CurrentGeisinger Health PlanPolicy MP129

Total Parenteral Nutrition

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This policy governs coverage criteria, indications, limitations, and coding guidance for Total Parenteral Nutrition (TPN) for Geisinger Health Plan members across applicable lines of business.

Policy Summary

PayerGeisinger Health Plan

PolicyTotal Parenteral Nutrition

Policy CodePolicy MP129

Change TypeNo material change

Effective DateApr 1, 2024

Next Review Date

Key ActionObtain prior authorization when a board-certified gastroenterologist or nutrition support physician documents an anticipated treatment period ≥10 days and at least one medical necessity criterion is met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 daysminimum anticipated treatment period referenced

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CurrentGeisinger Health PlanPolicy MP129

Total Parenteral Nutrition

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This policy governs coverage criteria, indications, limitations, and coding guidance for Total Parenteral Nutrition (TPN) for Geisinger Health Plan members across applicable lines of business.

Policy Summary

PayerGeisinger Health Plan

PolicyTotal Parenteral Nutrition

Policy CodePolicy MP129

Change TypeNo material change

Effective DateApr 1, 2024

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 daysminimum anticipated treatment period referenced

oral caloric intake threshold

750 cal/dayminimum daily calories

10-14 dayscancer patient duration cited

S9364example HCPCS listed

appliesPA Medicaid applicability

Coverage Criteria for Total Parenteral Nutrition (TPN)

Criteria for determination of medical necessity

Total parenteral nutrition may be considered medically necessary when ALL of the following are met:

Primary requirements: Evaluation by a physician who is board certified in gastroenterology or nutritional support; a treatment period of 10 days or more is anticipatedtreatment period >= 10 days

physician certification required; anticipated treatment duration documented

At least one of the following clinical indications

Absence of a functional and/or usable gastrointestinal tract capable of absorption
Documented inability to receive more than 30% of the caloric intake orallyoral intake <= 30% of needs
Documented inability to benefit from tube feedings as a result of malabsorption due to severe pathology of the gastrointestinal tract
A minimum of 750 calories per day will be administered by TPN>= 750 calories/day by TPN
A treatment regimen of at least 5 days per week is planned

Line-of-Business Applicability — Coverage and applicability notes

Coverage and applicability notes present in this portion of the policy

Line of Business Applicability: Eligibility and contract-specific benefits, limitations, and exclusions apply; line-of-business specific benefit documents supersede this policy. For Medicare, applicable LCDs and NCDs supersede this policy. For the Pennsylvania Medicaid business segment, this policy applies as written. Requests that do not meet PARP criteria may be evaluated on a case-by-case basis.

Consult member contract and Geisinger provider resources for prior authorization/pre-certification requirements and lists; see MP015 for investigational/excluded services.

Requests for total parenteral nutrition (TPN) in patients with cancer should be carefully evaluated. The policy states that the indiscriminate use of TPN in well-nourished or mildly malnourished cancer patients who are undergoing surgery, chemotherapy, or radiotherapy and in whom adequate oral intake is anticipated is considered investigational and NOT COVERED.

Coverage for experimental or investigational treatments, services, and procedures, as well as unproven services performed outside of an approved clinical trial, are specifically excluded under the member's certificate with Geisinger Health Plan. The policy refers providers to MP015 for the process used to determine whether a service is experimental or investigational.

TPN is considered not medically necessary/investigational for well-nourished or mildly malnourished cancer patients when adequate oral intake is anticipated. Such requests may be denied on that basis.

This policy does not expand coverage to items or services that are specifically excluded by a member's certificate. Experimental, investigational, or unproven services (including those outside an approved clinical trial) are excluded and may result in denial of requested TPN services per the member contract and MP015.

Coding and Billing Guidance

Informational HCPCS CodesHCPCS

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 (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem (do not use with home infusion codes S9365-S9368 using daily volume scales)

Covered HCPCS per diem (informational list)HCPCS

S9364

TPN volume-based per diem HCPCS codesHCPCS

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 (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits are coded separately), per diem
S9366	Home infusion therapy, total parenteral nutrition (TPN); more than one liter per day but no more than two liters per day, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits are coded separately), per diem
S9367	Home infusion therapy, total parenteral nutrition (TPN); more than two liters per day but no more than three liters per day, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits are coded separately), 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 (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits are coded separately), per diem

Parenteral nutrition solution, supplies, and equipment HCPCSHCPCS

B4164	Parenteral nutrition solution; carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix
B4168	Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix
B4172	Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix
B4176	Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix
B4178	Parenteral nutrition solution; amino acid, greater than 8.5%, (500 ml = 1 unit) - home mix
B4180	Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix
B4185	Parenteral nutrition solution, not otherwise specified, 10 grams lipids
B4187	Omegaven, 10 grams lipids
B4189	Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix
B4193	Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix

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inv-11: Minimum daily TPN calories

Minimum daily calories required via TPN750 calories per day

Context in criteriaListed as one of the ANY clinical indicators that make TPN medically necessary

Documentation implicationMedical record must support that at least 750 kcal/day will be administered by TPN

inv-12: Anticipated treatment duration

General anticipated treatment duration10 days or more (treatment period of ≥10 days is anticipated)

Cancer patients with inadequate intake

Provider Actions, Authorization, and Documentation

Prior Authorization

Request prior authorization when policy criteria and duration are met

Prior authorization is expected when the medical necessity criteria are met: a board-certified gastroenterologist or nutrition support physician has evaluated the member, a treatment period of 10 days or more is anticipated, and at least one of the listed clinical indicators (e.g., inability to receive >30% of caloric intake orally, absence of a functional GI tract, minimum of 750 calories/day via TPN, etc.) is documented.

Prior authorization applies where criteria in the policy are satisfied (evaluation by board-certified gastroenterologist/nutrition support, anticipated treatment ≥10 days, and at least one medical necessity indicator).
Cancer patients with anticipated inadequate intake for 10–14 days are addressed separately in the policy criteria.

Prior Authorization

Prior authorization may be required — consult Geisinger resources

Prior authorization and/or pre‑certification may be required for TPN services and associated supplies; providers must consult Geisinger's prior authorization resources and the member's contract-specific benefit documents for requirements.

Definitions and Background

inv-24: Total parenteral nutrition (TPN) definition

DefinitionTotal parenteral nutrition (TPN) is intravenous administration of macronutrients and micronutrients through a centrally placed catheter (fats, carbohydrates, proteins, vitamins and other substances)

Indication summaryIntended for patients unable to use the gastrointestinal tract or with impaired intestinal absorption where enteral/oral feeding is not feasible or adequate

Route and accessAdministered via a central venous catheter

inv-25: TPN as referenced in clinical guidelines and position statements

Referenced guideline sourcesAGA medical position statement; ASPEN guidelines; ESPEN guideline: home parenteral nutrition

Clinical context references

Policy Revision History

2026-06policy_review

Document lists review entries through 6/26 indicating ongoing annual reviews and oversight committee approvals; policy reviewed no less than annually.

2025-06cms_um_oversight_approval

CMS UM Oversight Committee approval recorded for 6/25.

2024-04-01effective_date_or_reference_update

Policy entry notes addition of link and reference to CMS NCD (added 4/24) and cites CMS NCD accessed April 1, 2024.

Policy Summary

PayerGeisinger Health Plan

PolicyTotal Parenteral Nutrition

Policy CodePolicy MP129

Change TypeNo material change

Effective DateApr 1, 2024

Next Review Date

SourceLink

On This Page

May be considered medically necessary when inadequate oral/enteral intake is expected for more than 10–14 days

Frequency requirementA treatment regimen of at least 5 days per week is listed as an indicator

inv-13: Oral intake threshold

Oral intake threshold for medical necessityDocumented inability to receive more than 30% of caloric intake orally

Role in criteria logicListed as one of the ANY clinical indicators required for coverage when combined with physician evaluation and anticipated ≥10-day treatment

Documentation implicationClinical documentation must explicitly state the percent of oral caloric intake (≤30%)

inv-14: TPN volume per day

TPN volume categories referenced by HCPCSone liter; greater than 1–2 L; greater than 2–3 L; greater than 3 L per day

Associated per-diem codesS9365 (1 L), S9366 (>1–2 L), S9367 (>2–3 L), S9368 (>3 L)

Coding noteVolume categories align with home infusion per-diem coding descriptions in the policy

Pre-certification lists are found in the member's contract-specific benefit document.
Prior authorization requirements are available at Geisinger’s provider clinical policies webpage.

Step Therapy

Step therapy — none specified

No step therapy requirements are specified in the policy text; there is no documented mandated sequence of therapies before TPN in the policy.

Step Therapy

No alternate step‑therapy pathway required

The policy does not list additional step therapy protocols for TPN; clinical indications and duration thresholds (e.g., anticipated ≥10 days) govern medical necessity rather than a step sequence.

Documentation Required

Required clinical evaluation and documentation by board‑certified physician

Evaluation by a physician board certified in gastroenterology or nutritional support is required, and documentation must support an anticipated treatment period of 10 days or more and at least one of the policy's medical necessity indicators.

Document evaluation by a board‑certified gastroenterologist or nutrition support physician.
Document anticipated treatment duration (≥10 days) and one qualifying clinical indicator (e.g., inability to receive >30% oral calories, absence of functional GI tract, planned ≥750 calories/day by TPN).

Prior Authorization

Confirm prior authorization & pre‑certification per contract

Prior authorization and pre‑certification requirements may apply per the member's contract; providers should use the member's contract benefit document and Geisinger’s prior authorization web resources to verify requirements for the requested services and supplies.

Check member contract-specific benefit documents for pre‑certification lists.
Verify prior authorization processes and submit requests per Geisinger provider guidance.

Denial Risk

Denial risk: investigational use in well‑nourished/mildly malnourished cancer patients

Requests for indiscriminate use of TPN in well‑nourished or mildly malnourished cancer patients when adequate oral intake is anticipated are considered investigational and not covered; such requests may be denied.

Do not submit authorization requests for routine TPN in well‑nourished or mildly malnourished cancer patients if adequate oral intake is anticipated—these are investigational and not covered.

Denial Risk

Denial risk: experimental/unproven services excluded

Coverage for experimental, investigational, or unproven treatments and services (including those outside an approved clinical trial) is specifically excluded under the member's certificate and may result in denial of the TPN service.

If the requested TPN service is considered experimental or unproven under the member certificate, coverage is excluded and the request may be denied.
Refer to MP015 for the process by which services are determined investigational or unproven.

Policy cites AGA, ASPEN, ESPEN and other clinical literature supporting appropriate use of TPN

Policy review notePolicy references these guidelines in the References section to inform coverage and practice

Total parenteral nutrition (TPN) is the intravenous administration of macro- and micronutrients via a centrally placed catheter for patients who are unable to use the gastrointestinal tract for adequate nutrition. TPN provides fats, carbohydrates, proteins, vitamins and other essential substances when enteral or oral feeding is not feasible or adequate, and is intended to treat malnutrition due to impaired intestinal absorption or other conditions preventing sufficient oral/enteral intake.

2024-04annual_review

Policy entry records an annual review in 4/24 as part of ongoing yearly reviews.

2006-04revision

Revision in 4/06 updated limitations, exclusions and references.

2005-04revision

Revision in 4/05 updated criteria.

2004-02devised

Policy originally devised in February 2004.

2026-06-01cms_um_oversight_approvalLatest

Most recent CMS UM Oversight Committee approval recorded in 6/26.