CurrentHealth-New-EnglandPolicy UM1007POL

Intradialytic Parenteral Nutrition - Medical Policy

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This policy governs medical necessity and coverage criteria for intradialytic parenteral nutrition (IDPN) used to treat protein-calorie malnutrition in members receiving dialysis. It applies to Health New England Commercial, Medicare Advantage, and Medicaid (BeHealthy) lines of business.

Policy Summary

PayerHealth-New-England

PolicyIntradialytic Parenteral Nutrition

Policy CodePolicy UM1007POL

Change TypeAdministrative updateno material clinical or coverage changes

Effective DateJuly 1, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence showing that the member meets the medical necessity criteria for the requested treatment or supply.

SourceLink

POLICY UPDATE CHANGES

Prior authorization was removed from all listed procedure codes in the July 2024 and May 2025 implementation history.

References were updated in May 2025 and the April 2026 update states that there were no criteria changes.

3 monthsInitial IDPN trial period

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CurrentHealth-New-EnglandPolicy UM1007POL

Intradialytic Parenteral Nutrition - Medical Policy

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Policy Summary

PayerHealth-New-England

PolicyIntradialytic Parenteral Nutrition

Policy CodePolicy UM1007POL

Change TypeAdministrative updateno material clinical or coverage changes

Effective DateJuly 1, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence showing that the member meets the medical necessity criteria for the requested treatment or supply.

SourceLink

POLICY UPDATE CHANGES

Prior authorization was removed from all listed procedure codes in the July 2024 and May 2025 implementation history.

References were updated in May 2025 and the April 2026 update states that there were no criteria changes.

3 monthsInitial IDPN trial period

Continuation approval after initial trial

30 mg/dlPrealbumin required for continuation

1.25Dialysis adequacy threshold

22 mmol/lCorrected acidosis threshold

NoPrior authorization for listed HCPCS codes

Medical Necessity and Coverage Criteria

Initial therapy

IDPN may be considered medically necessary for an initial three-month trial when all of the following are met.

Initial 3-month trial

Dialysis status: The patient is currently receiving dialysis for end-stage renal disease.
Malnutrition evidence
- Weight loss is greater than 10% of ideal body weight over three months or less, or greater than 20% of usual body weight.>10% of ideal body weight over <=3 months OR >20% of usual body weight
- Laboratory malnutrition criteria: Albumin is less than 3.4 g/dl and prealbumin is less than 30 mg/dl.Albumin <3.4 g/dl AND prealbumin <30 mg/dl
Adequate dialysis and corrected acidosis: The patient has an adequate dialysis prescription and corrected acidosis.Single-pool Kt/V >=1.25 AND serum tCO2 >=22 mmol/l
Oral or enteral nutrition limitation
- Limited oral nutrition: The patient cannot tolerate full nutrition with an oral supplement but can consume at least 50% of necessary caloric and protein intake.>=50% of necessary caloric and protein intake
  Example in policy: diabetic gastroparesis.
- Enteral feeding failure or intolerance: The patient has failed or is unable to tolerate adequate nasogastric tube feedings or PEG tube feedings with enteral nutritional supplements.

Continuation after initial 3-month trial

IDPN may be considered medically necessary for continuation after the initial three-month trial when both criteria are met.

Continuation after initial trial

Nutritional response: There is a significant rise in the prealbumin level to greater than 30 mg/dl.Prealbumin >30 mg/dl
Ongoing eligibility and compliance: Continued documented compliance with the initial trial criteria is maintained.

Continuation after first year

IDPN may be considered medically necessary for continuation after the first year when all criteria are met.

Dialysis dependence: The member remains continuously dependent on dialysis.
Clinical response: The member has a positive clinical response to therapy.
Safety: The member has not experienced a drug-related adverse event or toxicity associated with IDPN treatment.

IDPN is not medically necessary when it is provided in addition to regularly scheduled infusions of total parenteral nutrition (TPN).

For members who cannot tolerate any oral feedings, TPN is the appropriate therapy. IDPN used as the sole therapy in this circumstance is considered investigational.

Discontinuation of IDPN may be reasonable when the member tolerates adequate oral or enteral nutrition.

Discontinuation of IDPN may be reasonable when protein and/or nutrition status does not improve after six months of IDPN therapy.

Discontinuation of IDPN may be reasonable when there is reasonable sustained improvement in protein and nutrition status, indicated by serum albumin greater than 4.0 g/dL and BMI greater than or equal to 18.5 kg/m².

Coding and Clinical Thresholds

Parenteral nutrition solutionsHCPCS

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

Parenteral nutrition solutions, additives, and supply kitsHCPCS

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
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
B4197	Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix
B4199	Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix
B4216	Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes), home mix, per day

1–10 of 11

1/2

Parenteral nutrition supply kits and compounded solutionsHCPCS

B4222	Parenteral nutrition supply kit; home mix, per day
B4224	Parenteral nutrition administration kit, per day
B5000	Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal-aminosyn-rf, nephramine, renamine-premix
B5100	Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, hepatamine-premix
B5200	Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength

Weight loss

Ideal body weight loss> 10% of ideal body weight

Assessment periodOver three months or less

Usual body weight loss alternative> 20% of usual body weight

Malnutrition laboratory values

Serum albumin< 3.4 g/dl

Serum prealbumin< 30 mg/dl

Required relationship

Provider Submission and Decision Guidance

Documentation Required

Clinical Evidence Required for Review

Submit clinical evidence supporting medical necessity with the request so Health New England can review whether the patient meets the IDPN criteria.

Step Therapy

Oral and Enteral Nutrition Sequence

Use a stepwise nutrition approach before IDPN. Begin with dietary counseling and diet modification, followed by oral nutritional supplements; when appropriate, use enteral nutrition before considering parenteral supplementation such as IDPN.

Address oral supplementation first.
If oral supplementation is inadequate or not tolerated, address appropriate enteral nutrition, including nasogastric or PEG tube feeding, before IDPN.

Policy Background

Intradialytic parenteral nutrition (IDPN) is the infusion of hyperalimentation, such as amino acids, glucose, and lipids, during hemodialysis or peritoneal dialysis to treat protein-calorie malnutrition. In dialysis patients, malnutrition may be associated with inadequate dialysis, chronic inflammation, protein loss, metabolic acidosis, or reduced oral intake. Nutritional status is assessed using multiple measures; serum albumin is useful but may also be affected by other disease states.

Key Definitions

Intradialytic parenteral nutrition (IDPN)

AdministrationIntravenous infusion during dialysis

Formula componentsAmino acids, glucose, and lipids

PurposeTreat protein-calorie malnutrition

Protein-calorie malnutrition

ConditionProtein-calorie malnutrition

AssociationA nutritional condition associated with dialysis

Assessment contextMay be assessed using multiple measures, including serum albumin

Policy Summary

PayerHealth-New-England

PolicyIntradialytic Parenteral Nutrition

Policy CodePolicy UM1007POL

Change TypeAdministrative updateno material clinical or coverage changes

Effective DateJuly 1, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence showing that the member meets the medical necessity criteria for the requested treatment or supply.

SourceLink

On This Page

Albumin and prealbumin thresholds must both be met

Dialysis adequacy

Dialysis adequacy measureSingle-pool Kt/V

Minimum thresholdAt least 1.25

Policy requirementAdequate dialysis prescription

Corrected acidosis

Laboratory measureSerum total carbon dioxide (tCO2)

Minimum thresholdGreater than or equal to 22 mmol/l

Required statusAcidosis corrected

Minimum oral intake

Caloric intakeAt least 50% of necessary caloric intake

Protein intakeAt least 50% of necessary protein intake

Clinical contextThe member cannot tolerate full nutrition with an oral supplement

Continuation response

Required responseSignificant rise in prealbumin

Prealbumin threshold> 30 mg/dl

Continuation timingAfter the initial three-month trial

Sustained nutritional improvement

Serum albumin> 4.0 g/dl

Body mass indexGreater than or equal to 18.5 kg/m2

Required relationshipBoth albumin and BMI thresholds indicate sustained improvement

Prior Authorization

Provider Submission Required

The treating physician or primary care provider must submit clinical evidence demonstrating that the patient meets the policy criteria. Without the required documentation and information, Health New England cannot properly review the prior authorization request.

Documentation Required

Document Medical Necessity and Treatment Response

Document the clinical factors supporting the initial IDPN request and the patient’s response to treatment, including dialysis status, malnutrition, dialysis adequacy, corrected acidosis, nutritional intake or enteral-feeding tolerance, and relevant laboratory and weight measures.

Current dialysis for end-stage renal disease.
Weight loss, albumin and prealbumin findings supporting malnutrition.
Adequate dialysis prescription with single-pool Kt/V of at least 1.25 and corrected acidosis with serum tCO2 at least 22 mmol/L.
Inability to tolerate full oral nutrition while consuming at least 50% of required caloric and protein intake, or failure/inability to tolerate adequate nasogastric or PEG tube feedings.
For continuation after the initial trial, document a significant rise in prealbumin to greater than 30 mg/dL and continued compliance with the initial criteria.

Denial Risk

Initial Trial Criteria Not Met

The initial three-month IDPN trial may be denied when the patient does not meet the required dialysis, malnutrition, dialysis adequacy, acidosis, or oral/enteral nutrition criteria.

Not currently receiving dialysis for end-stage renal disease.
Malnutrition criteria are not demonstrated: weight loss is not greater than 10% of ideal body weight over three months or less, or greater than 20% of usual body weight, and albumin is not less than 3.4 g/dL with prealbumin less than 30 mg/dL.
Dialysis is inadequate or acidosis is not corrected: single-pool Kt/V is below 1.25 or serum tCO2 is below 22 mmol/L.
The patient can tolerate full nutrition with oral supplementation, does not consume at least 50% of required caloric and protein intake when oral nutrition is not fully tolerated, or has not failed or been unable to tolerate adequate nasogastric or PEG tube feeding.

Denial Risk

Insufficient Response or Documentation

Continuation after the initial three-month trial may be denied when the required nutritional response or documentation is absent. If approved, continuation is limited to nine months after the initial trial and must be reevaluated for ongoing need.

Prealbumin has not risen significantly to greater than 30 mg/dL.
Continued compliance with the initial IDPN criteria is not documented.

Denial Risk

TPN Overlap or Inability to Tolerate Oral Feeding

IDPN is not medically necessary when provided in addition to regularly scheduled TPN. For patients who cannot tolerate any oral feedings, TPN is the appropriate therapy and IDPN as sole therapy is considered investigational.

Do not use IDPN as an overlap with regularly scheduled TPN.
Complete inability to tolerate oral feeding supports TPN rather than IDPN as sole therapy.

Denial Risk

Discontinuation Criteria Met

IDPN may be denied or discontinued when any one of the following conditions is met: the member tolerates adequate oral or enteral nutrition, protein or nutritional status fails to improve after six months, or sustained nutritional improvement makes continued IDPN unnecessary.

Adequate oral or enteral nutrition is tolerated.
Protein and/or nutritional status does not improve after six months on IDPN.
Sustained improvement is demonstrated by serum albumin greater than 4.0 g/dL and BMI at least 18.5 kg/m².

Denial Risk

Annual Continuation Criteria Not Met

After the first year, continued IDPN requires all continuation criteria to remain satisfied. Coverage may be denied or discontinued if any criterion is not met.

The member remains continuously dependent on dialysis.
There is a positive clinical response to IDPN.
The member has not experienced an IDPN-related drug adverse event or toxicity.

Clinical significanceAssociated with increased morbidity and mortality