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Medical Policy: 01.02.01
Original Effective Date: May 1995
Reviewed: September 2011
Revised: June 2004
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Total parenteral nutrition (TPN), also known as parenteral hyperalimentation, is administered to patients in whom gastrointestinal absorption is impaired to a degree incompatible with life. It may also be used for variable periods of time to bolster the nutritional status of severely malnourished patients with medical or surgical conditions. TPN involves percutaneous placement 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 used to facilitate a steady rate of administration.
Enteral nutrition is used for patients with a functioning intestinal tract but who have disorders of the pharynx, esophagus, or stomach that prevent nutrients from reaching the absorbing surfaces of the small intestine, thus placing the patient at risk of severe malnutrition. Enteral nutrition involves administering non-sterile liquids directly into the gastrointestinal tract through nasogastric, gastrostomy, or jejunostomy tubes. Feedings may be regulated with an infusion pump and may be administered intermittently or continuously.
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Prior Approval:
Not applicable
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Policy:
Total parenteral nutrition (TPN) may be considered medically necessary when administered for the treatment of malnutrition associated with the following conditions including, but not limited to:
- Crohn's disease
- Obstruction secondary to stricture or neoplasm of the esophagus or stomach
- Loss of swallowing mechanism due to a 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
- Motility disorders
- Prolonged paralytic ileus following a major surgical procedure or multiple injuries
- Newborns with catastrophic gastrointestinal anomalies such as tracheoesophageal fistula, gastroschisis, omphalocele, or massive intestinal atresia
- Failure to thrive in infants and young children with systemic disease or secondary intestinal insufficiency associated with short bowel syndrome, malabsorption, or chronic idiopathic diarrhea
- For an individual in a stage of wasting when ALL of the following criteria are met:
- Weight significantly less than normal body weight for a patient's height and age n comparison with pre-illness weight
- Serum albumin less than 2.5 gm
- BUN less than 10 mg
- Phosphorus less than 2.5 mg
- Able to tolerate no more than 30% of total caloric needs orally or cannot benefit from enteral nutrition as a result of a malabsorption disorder.
Enteral nutrition therapy may be considered medically necessary under the following conditions:
- An anatomical inability to swallow exists, (such as 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 exists.
Benefits are considered for enteral nutrition therapy ONLY when the prescribed feeding formula is administered through a tube.
Blenderized baby food and regular shelf food administered with an enteral feeding system are NOT considered eligible for benefits.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
The following HCPCS per Diem code ranges may be used to report TPN or enteral nutrition therapy:
- B4102 through B4162 Enteral formula
- B4164 through B5200 Parenteral solution
- B9000 through B9002 Enteral nutrition infusion pump
- B9004 through B9006 Parenteral nutrition infusion pump
- S9364 through S9368 Home infusion therapy, total parenteral nutrition
- S9340 through S9343 Home therapy, enteral nutrition
- 36557 through 36571 Insertion of tunneled centrally inserted central venous catheter
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Selected References:
- Blue Cross Blue Shield Association. Medical Policy Reference Manual.
- American Gastroenterological Association position statement: Parenteral Nutrition. Gastroenterology 2001 Oct; 121(4):966-9.
- American Society for Parenteral and Enteral Nutrition. Standards of practice: Standards for home nutrition support. Retrieved 5/14/2004 from http://www.clinnutr.org
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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