CurrentOklahoma Health Care AuthorityPolicy N/A

Home Parenteral Nutrition

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This guideline governs prior authorization and medical-necessity requirements for adult and pediatric home parenteral nutrition, including PN solutions, additives, supplies, and infusion pumps.

Policy Summary

PayerOklahoma Health Care Authority

PolicyHome Parenteral Nutrition

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateOctober 1, 2025

Next Review DateOctober 2028

Key ActionSubmit prior authorization for PN solutions, specialty formulas, additives, supply kits, compound solutions, and infusion pumps.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13 monthsCapped-rental period

1 per 5 yearsPump purchase limit

1/dayPN supply kits

30 cal/kg/daySufficient caloric intake

12 months

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CurrentOklahoma Health Care AuthorityPolicy N/A

Home Parenteral Nutrition

Customize your policy alerts

Sign up for all Oklahoma Health Care Authority policy alerts

Know when Oklahoma Health Care Authority releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This guideline governs prior authorization and medical-necessity requirements for adult and pediatric home parenteral nutrition, including PN solutions, additives, supplies, and infusion pumps.

Policy Summary

PayerOklahoma Health Care Authority

PolicyHome Parenteral Nutrition

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateOctober 1, 2025

Next Review DateOctober 2028

Key ActionSubmit prior authorization for PN solutions, specialty formulas, additives, supply kits, compound solutions, and infusion pumps.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13 monthsCapped-rental period

1 per 5 yearsPump purchase limit

1/dayPN supply kits

30 cal/kg/daySufficient caloric intake

12 months

Continuation authorization

3 monthsRequired GI dysfunction duration

Home Parenteral Nutrition Coverage Criteria

General medical necessity

PN is medically necessary when all of the following are met:

The alimentary tract does not allow absorption of sufficient nutrients to maintain weight and strength appropriate for the patient's general condition.
The patient cannot be sustained through oral or enteral feeding.
Nutrients are provided through the intravenous route.
The nonfunctioning or inaccessible GI tract is long term, persistent, and indefinite in duration.At least 3 months

Initial home PN authorization

Home PN requests for adults or children must include all of the following:

Hospital records include objective medical evidence supporting the clinical diagnosis.
PN is initiated in the hospital setting.
Inpatient records document the long-term condition or impairment of the alimentary tract.
Inpatient records document placement of a functioning central line.
Inpatient records document trials with oral or enteral nutrition.
Inpatient records include laboratory results and a history of the patient's height, weight, and BMI.
Discharge teaching documents caregiver education and training for in-home PN administration.

Calories above standard level

Caloric intake above the standard level requires additional justification:

Caloric-intake criterion

Total caloric intake from parenteral, enteral, and oral sources exceeds the level considered sufficient to achieve or maintain appropriate body weight.>30 cal/kg/day
The prescribing provider documents the medical necessity for the higher caloric intake.

Continuation therapy

Continuation authorization requires all of the following:

Documentation supports ongoing medical necessity for the requested nutritional products.
The CMN and PN prescription are submitted.
Office-visit records include weight and BMI history.
Laboratory results are submitted.
Home-health notes with assessments are submitted.
Patient and caregiver education is documented.

Home PN is not medically appropriate when the GI tract is functioning and the nutritional need results from dysphagia, a temporary gastric-emptying defect, a psychological or metabolic disorder impairing intake, a physical disorder impairing food intake, a medication side effect, or renal failure or dialysis.

Peripheral parenteral nutrition (PPN) may be used for a few days while the patient is an inpatient, but it should not be provided in the home setting.

Unbundled PN supplies, including gloves and tubing, are not covered. These items are included in the all-inclusive PN supply kits and should not be billed separately.

Covered Codes and Utilization Limits

CPT Codes Covered Requiring Prior Authorization (PA)HCPCSCovered

B4164-B4185	Parenteral Nutrition (PN) solutions
B4189-B4199	Specialty formulas requiring additional documentation
B4216	PN additives
B4220-B4224	Supply kits, limit 1/day with PN authorization
B5000-B5200	PN compound solutions
B9004-B9006	PN Enteral Nutrition Infusion Pumps

Duration of GI dysfunction

Minimum durationAt least 3 months

Required conditionThe GI tract is non-functioning or non-accessible

Duration profileLong term, persistent, and indefinite

Total caloric intake

Standard total intake30 cal/kg/day from parenteral, enteral, and oral sources

Above-standard intakeGreater than 30 cal/kg/day

Additional requirement

Prior Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required for PN Products and Pumps

Prior authorization is required for covered home parenteral nutrition (PN) products and infusion pumps.

B4164-B4185: PN solutions
B4189-B4199: Specialty formulas requiring additional documentation
B4216: PN additives
B4220-B4224: Supply kits, limited to 1 per day with PN authorization
B5000-B5200: PN compound solutions
B9004-B9006: PN enteral nutrition infusion pumps; capped rental after 13 months of continuous use, with no more than 1 purchase per 5 years

Documentation Required

Continuation Authorization

Authorization for home PN therapy may be approved for up to 12 months when documentation supports ongoing medical necessity for the requested nutritional products.

Parenteral Nutrition Overview

Home PN provides intravenous nutritional support when the alimentary tract cannot adequately support nutrition. It is intended for patients with a long-term alimentary-tract condition or impairment for whom oral or enteral nutrition cannot sustain adequate nutrition.

Key Terms

Alimentary tract/GI tract

Also calledGI tract

StructureA mucous membrane-lined tube of the digestive system

Function and componentsFood passes through it, digestion takes place, and wastes are eliminated; it includes the pharynx, esophagus, stomach, and intestines

BMI

Full termBody Mass Index

What it measuresA measure of body fat

Basis of measureHeight and weight

Equipment and Supply Medical Necessity

Home PN equipment and supply criteria

Equipment and supplies are medically necessary only when all of the following are met:

The patient has persistent, long-term, and indefinite nonfunction or inaccessibility of the GI tract.GI dysfunction lasting at least 3 months
Oral and enteral feeding cannot sustain adequate nutrition.
A functioning central line is documented.
The prescribed products and equipment are identified in the PN prescription and supported by the required authorization documentation.

PN Infusion Pump Rental and Purchase

Equipment	Rental terms	Purchase terms
PN infusion pumps	Capped rental for up to 13 months of continuous use; then converts to a purchase.	Purchase limited to one pump in a 5-year period.

Equipment Replacement Limits

PN infusion pumps

EquipmentPN infusion pumps

Purchase limit1 purchased in a 5-year period

Rental rulePumps are rented as capped rental for up to 13 months of continuous use and then converted into a purchase

Required Documentation and Supply Controls

Documentation Required

Document equipment, central-line access, and training

The prescription must identify the equipment and nutritional products to be used. The request must include documentation of functioning central-line access and caregiver education and training for home PN administration.

Billing Rule

Use bundled kits and verify refills

Use all-inclusive PN supply kits; unbundled gloves, tubing, and similar supplies are not covered. Before refilling, verify the ongoing prescription and supply needs with the prescribing physician and confirm an appropriate patient, home-health, or physician refill request.

PN supply kits B4220-B4224 are limited to 1 per day.
No more than one month's quantity of supplies may be dispensed at a time.

Noncovered Services and Supplies

The following are not covered: peripheral parenteral nutrition provided at home; unbundled PN supplies such as gloves and tubing; supply quantities exceeding one month at a time; and PN supply kits exceeding 1 per day.

Policy Summary

PayerOklahoma Health Care Authority

PolicyHome Parenteral Nutrition

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateOctober 1, 2025

Next Review DateOctober 2028

Key ActionSubmit prior authorization for PN solutions, specialty formulas, additives, supply kits, compound solutions, and infusion pumps.

SourceLink

On This Page

A Certificate of Medical Necessity is signed by the prescribing provider who has seen the patient within 30 days.

The PN prescription identifies formula type, amino acids, lipids, additives, and the percentage of daily nutritional needs supplied by PN.

The PN prescription specifies frequency, route, product name, volume, and duration of nutritional therapy.

Orders are submitted for monthly home-health visits by a registered nurse.

The prescribing provider documents the medical necessity of specialty formulas billed under B5000-B5200.

Attempts to provide some nutrition orally or enterally are documented.

The prescribing provider clearly documents the continued medical necessity for home PN and the patient's inability to transition to oral or enteral nutrition.

Documented medical necessity is required above 30 cal/kg/day

PN supply kits

Applicable suppliesPN supply kits B4220-B4224

Quantity limit1 per day

Authorization conditionWith PN authorization

Monthly supply dispensing

Dispensing limitNo more than one month’s quantity of supplies at a time

Billing basisProspective billing

Applies toPN supplies

PN pump purchase limit

EquipmentPN infusion pump

Purchase limit1 purchased per 5-year period

Rental transitionPump is rented as capped rental for up to 13 months of continuous use, then converted to a purchase

Prior Authorization

Out-of-Guideline Review

Requests that fall outside these guidelines require review by the Medical Director.

Documentation Required

Document Oral or Enteral Nutrition Attempts

For continued home PN, document attempts to provide nutrition orally or enterally and the patient's inability to transition to oral or enteral nutrition. The prescribing provider must clearly document the medical necessity for continued PN.

Use the gut as much as possible when clinically appropriate; failure to feed the gut may increase infection problems.

Documentation Required

Submit Initial Hospital Documentation

Initial home PN authorization requests must include hospital records and objective evidence supporting the diagnosis and long-term impairment of the alimentary tract.

Include inpatient diagnosis records, placement of a functioning central line, oral or enteral nutrition trials, laboratory results, height, weight, and BMI history.
Include discharge teaching and caregiver education and training for in-home PN administration.

Documentation Required

Submit the CMN and PN Prescription

Submit a timely Certificate of Medical Necessity (CMN) signed by the prescribing provider, who must have seen the patient within 30 days, together with the PN prescription.

The prescription must specify formula type, amino acids, lipids, additives, the percentage of daily nutritional needs supplied by PN, frequency, route, product name, volume, and duration.
Document medical necessity for caloric intake greater than 30 cal/kg/day; 30 cal/kg/day from parenteral, enteral, and oral sources is generally sufficient to achieve or maintain appropriate body weight.

Documentation Required

Home-Health and Specialty-Formula Documentation

Include monthly home-health orders for visits by a Registered Nurse and document medical necessity for specialty formulas.

The prescribing provider must document medical necessity for specialty formulas billed under B5000-B5200.

Billing Rule

Specify Supplies and Equipment

The PN prescription must identify all supplies, nutritional products, and equipment to be used. Supply kits are all-inclusive; unbundled supplies such as gloves and tubing are not covered for PN.

PN supply kits B4220-B4224 are limited to 1 per day.
Pumps are rented as capped rental for up to 13 months of continuous use and then converted to a purchase; purchase is limited to 1 pump in a 5-year period.

Documentation Required

Continuation Documentation

For continued authorization, submit the CMN and prescription described above along with records demonstrating ongoing medical necessity.

Include office-visit records with weight and BMI history, laboratory results, home-health notes with assessments, and documentation of patient and caregiver education.
Document the patient's inability to transition to oral or enteral nutrition and the ongoing need for home PN.

Denial Risk

Functioning GI Tract or Non-GI Cause

Home PN is not medically appropriate when the patient has a functioning gastrointestinal tract and the nutritional need is caused by a non-gastrointestinal condition or impairment.

Examples include dysphagia, temporary impaired gastric emptying, psychological or metabolic disorders impairing intake, severe pulmonary disease causing dyspnea, medication side effects, and renal failure or dialysis.

Denial Risk

PPN Is Not for Home Use

Peripheral parenteral nutrition (PPN), which is administered through a peripheral intravenous line, should not be provided in the home setting.

PPN may be used for a few days while the patient is an inpatient.

Denial Risk

Do Not Deliver Unauthorized Refills

DME suppliers must not deliver PN refills without a refill request from the patient, home health, or the prescribing physician.

Suppliers must verify with the prescribing physician the ongoing prescription and supplies needed.

Billing Rule

Quantity Limit on Supplies

No more than one month's quantity of PN supplies may be dispensed at a time based on prospective billing.

PN supply kits B4220-B4224 remain limited to 1 per day.

Capped rental

Payment typeMonthly payments for use of durable medical equipment

Rental periodA limited period not exceeding 13 months

Conversion ruleThe item is considered purchased after 13 months of continuous rental

Central venous line

DeviceAn indwelling catheter

PlacementPlaced percutaneously

LocationIn a central vein

Certificate of Medical Necessity

Document typeA certification

SignerThe prescribing provider: MD, DO, APRN, or PA

PurposeRequired to help document medical necessity

Dysphagia

DefinitionDifficulty swallowing

Clinical contextA swallowing disorder

Policy exampleDysphagia is listed as a reason home PN is not medically appropriate when the GI tract is functioning

Enteral nutrition

Delivery siteDirectly into the digestive tract

Permitted locationsStomach, duodenum, or jejunum

Nutrient routeNutrients are delivered through the gastrointestinal tract

Intravenous

MeaningInside the vein

Alternative descriptionTaking place within the vein

Application in this policyPN nutritional requirements are given intravenously

Malnutrition

DefinitionA lack of proper nutrition

CausesNot having enough to eat, not eating enough of the right things, or being unable to use consumed food

IncludesStunting, wasting, underweight, and micronutrient deficiencies or insufficiencies

Motility/dysmotility

MotilityHow food and liquids move through the GI tract

DysmotilityA motility issue in which food is not moving through as it should

Affected systemThe gastrointestinal tract

Oral nutrition

RouteThrough the mouth and esophagus

Intake typeOral intake of food

PurposeTo provide necessary nutrients for health and growth

Parenteral nutrition

DefinitionProvision of nutritional requirements

RouteGiven intravenously

AbbreviationPN

Peripheral parenteral nutrition

DefinitionParenteral nutrition given through a peripheral intravenous line

Inpatient useMay be given for a few days while an inpatient

Home-use limitationPatients should not receive PPN at home

PICC line

Full termPeripherally Inserted Central Catheter

Usual placementUsually inserted in the arm

Configuration and tip locationA single-, double-, or triple-lumen catheter with the tip residing in the distal superior vena cava

Prescribing provider

DefinitionA licensed prescribing professional

Included professionalsMD, DO, APRN, or PA

Policy roleThe provider who signs the Certificate of Medical Necessity and prescribes PN