Home Nutritional Support (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 for variable periods of time to bolster the nutritional status of severely malnourished individuals with medical or surgical conditions. TPN involves 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 either on a continuous (24-hour) or intermittent schedule. The catheter is kept patent between infusions.
Enteral nutrition (EN) is used for individuals with a functional gastrointestinal tract who are unable to meet nutritional requirements by the oral route. EN can be defined as a life-sustaining therapy and should be considered if an individual’s nutritional intake is likely to be qualitatively or quantitatively insufficient for a week or more due to a complex health condition. EN involves administering non-sterile liquids directly into the gastrointestinal tract through a nasogastric, gastrostomy or jejunostomy tubes. An infusion pump may be used to assist the flow of liquids. Feedings may be intermittent or continuous (infused 24 hours a day).
Relizorb® is a single-use, point-of-care digestive enzyme cartridge that connects in-line with existing enteral feeding circuits. Relizorb® is designed to hydrolyze (digest) fats contained in enteral formulas from triglycerides into fatty acids and monoglycerides to allow for their absorption and utilization by the body. This hydrolysis of fats is intended to mimic the function of the digestive enzyme lipase in individuals who do not excrete sufficient levels of the lipase enzyme. Relizorb® is comprised of a clear cylindrical, plastic cartridge with a single inlet connection port and a single outlet connection port. Lipase is covalently bound to small white beads contained within the cartridge. The fat in enteral formulas is hydrolyzed when it makes contact with the lipase.
POLICY
Home nutritional support is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
The use of in-line cartridges containing digestive enzymes (i.e., Relizorb®) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Home nutritional support (total parenteral nutrition/enteral nutrition) for the treatment of dementia is considered investigational.
MEDICAL APPROPRIATENESS
Home nutritional support is considered medically appropriate if ANY ONE of the following criteria are met:
Enteral nutrition (EN) for individuals with ALL of the following:
Functioning GI tract of sufficient length and conditions to allow adequate nutritional absorption
Documentation of malnourishment or risk of malnutrition due to complex medical condition including, but not limited to ANY ONE of the following:
Increased nutritional requirements (such as burns, cystic fibrosis)
Swallowing disorder due to neurological disorder
Obstruction due to malignancy
Cachexia due to cancer
Chronic obstructive pulmonary disease
Heart disease
Chronic infection
Mild to moderate malabsorption/maldigestion due to liver, pancreas, or intestinal diseases
Use of in-line cartridges containing digestive enzymes (i.e., Relizorb®) with ALL of the following:
Diagnosis of pancreatic insufficiency due to cystic fibrosis
Documented failure of pancreatic enzyme replacement therapy (PERT)
Individual is 5 years of age or older
Individual requires enteral nutrition
Total parenteral nutrition (TPN) 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:
Prolonged gastrointestinal failure
Chronic small bowel disease with malabsorption and dysmotility syndrome (e.g., short bowel, fistula)
Inflammatory bowel disease
Surgical complications
Mesenteric vascular disease
Radiation enteritis
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 REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
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 or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
CMS.gov: Centers for Medicare & Medicaid Services. CGS Administrators, LLC. (2021, September). Enteral Nutrition. (LCD ID L38955). Retrieved December 28, 2023 from https://www.cms.gov.
CMS.gov: Centers for Medicare & Medicaid Services. CGS Administrators, LLC. (2021, September). Parenteral Nutrition. (LCD ID L38953). Retrieved December 28, 2023 from https://www.cms.gov.
Cystic Fibrosis Foundation. (1995, November; last reviewed April 2019). Pancreatic enzymes clinical care guidelines. Retrieved September 23, 2020 from www.cff.org.
Cystic Fibrosis Foundation. (2016). Enteral tube feeding for individuals with cystic fibrosis. Retrieved July 3, 2018 from www.cff.org.
European Society for Clinical Nutrition and Metabolism. (2009). ESPEN guidelines on parenteral nutrition: Home parenteral nutrition (HPN) in adult patients. Retrieved October 13, 2021 from https://www.espen.org/guidelines-home/espen-guidelines.
European Society for Clinical Nutrition and Metabolism. (2013). ESPEN endorsed recommendations: Nutritional therapy in major burns. Retrieved October 8, 2021 from https://www.espen.org/guidelines-home/espen-guidelines.
European Society for Clinical Nutrition and Metabolism. (2015). ESPEN guidelines on nutrition in dementia. Retrieved October 8, 2021 from https://www.espen.org/guidelines-home/espen-guidelines.
European Society for Clinical Nutrition and Metabolism. (2016). ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis. Retrieved October 8, 2021 from https://www.espen.org/guidelines-home/espen-guidelines.
European Society for Clinical Nutrition and Metabolism. (2018). ESPGHAN-ESPEN-ECPR-CSPEN guidelines on pediatric nutrition: Home parenteral nutrition Retrieved October 13, 2021 from https://www.espen.org/guidelines-home/espen-guidelines.
European Society for Clinical Nutrition and Metabolism. (2020). ESPEN guideline on home enteral nutrition. Retrieved October 8, 2021 from https://www.espen.org/guidelines-home/espen-guidelines.
European Society for Clinical Nutrition and Metabolism. (2020). ESPEN guideline on home parenteral nutrition. Retrieved October 8, 2021 from https://www.espen.org/guidelines-home/espen-guidelines.
Freedman, S., Orenstein, D., Black, P, Brown, P., McCoy, K., Stevens, J., et al. (2017). Increased fat absorption from enteral formula through an in-line digestive cartridge in patients with cystic fibrosis. JPGN, 65 (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 June 26, 2019 from www.nice.org.uk.
U. S. Food and Drug Administration. (2014, December). Center for Devices and Radiological Health. Evaluation of Automatic Class III Designation (De Novo) Summaries. DEN150001. Retrieved October 8, 2021 from http://www.fda.gov/cdrh/pdf4/k040126.pdf.
ORIGINAL EFFECTIVE DATE: 5/4/1982
MOST RECENT REVIEW DATE: 2/8/2024
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.