Intradialytic Parenteral Nutrition
DESCRIPTION
Individuals with renal failure who receive dialysis to remove waste products from the blood may also experience a condition called protein calorie malnutrition. Twenty-five to forty percent of people receiving dialysis experience protein calorie malnutrition leading to increased mortality and morbidity. Individuals who sustain inadequate intake for extended periods of time should be assessed for protein malnutrition. Serum albumin level and BUN are simple markers of nutritional status. The risk of death increases more than 10 times for individuals who have serum albumin levels of less than 2.5 g/dL,
For individuals unable to tolerate enteral feeds or unable to adequately utilize nutrients provided through the intestines, parenteral nutrition should be considered. Intradialytic parenteral nutrition (IDPN) involves infusing hyperalimentation fluids during the time of dialysis, through the vascular shunt or into the peritoneal cavity to normalize the amounts of albumin, glucose, and other nutrients in the blood stream. This technique of nurtritional support has been investigated as a means of decreasing the associated morbidity and mortality associated with protein calorie malnutrition.
POLICY
Intradialytic parenteral nutrition (IDPN) when offered as an alternative to a regularly scheduled infusion of total parenteral nutrition (TPN) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Intradialytic parenteral nutrition (IDPN) when offered in addition to regularly scheduled infusions of TPN to individuals who are considered appropriate candidates for TPN is considered not medically necessary.
Intradialytic parenteral nutrition (IDPN)for individuals who would not be considered candidates for TPN is considered investigational.
Policy with similar title: Home Hyperalimentation (Total Parenteral/Enteral Nutrition)
MEDICAL APPROPRIATENESS
Intradialytic parenteral nutrition (IDPN) is considered medically appropriate if ALL of the following criteria are met:
Individual is currently receiving dialysis
IDPN is being offered as an alternative to a regularly scheduled infusion of TPN
Individual is a candidate for total parenteral nutrition (TPN) as evidenced by ALL of the following:
Individual must be in a stage of wasting as indicated by ALL of the following:
Serum albumin is less than 3.4 gm/dl
10%weight loss over 3 months or less
Can receive no more than 30% of the caloric intake orally
Unable to benefit from tube feedings due to severe pathology of the alimentary tract that does not allow for absorption of sufficient nutrients due to ANY ONE of the following conditions:
Crohn's disease
Obstruction secondary to stricture or neoplasm of the esophagus or stomach such that an anatomic inability to swallow exists
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
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
Evidence of efficacy of IDPN treatment is limited. Available evidence demonstrates improvements in intermediate outcomes such as increases in serum albumin and catabolic rate. However, long-term data on survival, quality of life, and other nutritional status outcomes are unavailable. IDPN is considered not medically necessary when delivered in addition to regularly scheduled infusions of TPN and may be harmful due to the excess administration of lipids. Finally, due to the limited availability of data on IDPN in patients who would not otherwise be considered TPN candidates, the impact on net health outcome is not known and therefore, is considered investigational in these patients.
For individuals with an intact functional intestinal tract, the enteral route of nutritional support is preferred. Oral nutritional supplementation during HD has been demonstrated to contribute to increases in serum albumin, serum prealbumin, and subjective global assessment scores. Appropriate use of IDPN should be limited to a very small sample of people who are on dialysis and have severe pathology of the alimentary tract..
SOURCES
American Society for Parenteral and Enteral Nutrition. (2009). Clinical guidelines: Nutrition support in adult acute and chronic renal failure. Journal of Parenteral and Enteral Nutrition, 34 (4), 366-377.
BlueCross BlueShield Association. Medical Policy Reference Manual. (6:2011). Intradialytic parenteral nutrition (8.01.44). Retrieved August 15, 2011 from BlueWeb.
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Total parenteral nutrition and enteral nutrition in the home – Archived (1.02.01). Retrieved August 15, 2011 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.(Level 2 evidence - Independent)
Complete Guide to Medicare Coverage Issues [Computer software]. (2010, April). Enteral and parenteral nutritional therapy covered as a prosthetic device (NCD 180.2, p. 2-84 -2-85). Ingenix.
DiBiase, J., & Scolapio., J. (2007) Home parenteral and enteral nutrition. Gastroenterology Clinics, 36 (1), 123-144.
Druml, W., Kierdorf, H.,Working group for developing the guidelines for parenteral nutrition of The German Association for Nutritional Medicine. (2009) Parenteral nutrition in patients with renal failure - Guidelines on parenteral nutrition. German Medical Science, 18 (7), Chapter 17.
Dukkipati, R., Kalantar-Zadeh, K.,& Kopple, J. (2010). Is there a role for intradialytic parenteral nutrition? A review of the evidence. American Journal of Kidney Diseases, 55 (2), 352-364. (Level 5 evidence - Independent)
HCFA Rulings. (1996, December). Ruling No. 96-3. Retrieved November 3, 2009 from http://www.cms.hhs.gov/Rulings/downloads/hcfar963.pdf.
National Institute for Health and Clinical Excellence. (2006, February). Nutrition support in adults. Retrieved August 16, 2011 from http://www.nice.org.uk/guidance/CG32/niceguidance/pdf/english.
National Kidney Foundation. (2008). KDOQI clinical practice guidelines for nutrition in children with CKD: 2008 update. Retrieved August 16, 2011 from http://www.kidney.org/professionals/kdoqi/guidelines_updates/pdf/CPGPedNutr2008.pdf.
ORIGINAL EFFECTIVE DATE: 10/1/2004
MOST RECENT REVIEW DATE: 11/19/2011
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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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