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MEDICARE QUALIFYING COVERAGE CRITERIA FOR TOTAL PARENTERAL NUTRITION

Please note the following information was taken from the Region C DMEPOS Supplier Manual. The manual details Medicare's guidelines for parenteral therapy.

TPN QUALIFYING CHECKLIST

GENERAL CRITERIA

If NO is answered to the following questions, the patient does not meet the GENERAL CRITERIA and claims will be denied at entry level.

1. YES NO The patient has permanent impairment (at least 3 months)
2. YES NO The patient has (A) a condition involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients or (B) disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported through the GI system. There must be objective evidence supporting the clinical diagnosis.
3. YES NO A concerted effort was made to place a tube
4. YES NO A trial with enteral nutrition was made, with appropriate attention to dilution, rate, and alternative formulas to address the side effects of diarrhea.

In addition to the above questions, patients MUST meet the following core coverage criteria in order to qualify for Medicare.

CORE COVERAGE CRITERIA: Maintenance of weight and strength commensurate with the patient's overall health must necessitate IV nutrition and cannot otherwise be managed by:

1. YES NO Modifying the nutrient composition of the enteral diet (e.g. lactose-free, gluten-free low in long chain triglycerides, substitution with medium chain triglycerides, provision of protein as peptides or amino acids, etc.), and
2. YES NO Utilizing pharmacologic means to treat the etiology of the malabsorption (e.g. pancreatic enzymes or bile salts, broad spectrum antibiotics for bacterial overgrowth, prokinetic medication for reduced motility, etc.)

SUPPORTING CRITERIA

If YES is answered to the above General Criteria and Core Coverage Criteria. Parenteral Nutrition will be covered if one of the following is met.

1. YES NO The patient has undergone recent (within the past three months) massive small bowel resection leaving 5 feet or less of small bowel beyond the ligament of Treitz, or
2. YES NO The patient has a short bowel syndrome that is severe enough that the patient has net gastrointestinal fluid and electrolyte malabsorption such that on an oral intake of 2.5-3 liters/day the enteral losses exceed 50% of the oral/enteral intake and the urine output is < 1 liter/day, or
3. YES NO The patient requires bowel rest for at least three months and is receiving intravenously 20-35 cal/kg/day for treatment of
   1. Symptomatic pancreatitis with/without pancreatic pseudocyst, or
   2. Severe exacerbation of regional enteritis, or
   3. A proximal enterocutaneous fistula where tube feeding distal to the fistula isn't possible, or
4. YES NO The patient has complete mechanical small bowel obstruction where surgery is not an option, or
5. YES NO The patient is significantly malnourished as evidenced by:
   1. 10% weight loss over 3 months or less and
   2. Serum albumin is less than or equal to 3.4 gm/DL and
   3. Severe fat malabsorption
6. YES NO The patient is significantly malnourished as evidenced by:
   1. 10% weight loss over 3 months or less and
   2. Serum albumin is less than or equal to 3.4 gm/DL and
   3. Severe motility disturbance of the small intestine and/or stomach which is unresponsive to prokinetic medication and is demonstrated either scintigraphically or radiographically.

Patients who do not meet criteria A-F above must meet core coverage criteria 1-2 above (modification of diet and pharmacologic intervention) plus criteria G and H below:

7. YES NO The patient is malnourished
1. 10% weight loss over 3 months or less and
2. Serum albumin is less than or equal to 3.4 gm/DL and
8. YES NO A disease and clinical condition has been documented as being present and it has not responded to altering the manner of delivery of appropriate nutrients, (e.g. slow infusion of nutrients through a tube with the tip located in the stomach or jejunum.)