Alternative Modes of Nutrition in the Outpatient and Home Setting
© Blue Cross and Blue Shield of Montana
Current Effective Date:
December 27, 2013
Original Effective Date:
January 01, 2001
September 27, 2013
December 15, 2004; March 1, 2010; November 15, 2011; August 14, 2013
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;
- 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);
- 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);
- 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.
Refer to the ICD-9-CM manual.
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
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||Title change. Previously titled: Total Parenteral Nutrition (TPN) And Enteral Nutrition In The Home (EN)|
||Added: Note: Currently there are no prior authorization requirements for Total Parenteral Nutrition (TPN).|
||Removed over the counter and blenderized baby food from the Not Medically Necessary Policy Statement.|
||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".|