Home Hyperalimentation (Total Parenteral/Enteral Nutrition)
*Disclaimer notation: Special consideration should be evaluated for oral nutrition requirements (replacement/supplement) related to medical conditions*
DESCRIPTION
Total parenteral nutrition (TPN), also known as parenteral hyperalimentation, is used for individuals with medical conditions that impair gastrointestinal absorption to a degree incompatible with life. It is also used during periods when individuals are severely malnourished due to medical or surgical conditions. TPN involves the percutaneous transvenous implantation of a central venous catheter into the vena cava or right atrium. A nutritionally adequate hypertonic solution consisting of glucose, amino acids, electrolytes, vitamins, and minerals and sometimes fats, is administered daily. An infusion pump is generally used to assure a steady flow of the solution. The catheter is kept patent between infusions with diluted heparin. The procedure may involve infusion over night or may involve infusion 24-hours a day, depending on the nutritional needs and may be provided safely in the home.
Enteral nutrition (EN) is used for individuals with disorders of the pharynx, esophagus, or stomach that prevents the intake of nutrients. These individuals have a functional intestinal tract. EN involves the administering of non-sterile liquids directly into the gastrointestinal tract through a nasogastric, gastrostomy, or jejunostomy tube. An infusion pump may be needed to assist the flow of the nutrients or it may be delivered only by gravity flow. The infusion can be intermittent or continuous, depending upon the caloric needs of the individual and may be provided safely in the home.
POLICY
Home hyperalimentation for the treatment of malnutrition is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Policies with similar title: Intradialytic Parenteral Nutrition
MEDICAL APPROPRIATENESS
Home hyperalimentation for the treatment of malnutrition associated with conditions resulting in impaired absorption is considered medically appropriate if ANY ONE of the following criteria are met:
Enteral nutrition for individuals with a functioning gastrointestinal tract and ANY ONE of the following:
Anatomical inability to swallow, (i.e., head and neck cancer or an obstructing tumor or stricture of the esophagus or stomach)
Central nervous system disorder leading to sufficient interference with the neuromuscular coordination of chewing and swallowing that a risk of aspiration exists
Total parenteral nutrition for individuals with ALL of the following:
Unable to benefit from tube feedings due to severe pathology of the alimentary tract that does not allow absorption of sufficient nutrients, including but not limited to, ANY ONE of the following conditions:
Crohn’s disease
Obstruction secondary to stricture or neoplasm of the esophagus or stomach
Loss of ability to swallow due to central nervous system disorder, where the risk of aspiration is great
Short bowel syndrome secondary to massive small bowel resection
Malabsorption due to enterocolic, enterovesical or enterocutaneous fistulas (TPN temporary until the repair of the fistula)
Motility disorder (pseudo-obstruction)
Prolonged paralytic ileus following a major surgical procedure or multiple injuries
Newborn infants with catastrophic gastrointestinal anomalies such as tracheoesophageal fistulas, gastroschisis. omphalocele or massive intestinal atresia
Infants and young children who fail to thrive due to systemic disease or secondary to intestinal insufficiency associated with short bowel syndrome, malabsorption or chronic idiopathic diarrhea
Receiving no more than 30% of caloric intake orally
In a stage of wasting as indicated by ANY ONE of the following:
10% weight loss over 3 months or less
Serum albumin less than or equal to 3.4 gm/dl
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member’s health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Hyperalimentation may be provided safely in the home.
Generally, a daily caloric intake of 2000-2200 calories for adults is sufficient to maintain body weight. Energy expenditure should be assessed throughout illness for children to determine sufficient energy requirements and avoid under- or over-estimating of requirements.
SOURCES
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). (2009). Enteral nutrition practice recommendations. Retrieved April 22, 2011 from http://pen.sagepub.com/content/early/2009/01/27/0148607108330314.
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). Board of Directors. (2009). Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Retrieved June 29, 2009 from http://pen.sagepub.com/cgi/reprint/33/3/255.
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). (2009). Nutrition support of the critically ill child. Retrieved April 22, 2011 from http://pen.sagepub.com/content 33/3/260.
American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). (2011). Nutrition screening, assessment, and intervention in adults. Retrieved April 22, 2011 from http://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines/A_S_P_E_N__Clinical_Guidelines_Nutrition_Screening,_Assessment,_and_Intervention_in_Adults/.
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Total parenteral nutrition and enteral nutrition in the home (1.02.01). Retrieved February 14, 2011 from BlueWeb.
CIGNA Government Services. Local Coverage Article. Parenteral Nutrition (L11561). Retrieved July 14, 2011 from http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDid=11561.
CIGNA Government Services. Local Coverage Decision. Parenteral Nutrition (A37054). Retrieved July 14, 2011 from http://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=37054.
Complete Guide to Medical Coverage Issues [Computer software]. (2011, April). Enteral and parenteral nutritional therapy covered as a prosthetic device (NCD 180.2, pp. 2-89, 2-90). Ingenix.
DiBaise, J. K, & Scolapio, J. S. (2007). Home parenteral and enteral nutrition. Gastroenterology Clinics, 36 (1). Retrieved 4/18/2011 from http://www.mdconsult.com/das/article/body/266650613-3/jorg=clinics&source=MI&sp=19487145&sid=1180527282/N/581128/1.html?issn=0889-8553.
ORIGINAL EFFECTIVE DATE: 5/4/1982
MOST RECENT REVIEW DATE: 1/14/2012
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.