Home Total Parenteral Nutrition (TPN) for Adults
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Defines medical necessity, coverage criteria, limitations, and prior authorization/administrative requirements for reimbursement of home TPN (including IDPN) for adult members of University Health Alliance.
No material clinical or coverage changes in this revision.
Home TPN Coverage Criteria
Home TPN Coverage Criteria
Covered when the patient has a severe impairment of the alimentary tract expected to last one week or longer and the specific medical necessity criteria below are satisfied.
ALL of the following
ONE of the following
- Small bowel resection within the past three months leaving five feet or less of small bowel beyond the ligament of Treitz.
- Short bowel syndrome with net gastrointestinal fluid and electrolyte malabsorption: enteral losses exceed 50% of an oral/enteral intake of 2.5-3 L/day AND urine output < 1 L/day.
- Requirement for bowel rest expected >= 1 week and receiving 20-35 kcal/kg/day IV for symptomatic pancreatitis (with or without pancreatic pseudocyst), severe exacerbation of regional enteritis, or a proximal enterocutaneous fistula when tube feeding distal to the fistula is not possible.
- Complete mechanical small bowel obstruction when surgery is not an option.
- Significant malnutrition (>=10% weight loss in <=3 months and serum albumin <= 3.4 g/dL) with severe fat malabsorption: fecal fat exceeds 50% of oral/enteral intake on a diet of >=50 g fat/day as measured by a standard 72-hour fecal fat test.
- Malnutrition (>=10% weight loss in <=3 months and serum albumin <= 3.4 g/dL) with motility disturbance of the small intestine and/or stomach unresponsive to maximal-dose prokinetic medication (daily symptoms of nausea and vomiting while taking maximal dose), demonstrated by radiographic/scintigraphic or manometric studies.
ALL of the following
- Intravenous nutrition is required to maintain weight and strength and cannot be achieved by BOTH: (i) modifying the nutrient composition of the enteral diet (e.g., lactose-free, gluten-free, low long-chain triglycerides, medium chain triglyceride substitution, peptide/amino acid formulas) AND (ii) using pharmacologic treatment of malabsorption (e.g., pancreatic enzymes, bile salts, antibiotics for bacterial overgrowth, prokinetics).
- The patient is malnourished: 10% weight loss over <=3 months AND serum albumin <= 3.4 g/dL.
- A documented disease/clinical condition has not responded to altering the manner of delivery of nutrients (e.g., slow infusion through a tube with tip in stomach or jejunum).
ALL of the following
Examples
- Moderate fat malabsorption: fecal fat exceeds 25% of oral/enteral intake on a diet of >=50 g fat/day measured by a standard 72-hour fecal fat test.
- Malabsorption diagnosed and objectively confirmed by methods other than 72-hour fecal fat test (e.g., Sudan stain, d-xylose test).
- Gastroparesis demonstrated radiographically/scintigraphically (isotope/pellets failing to reach jejunum in 3–6 hours) or by manometry and unresponsive to prokinetic medication.
- Small bowel motility disturbance unresponsive to prokinetic medication (gastric to right colon transit time 3–6 hours).
- Small bowel resection leaving more than five feet of small bowel beyond the ligament of Treitz (non-severe short bowel).
- Short bowel syndrome that is not severe.
- Mild to moderate exacerbation of regional enteritis or an enterocutaneous fistula.
- Partial mechanical small bowel obstruction when surgery is not an option.
ALL of the following
- Concerted effort to place an enteral tube; for gastroparesis placement must be post-pyloric (preferably jejunal) with objective radiographic/fluoroscopic or endoscopic/surgical verification of position.
- Trial must include appropriate attention to dilution, infusion rate, and alternative formulas to manage side effects (e.g., diarrhea).
- Examples of failed trials include persistent problems despite post-pyloric tube placement (tube returns to stomach), inability to advance tube into jejunum after 5–6 hours, intolerance when increasing infusion rate, persistent vomiting/distension after jejunal feeding, or inability to reach nutritional goals after gradual attempts over 3–4 weeks due to symptoms limiting advancement.
ALL of the following
- There is persistence or insufficient improvement of the underlying condition that would permit discontinuation of TPN, OR there is worsening of the underlying condition during attempts to resume oral or enteral feeding.
- There is clinical improvement demonstrated by increase in weight and/or serum albumin/prealbumin.
ALL of the following
- IDPN is covered only if the patient meets the TPN coverage criteria above.
- Documentation must verify permanently impaired GI tract, insufficient absorption to maintain weight/strength, inability to be maintained on oral/enteral feedings, and that infusions are vital to nutritional stability (not supplemental).
ALL of the following
NOT covered if
- Impairment expected to last < 1 week.
- Need for TPN solely due to a functioning GI tract issue such as swallowing disorder, temporary metabolic/electrolyte gastric emptying defect, psychological disorder impairing intake (e.g., depression), metabolic disorder inducing anorexia (e.g., cancer), physical impairment of intake (e.g., dyspnea, severe pulmonary/cardiac disease), medication side effects, or renal failure/ dialysis.
ALL of the following
- Prior authorization is required and requests are often submitted by the IV therapy provider; physicians must provide updated orders, diagnoses, clinical support, a current nutritional care plan with patient-specific goals, and amount of oral intake.
- Prior authorization for extension requires documentation of persistence/insufficient improvement or worsening during attempts to resume oral feedings, plus evidence of treatment effectiveness (improved weight and/or serum albumin/prealbumin). If no clinical improvement, continuation requests are denied unless physician documents medical necessity and planned regimen changes.
ALL of the following
- When coverage requirements are met, medically necessary nutrients, administration supplies, and equipment are covered.
Reimbursable Items and Diagnostic Thresholds
| Medically necessary nutrients, administration supplies, and equipment are covered when TPN criteria are met. |
Prior Authorization and Documentation Requirements
Prior authorization required — submit complete physician documentation
Prior authorization is required. Prior authorization requests are often submitted by the IV therapy provider, but physicians must provide IV therapy providers with updated orders, clinical information, and other documentation necessary to meet prior authorization requirements. Submit all of the following: physician's orders/prescription for TPN including expected duration of treatment; clearly identifiable primary and secondary diagnoses; clinical information supporting that the above criteria are met; a current nutritional care plan with patient-specific nutritional goals; and the amount of oral intake. Prior authorization is also required for extension of therapy and must include documentation demonstrating persistence, insufficient improvement, worsening during attempts to resume oral feedings, and effectiveness of treatment (improvement in weight and/or serum albumin/pre-albumin).
- Physician's orders/prescription for TPN including expected duration of treatment
- Clearly identifiable primary and secondary diagnoses
- Clinical information supporting that the TPN criteria are met
- Current nutritional care plan with patient-specific nutritional goals
- Amount of oral intake
- For extensions: documentation of persistence, insufficient improvement, or worsening, and evidence of treatment effectiveness (weight and/or serum albumin/pre-albumin)
IDPN coverage requires documentation of permanent GI impairment and meeting TPN criteria
To cover intradialytic parenteral nutrition (IDPN), documentation must verify a permanently impaired gastrointestinal tract with insufficient absorption such that the patient cannot be maintained on oral or enteral feedings; infusions must be vital to nutritional stability (not supplemental). Patients receiving IDPN must meet the TPN coverage criteria. If there is no clinical improvement, continued therapy requests will be denied unless the physician documents medical necessity and planned therapeutic changes.
- Document permanently impaired GI tract and insufficient nutrient absorption
- Document that patient cannot be maintained on oral or enteral feedings
- Show that infusions are vital to nutritional stability and not supplemental to dialysis-related deficiencies
- Patients receiving IDPN must meet the TPN coverage criteria
- If no clinical improvement, continued therapy requires physician justification and planned regimen changes
Clinical Definitions and Diagnostic Demonstrations
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