Intradialytic Parenteral Nutrition
DESCRIPTION
Individuals who receive hemodialysis to remove waste products from the blood may also experience a condition called protein calorie malnutrition. Measuring serum albumin levels assesses this disorder. Twenty-five to forty percent of people receiving dialysis experience protein calorie malnutrition leading to increased mortality and morbidity. The risk of death increases more than 10 times for individuals who have serum albumin levels of less than 2.5 g/dL, and those with serum albumin levels near normal of between 3.5-3.9 g/dL have a mortality rate twice as high as those with albumin greater than 4.0 g/dL. Most labs consider an albumin level of 3.5 to 5.5 g/dL to be normal.
Intradialytic parenteral nutrition involves infusing hyperalimentation fluids during the time of dialysis, through the vascular shunt or intraperitoneally to normalize the amounts of albumin, glucose, and other nutrients in the blood stream decrease the associated morbidity and mortality associated with protein calorie malnutrition.
POLICY
Intradialytic parenteral nutrition when offered as an alternative to a regularly scheduled regimen of total parenteral nutrition is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Intradialytic parenteral nutrition for individuals who would be considered a candidate for TPN and the intradialytic parenteral nutrition is not offered as an alternative to TPN, but in addition to regularly scheduled infusions to TPN is considered investigational.
Intradialytic parenteral nutrition for individuals who would not be considered candidates for TPN is considered investigational.
Policy with similar title: Home Hyperalimentation/Enteral Nutrition
MEDICAL APPROPRIATENESS
Intradialytic parenteral nutrition for individuals who would otherwise be considered candidates for total parenteral nutrition is considered medically appropriate if ANY ONE of the following criteria are met:
Inability to orally consume at least 1.2 grams of protein per kilogram of body weight per day and unable to tolerate oral supplements or enteral (tube) feedings
Inability to consume adequate energy producing foods as evidenced by ANY ONE of the following:
Consumption of less than the recommended dietary intake of 35 kilocalories per kilogram of body weight per day for individuals less than 60 years of age
Consumption of less than the recommended dietary intake of 30 to 35 kilocalories per kilogram of body weight per day for individuals 60 years of age and older
An anatomical inability to swallow (such as stricture of the esophagus, obstructing tumors of the head and neck)
Central nervous system disorder leading to sufficient interference with the neuromuscular coordination of chewing and swallowing that causes a risk of aspiration
ADDITIONAL INFORMATION
Large, randomized controlled trials are lacking in peer-reviewed published literature that validate the use of intradialytic parenteral nutrition in addition to regularly scheduled infusions of TPN or for individuals who would not otherwise be considered as a candidate for TPN.
SOURCES
American Society for Parenteral and Enteral Nutrition. (2009). Clinical guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients, 2009. Journal of Parenteral and Enteral Nutrition, 33 (3), 255-259.
BlueCross BlueShield Association. Medical Policy Reference Manual. (7:2008). Intradialytic parenteral nutrition (8.01.44). Retrieved November 3, 2009 from BlueWeb.
Cano, N.J., Fouque, D., Roth, H., Aparicio, M., Azar, R., Canaud, B., et al. (2007). Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2 year multicenter, prospective, randomized study. Journal of the American Society of Nephrology, 18 (9), 2583-2591.
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, July). 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.
HCFA Rulings. (1996, December). Ruling No. 96-3. Retrieved November 3, 2009 from http://www.cms.hhs.gov/Rulings/downloads/hcfar963.pdf.
National Kidney Foundation. (2008). KDOQI clinical practice guidelines for nutrition in children with CKD: 2008 update. Retrieved November 3, 2009 from http://www.kidney.org/professionals/KDOQI/guidelines_updates/pdf/CPGPedNutr2008.pdf.
Pupim, L. B., Flakoll, P. J., Brouillette, J. R., Levenhagen, D. K., Hakim, R. M., & Ikizler, T. A. (2002). Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. Journal of Clinical Investigation, 110 (4), 483-492.
Rakel, R.E. & Bope, E.T. (2008). Latest approved methods of treatment for the practicing physician. H.F. Conn & others (Eds). Conn’s current therapy 2009. (Chapter 3). Philadelphia: Saunders, an Imprint of Elsevier Inc.
ORIGINAL EFFECTIVE DATE: 10/1/2004
MOST RECENT REVIEW DATE: 12/10/2009
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.
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