional insufficiency and GI criteria referenced in the policy.

Meets TPN criteria in section A
Stage 5 chronic kidney disease
Undergoing hemodialysis
IDPN offered as an alternative to regularly scheduled TPN

Evidence summary

Hayes evaluationLow-quality evidence that IDPN is relatively safe and associated with improvements in lab measures and weight versus conventional therapies; heterogeneity and patient selection questions remain.

2024-02revised

Annual review with minor rewording in criteria and clarifying language added to Criteria I.A.1.a; background updated with no impact to criteria; minor HCPCS rewording with no clinical significance.

2023-04revised

Annual review: minor rewording in criteria, clarifying language in I.A.1.a, background updates, ICD-10 codes removed, references updated.

2016-04revised

Policy developed and approved; added indications for radiation enteritis, liver failure (children and adults), and acute necrotizing pancreatitis in adults; changed terminology in I.B.2 from 'end-stage renal disease' to 'stage 5 chronic kidney disease' in later revisions.