BlueCross BlueShield of Tennessee Medical Policy Manual

Home Hyperalimentation (Total Parenteral/Enteral Nutrition)

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 a medical or surgical condition. TPN involves the 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. The procedure may involve infusion intermittently, overnight 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, and chronic or acute disorders that prevent the intake of adequate nutrients. These individuals have a functional intestinal tract and ET is preferred over parenteral nutrition. EN involves the administering of non-sterile liquids directly into the gastrointestinal tract through a nasogastric, gastrostomy, jejunostomy, or percutaneous endoscopic gastrostomy (PEG) tube. Pediatric EN access is often referred to as a ‘mickey button’.  An infusion pump or syringe may be needed to assist the flow of the nutrients or it may be delivered by gravity flow. The infusion can be intermittent or continuous, depending upon the caloric needs and size of the individual and may be provided safely in the home with the appropriate supervision. Enteral feeding supplies are specific to the route of administration and come in kit form.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

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 Academy of Pediatrics (2016, April) Clinical practice guidelines from the cystic fibrosis foundation for preschoolers with cystic fibrosis. Retrieved July 11, 2017 from https://www.aap.org.

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). (2002). Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Retrieved July 12, 2017 from http://pen.sagepub.com.

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). (2004). Special report: safe practices for parenteral nutrition. Retrieved July 12, 2017 from http://pen.sagepub.com

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). (2009). Enteral nutrition practice recommendations. Retrieved July 11, 2017 from http://pen.sagepub.com. 

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.

Bharadwaj, S., Gohel, T. D., Deen, O. J., Coughlin, K. L., Corrigan, M. L., Fisher, J., et al. (2014). Prevalence and predictors of vitamin D deficiency and response to oral supplementation in patients receiving long-term home parenteral nutrition. Nutrition in Clinical Practice, 29 (5), 681-685. Abstract retrieved March 28, 2017 from PubMed database.

Cahaba Government Services Administrators, LLC (2017, January) Local Coverage Determination (LCD) enteral nutrition (L33783). Retrieved July 11, 2017 from https://www.cms.gov.

Centers for Medicare & Medicaid Services. (1984, July) National Coverage Determination(NCD) for enteral and parenteral nutritional therapy (180.2). Retrieved March 28, 2017 from https://www.cms.gov.  

Cystic Fibrosis Foundation (2009) Evidence-based guidelines for management of infants with cystic fibrosis. The Journal of Pediatrics. Vol.155(6)73-93.

Freedman, S., Orenstein, D., Black, P., Brown, P., McCoy, K., Stevens, J., et. al., (2017, July) Increased fat absorption from enteral formula through an in-line digestive cartridge in patients with cystic fibrosis. Journal of Pediatric Gastroenterology and Nutrition, Vol. 65, No. 1, 97-101. (Level 2 evidence)

National Institute of Health and Clinical Excellence. (2006). Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Retrieved May 6, 2016 from www.nice.org.uk.

Pironi, L., Arends, J., Bozzetti, F., Cuerda, C., Gillanders, L., Jeppesen, P., et al. (2016). ESPEN guidelines on chronic intestinal failure in adults. Clinical Nutrition, 35 (2), 247-307. Abstract retrieved March 28, 2017 from PubMed database.

Scanzano, C., Iacone, R., Alfonsi, L., Galeotalanza, M., Sgambati, D., Pastore, E., et al. (2014). Composition of personalized and standard nutritional mixtures in patients on home parenteral nutrition. European Journal of Clinical Nutrition, 68 (4), 433-436. Abstract retrieved March 28, 2017 from PubMed database.

Taylor, C., Thieroff-Ekerdt, R., Shiff, S., Magnus, L., Fleming, R., and Gommoll, C. (2016, March) Comparison of two pancreatic enzyme products for exocrine insufficiency in patients with cystic fibrosis. Journal of Cystic Fibrosis 15, 675-680. (Level 1 evidence)

U. S. Food and Drug Administration. (2014, December) Center for Devices and Radiologic Health De Novo Classification DEN15000 (Relizorb™) Retrieved July 10, 2017 from http://www.fda.gov.

ORIGINAL EFFECTIVE DATE:  5/4/1982

MOST RECENT REVIEW DATE:  9/20/2017         

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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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