BlueCross and BlueShield of Montana Medical Policy/Codes
Alternative Modes of Nutrition in the Outpatient and Home Setting
Chapter: Medicine: Treatments
Current Effective Date: December 27, 2013
Original Effective Date: January 01, 2001
Publish Date: September 27, 2013
Revised Dates: December 15, 2004; March 1, 2010; November 15, 2011; August 14, 2013
Description

Enteral nutrition therapy is used for the treatment of patients with severe malabsorption or for patients with a functioning intestinal tract, but with disorders of the pharynx, esophagus or stomach that prevent nutrients from reaching the absorbing surfaces in the small intestine.  EN involves administering special nutritional liquids directly into the gastrointestinal tract through nasogastric, gastrostomy, or jejunostomy tubes.  An infusion pump may be used to assist the flow of liquids.  Feedings may be either intermittent or continuous (infused 24 hours a day).

Oral nutrition therapy is formula or medical food taken orally to replace or supplement a diet. 

Inborn errors of metabolism are a group of disorders resulting in the excessive accumulation of an amino acid or other product along the metabolic pathway.  Manifestations may include:

  • Central nervous system dysfunction;
  • Developmental delay;
  • Seizures;
  • Liver dysfunction.

The clinical manifestations in many of these disorders can be prevented if diagnosis is achieved early and appropriate treatment with dietary protein or amino acid restriction is initiated immediately.  These disorders are named for the accumulating amino acid and include (but are not limited to):

  • Phenylketonuria (PKU);
  • Citrullinemia;
  • Cystinosis;
  • Homocystinuria;
  • Methylmalonic acidemia.

For some of the inborn errors of metabolism, special formulas and medical foods have been developed, which eliminate the amino acid that cannot be metabolized from the protein context of the food.

Total parenteral nutrition, also known as parenteral hyperalimentation, is the provision of nutritional requirements intravenously.  TPN is used for patients with medical conditions that impair gastrointestinal absorption to a level incompatible with life.  It is also used for intermittent periods of time to reinforce the nutritional status of severely malnourished patients with medical or surgical conditions.  TPN may consist of:

  • Glucose (sugar);
  • Amino Acids (protein);
  • Electrolytes (sodium and potassium);
  • Vitamins;
  • Minerals;
  • Lipids (fats).

Administration of TPN usually occurs daily but may be cyclic, depending upon the patient’s nutritional needs.  An infusion pump is usually used to guarantee a steady flow of the solution.

Parenteral nutrition with dialysis can be grouped into categories based on the mode of dialysis and delivered simultaneously with dialysis.  The current categories are IDPN, IPAA, and Intraperitoneal TPN.  IDPN utilizes a hemodialyzer during delivery.  IPAA is infused with dialysate fluid, and allowed to dwell with the dialysate fluid for optimal fluid infusion of the amino acids.  The peritoneal route is limited in the volume amount available for nutrition due to the capacity of the peritoneal cavity.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

NOTE:  Nutritional supplements that can be sold or dispensed without a physician's prescription are not a covered benefit.

NOTE:  Nutritional supplements that do not require a physician’s prescription are not a covered benefit.

Alternative modes of nutrition consist of therapies in the outpatient and home setting that include the following:

ENTERAL NUTRITION (EN)

Blue Cross and Blue Shield of Montana (BCBSMT) may consider Enteral Nutrition (EN) formula (available only by physician’s prescription) medically necessary when administered via a surgically placed feeding tube when one of the following criteria is met:

  • Presence of nonfunctional proximal gastrointestinal tract or disease of the structures that normally allows food to reach the small bowel (i.e. head and neck cancer or tumor obstructing the esophagus or stomach) where the tube feedings are needed to provide adequate nutrition to maintain the patient's overall health status; OR
  • Presence of a central nervous system disease interfering with the neuromuscular coordination of chewing and swallowing and where a risk of aspiration exists (i.e. dysphagia secondary to Cerebral Vascular Accident [CVA]).

ORAL NUTRITION (ON)

Oral Nutrition (ON) formula, (when used as a supplement or for dietary replacement and available only by prescription) may be considered medically necessary for the treatment of inborn errors of metabolism when:

  • Used to prevent illness resulting from a by product of metabolism or amino acid accumulation; OR
  • Required to restore an essential nutrient that is lacking because of an inborn error of metabolism.

TOTAL PARENTERAL NUTRITION (TPN)

Total Parenteral Nutrition (TPN) may be considered medically necessary in the treatment of severe wasting (weight deterioration, emaciation) associated with conditions resulting with impaired gastrointestinal absorption. Some conditions may include:

  • Inflammatory bowel disease (Crohn's disease or Ulcerative Colitis); OR
  • Obstruction secondary to a stricture or neoplasm of the esophagus or stomach; OR
  • Loss of the swallowing mechanism due to a central nervous system disorder, where there is a great risk of aspiration; OR
  • Short bowel syndrome secondary to massive small bowel resection; OR
  • Malabsorption due to enterocolic, enterovesical, or enterocutaneous fistulas (TPN being temporary until fistula repair); OR
  • Intractable motility disorders (i.e. intestinal pseudo obstruction and gastroparesis); OR
  • Newborn infants with gastrointestinal anomalies (i.e. tracheoesophageal fistula, gastroschisis, omphalocele or intestinal atresia); OR
  • Infants and young children with a diagnosis of failure to thrive, due to systemic disease or secondary to intestinal insufficiency (associated with short bowel syndrome, malabsorption, or chronic idiopathic diarrhea; OR
  • Patients with prolonged paralytic ileus following major surgery or multiple injuries.

Prior to the initial start of TPN, the patient must be in a state of wasting and meet all the following criteria:          

  • Serum albumin less than 3.4 grams; AND
  • Weight is significantly less than normal body weight for a patient's height and age in comparison to pre-illness weight; AND
  • Blood urea nitrogen (BUN) value below 10 (except in patients with protein catabolism due to dialysis); AND
  • Phosphorus level less than 2.5 mg (normal range 3-4.5 mg); AND
  • The patient can receive no more than 30% of his/her calorie needs orally OR cannot benefit from tube feedings as a result of a malabsorptive disorder. 

Generally a daily caloric intake of 2000-2200 calories is sufficient to maintain body weight.  If 750 calories per day or less are being administered by EN or TPN, it is considered not medically necessary and is considered supplemental because it is not the primary source of caloric intake for the patient.

INTRADIALYTIC PARENTERAL NUTRITION (IDPN)

Intradialytic Parenteral Nutrition (IDPN) may be considered medically necessary when provided for hemodialysis patients with severely impaired gastrointestinal absorption and with malnutrition uncorrected by oral, enteral or parenteral nutrition.  Prior to the beginning of IDPN, all the following criteria must be met:

  • Serum albumin less than 3.4 grams; AND
  • Weight is significantly less than normal body weight for a patient’s height and age in comparison with pre-illness weight; AND
  • The patient can receive no more than 30% of his/her calorie needs orally OR cannot benefit from tube feedings as a result of a malabsorptive disorder. 

IDPN is considered not medically necessary in patients who are considered candidates for TPN in which IDPN is to be used in addition to regularly scheduled infusions of TPN.

IDPN is considered not medically necessary when provided for patients with impaired nutrition due to a poor appetite but without significant gastrointestinal disease.

INTRAPERITONEAL AMINO ACID (IPAA)   

Intraperitoneal Amino Acid (IPAA) is considered experimental, investigational and unproven.  

NUTRITIONAL SUPPLEMENTS

Coverage for nutritional supplements or substances is considered not medically necessary when used:

  • To increase protein or caloric intake (i.e. protein powders used to enhance muscle development) in addition to the patient's daily diet; OR
  • For routine pre and post operative care; OR
  • For dietary supplements or replacements (over the counter enteral nutrition not meeting criteria); OR
  • In patients with stable nutritional status, where short-term parenteral nutrition might be used for 14 days or less.

Blenderized baby food and regular shelf food used with an enteral system are not considered medically necessary.

Policy Guidelines

Approved services for Alternative Modes of Nutrition (those meeting criteria) may include:

  • cost of nutritional solutions
  • cost of rental and/or purchase of infusion pumps
  • cost of supplies and/or equipment required for effective delivery of nutrients
  • home visits by a Medical Practitioner administering skilled care.  

Rationale

Enteral nutrition, oral nutrition and total parenteral nutrition therapies are seen as valuable adjunctive treatments in the management of select patients requiring nutritional support to prevent the adverse effects of malnutrition.  To determine the type of nutritional support and accurately calculate the patient's nutritional needs review of the following data is necessary:

  • Patient age and gender;
  • Review of pre-existing medical conditions and history;
  • Body mass index determination.

In 1997, a joint conference report published by the National Institutes of Health and the American Society for Parenteral and Enteral Nutrition reviewed current literature concerning the importance of nutritional support.  The review included prospective, randomized, controlled trials where nutritional therapy was administered for a minimum of five days and provided satisfactory nutrients to meet daily requirements.  All told, more than 2500 patients were included in the studies reviewed.  With one final statement, the report concluded that:

  • The usage of nutritional therapy requires careful integration of data from pertinent clinical trials;
  • Clinical expertise is required in the illness or injury being treated;
  • Clinical input from nutritional therapy clinicians;
  • Input from the patient and family.

IDPN has been investigated as a technique to treat protein calorie malnutrition in an effort to decrease morbidity and mortality in the dialysis population.  Goldstein, et al reported on three malnourished adolescent patients receiving chronic hemodialysis.  All patients established a reversal of weight loss and initiation of weight gain within six weeks of initiation of IDPN.  With IDPN discontinued after five months, two of the three patients attained ideal body weight.  Pupim and colleagues (2002) reported on seven chronic hemodialysis patients, (at two separate dialysis sessions) with and without IDPN management.  Patients were studied two hours before, during dialysis and two hours following a dialysis session.  Results showed IDPN encouraged a large increase in whole body protein synthesis.  In 2002, Cherry and Shalansky examined IDPN use in malnourished hemodialysis patients between June 1997 and December 2000.  IDPN was administered during the 3rd weekly session of hemodialysis.  Twenty-four patients (with 26 courses IDPN administered) met the inclusion criteria of the study.  The data revealed baseline serum albumin (concentrations of less than or equal to 34 grams per liter) levels at 12%, six months - 39% and at nine months - 47%.  In 2002, the American Society for Parenteral and Enteral Nutrition recommended IDPN “should only be considered in situations of gut failure or other unusual circumstances where EN or PN are not feasible."  Although limited by the number of participants studied, IDPN opens another avenue in treating the malnourished hemodialysis patient. 

A search of the literature was completed through MEDLINE database for the period of January 2004 through September 2006.  No additional published studies were identified that would prompt reconsideration of the policy statement.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

Refer to the ICD-9-CM manual.

Procedural Codes: 36510, 36555, 36556, 36557, 36558, 36560, 36561, 36565, 36566, 36568, 36569, 36570, 36571, 43246, 43752, 43753, 43754, 43755, 43756, 43757, 43760, 43761, 44015, 49440, 49441, 49446, 49451, 49452, 90935, 90937, 90940, 90945, 90947, 99601, 99602, A4221, A4222, A4223, B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9000, B9002, B9004, B9006, E0781, S9335, S9340, S9341, S9342, S9343, S9364, S9365, S9366, S9367, S9368, S9433, S9434, S9435
References
  1. Berkow, Robert M.D., and Andrew J. Fletcher, M.B., B.Chir, eds. 1992. The Merck Manual, 17th edition. New Jersey: Merck & C., Inc.: 946.
  2. Total Parenteral Nutrition and Enteral Nutrition in the Home.  Chicago, Illinois:  Blue Cross Blue Shield Association Consortium Health Plan Medical Policy Reference Manual (1996 July 31) Durable Medical Equipment: 1.02.01.
  3. 20% ProSol™.  Baxter Healthcare Corporation, (1997 March): 1-10 Product Information.
  4. Ireton-Jones, C., et al.  Clinical pathways in home nutrition support.  Journal of the American Dietetic Association (1997 September) 97(9): 1003-7.
  5. WebMD - Scientific American Medicine XIII: Enteral and Parenteral Nutritional Support. (1999): 1-26. Prepared by WebMD Professional Library.  http://www.samed.com .
  6. Kumpf, V.J., PharmD. Board certified in nutrition support pharmacy (BCNSP). Nutrition: Current guidelines for the use of parenteral nutrition.  Home Health Care Consultant - Journal of Alternative Site Medicine and Management (1999) 6(4): 20-25.
  7. The Merck Manual Nutritional Support, Section 1, Chapter 1 Nutrition: General Considerations. (2001): 1-6. Published by Merck & Co., Inc. http://www.merck.com
  8. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. Journal of Parenteral and Enteral Nutrition, American Society of Parenteral and Enteral Nutrition (2002 Jan/Feb) 26(1 Supplement): 1-138.
  9. Goldstein, S., Baronette, S. et al.  nPCR assessment and IDPN treatment of malnutrition in pediatric hemodialysis patients.  Pediatric Nephrology (2002 July) 17(7): 531-534. (6/3/2003) http://www.ncbi.nlm.nih.gov
  10. Pupim, L., Flakoll, P., et al.  Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients.  Journal of Clinical Investigation (2002 August 15) 110(4): 483-492. (Web site accessed 6/3/2003) http://www.pubmedcentral.nih.gov .
  11. Cherry, N. and Shalansky, K.  Efficacy of Intradialytic parenteral nutrition in malnourished hemodialysis patients.  American Journal of Health System-Pharmacy (2002 September 15) 59(18): 1736-1741 (Web site accessed 9/9/2003) http://www.medscape.com .
  12. DMERC Manual Parenteral Nutrition Chapter 63.  (Revised date 4/1/2003) (Web site accessed 6/2/2003) http://www.palmettogba.com .
  13. DMERC Manual Enteral Nutrition Chapter 62.  (Revised date 4/1/2003) Web site accessed 9/9/2003.) http://www.palmettogba.com .
  14. The Merck Manual of Diagnosis and Therapy Special Subjects, Section 21, Chapter 296.  Normal Laboratory Values. (2002) (Web site accessed 9/25/2003) http://www.merck.com .
  15. Intradialytic Parenteral Nutrition.  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual. (2003 December 17). Therapy: 8.01.44.
  16. Peter, J.V., Moran, J.L., et al.  A Metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients.  Critical Care Medicine (2005 January) 33(1): 213-20; discussion 260-1.
  17. Graves, C., Saffle, J., et al.  Caloric requirements in patients with necrotizing fasciitis.  Burns (2005 February) 31(1): 55-9.
  18. Javid, P.J., Collier, S., et al.  The role of enteral nutrition in the reversal of parenteral nutrition-associated liver dysfunction in infants.  Journal of Pediatric Surgery (2005 June) 40(6): 1015-8.
  19. Grau, T., and A. Bonet, A.  Multicenter study on incidence of total parenteral nutrition complications in the critically-ill patient.  ICOMEP study.  Part II Nutricion Hospitalaria (2005 July-August) 20(4): 278-85.
  20. Goonetilleke, K.S., and A.K. Siriwardena.  Systematic review of peri-operative nutritional supplementation in patients undergoing pancreatiocoduodenectomy.  Journal of the Pancreas (2006) 7(1): 5-13.
History
March 2010  Title change. Previously titled: Total Parenteral Nutrition (TPN) And Enteral Nutrition In The Home (EN)
November 2011 Added: Note: Currently there are no prior authorization requirements for Total Parenteral Nutrition (TPN).
February 2013 Removed over the counter and blenderized baby food from the Not Medically Necessary Policy Statement.
August 2013 Policy formatting and language revised.  Revised policy statement to include coverage criteria for TPN, oral nutrition, and intradialytic parenteral nutrition.  Title changed from "Enteral Nutrition In The Home" to "Alternative Modes of Nutrition in the Outpatient and Home Setting".
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Alternative Modes of Nutrition in the Outpatient and Home Setting