Total Parenteral Nutrition (TPN)
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Defines coding, coverage considerations, prior authorization expectations, and references for home and inpatient total parenteral nutrition services for Geisinger Health Plan members; applies across lines of business with specific notes for Medicare and PA Medicaid segments.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity
Overall coverage determination
Coverage and medical necessity are determined by member-specific benefit documents and applicable CMS LCD/NCD guidance; PA Medicaid segment follows this policy as written.
Use CMS and local MAC guidance for Medicare members
Follow PA Medicaid applicability as stated in the line-of-business guidance
Verify member-specific benefit documents prior to authorization or payment decisions
Coverage for experimental, investigational, or unproven treatments, services, and procedures is expressly excluded under the member's certificate with Geisinger Health Plan. This policy does not expand coverage to items or services that are specifically excluded by the member's contract or certificate.
Services or therapies that are unproven and provided outside of an approved clinical trial are specifically excluded under the member's certificate with Geisinger Health Plan and are not covered under this policy.
Billing Codes and HCPCS/CPT/NDC Listings
| 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) |
| 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 |
| 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 |
Prior Authorization, Documentation, and Provider Steps
Prior authorization may be required
Prior authorization and/or pre-certification may be required for TPN services and supplies; providers should consult the member’s contract-specific benefit document and the Geisinger prior authorization resources online for current requirements.
- See Geisinger prior authorization listings at https://www.geisinger.org/health-plan/providers/ghp-clinical-policies
- Pre-certification lists may be found in the member’s contract-specific benefit document
Case‑by‑case evaluation (no step therapy specified)
Any requests that do not meet the PARP criteria may be evaluated on a case‑by‑case basis; the policy segment does not describe a step‑therapy algorithm for TPN.
- Case‑by‑case review available when PARP criteria are not met
- No step‑therapy algorithm provided in this policy segment
Follow member benefit and prior authorization documents
Follow the member’s contract-specific benefit document for eligibility, limitations, and pre-certification lists; prior authorization requirements are posted on the Geisinger Health Plan provider clinical policies page.
- Coverage statements in the line‑of‑business benefit document supersede this policy
- Prior authorization requirements: https://www.geisinger.org/health-plan/providers/ghp-clinical-policies
Experimental/Investigational exclusions may trigger denial
Coverage for experimental, investigational, or unproven treatments, services, and procedures is specifically excluded under the member’s certificate and may result in denial if TPN or related items are considered experimental or unproven.
- Unproven services outside an approved clinical trial are excluded
- See MP015 for additional information on Experimental, Investigational or Unproven Services
Clinical Background
Total parenteral nutrition (TPN) provides intravenous nutritional support when enteral feeding is not possible or adequate. The policy references professional society guidelines and CMS national and local coverage determinations as background for appropriate use and oversight, and applies the plan's benefit terms and any applicable Medicare guidance when determining coverage and medical necessity for TPN services.
Definitions and Code Tier Descriptions
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