Home Hyperalimentation/Enteral Nutrition (Tube feedings - Total Parenteral 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.
Enteral nutrition (EN) is used for individuals with disorders of the pharynx, esophagus or stomach that prevents the absorption 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.
POLICY
Total parenteral nutrition for the treatment of malnutrition associated with conditions resulting in impaired absorption is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Enteral nutrition, for the treatment of malnutrition associated with conditions resulting in impaired absorption is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Total parenteral nutrition or enteral nutrition of 750 calories per day or less for the treatment of malnutrition is considered not medically necessary.
Policies with similar title: Intradialytic Parenteral Nutrition
MEDICAL APPROPRIATENESS
Total parenteral nutrition for the treatment malnutrition associated with conditions resulting in impaired absorption is considered medically appropriate if ALL of the following criteria are met:
ALL the following criteria must be met prior to the initial implementation of TPN:
Individual must be in a stage of wasting as indicated by the following:
Weight significantly less than normal body weight for an individual's height and age in comparison with pre-illness weight (see Metropolitan Insurance Height and Weight Table)
Serum albumin is less than 2.5 gm
BUN is below 10 mg (not a good marker in individuals receiving dialysis due to protein catabolism)
Phosphorous level is less than 2.5 mg (normal range 3-4.5 mg)
Can receive no more than 30% of the caloric intake orally or cannot benefit from tube feedings as a result of a malabsorption disorder
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 major a 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
Enteral nutrition for the treatment of malnutrition associated with conditions resulting in impaired absorption is considered medically appropriate if ANY ONE the following criteria are met:
An anatomical inability to swallow exists, (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 exist
ADDITIONAL INFORMATION
Note: Generally, a daily caloric intake of 2000-2200 calories for adults is sufficient to maintain body weight.
SOURCES
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, 2009. Retrieved June 29, 2009 from http://pen.sagepub.com/cgi/reprint/33/3/255.
American Society for Parenteral and Enteral Nutrition. (1999, June). Standards of practice: Standards for home nutrition support. Retrieved May 6, 2002 from http://www.clinnutr.org/homelink.asp?Link=www.nutritioncare.org/profdev/stnds.html.
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Total parenteral nutrition and enteral nutrition in the home (1.02.01). Retrieved June 29, 2009 from BlueWeb. (0 articles and/or guidelines reviewed)
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, April). Enteral and parenteral nutritional therapy covered as a prosthetic device. (NCD 180.2, p. 2-84, 2-85). The Ingenix Complete Guide to Medicare Coverage Issues.
Moukarzel, A. A., Ament, M. E., Buchman, A., Dahlstrom, K. A., & Vargas, J. (1991). Renal function of children receiving long-term parenteral nutrition. The Journal of Pediatrics, 119 (6), 864-868. Abstract retrieved May 3, 2002 from PubMed database.
National Guideline Clearinghouse. National Collaborating Centre for Acute Care. (2005, November). Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Retrieved June 16, 2007 from http://www.guidelines.gov.
National Institute for Health and Clinical Excellence. (2006, February). Nutrition support in adults. Retrieved June 26, 2007 from http://www.nice.org.uk/guidance/CG32/niceguidance/pdf/english.
Salas, J. S., Moukarzel, E., Dozio, E., Goulet, O. J., Putet, G., & Ricour, C. (1990). Estimating resting energy expenditure by simple lean-body-mass indicators in children on total parenteral nutrition. The American Journal of Clinical Nutrition, 51 (6), 958-962. Abstract retrieved May 3, 2002 from PubMed database.
ORIGINAL EFFECTIVE DATE: 5/4/1982
MOST RECENT REVIEW DATE: 8/13/2009
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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.
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