Home » Clinical Professionals » Parenteral Nutrition

Parenteral Nutrition

Patient's must meet the below core criteria for coverage:

1. A failed enteral nutrition tube trial. (The enteral nutrition trial must be made, with appropriate attention to dilution, rate and alternative formulas to address side effects of diarrhea).
2. Unresponsiveness to prokinetic medication. (Defined as the presence of daily symptoms of nausea and vomiting while taking maximal doses)
3. Patient must have a permanent impairment. (Permanence does not require a determination that there is no possibility that the patient's condition may improve sometime in the future. If the judgment of the attending physician, substantiated in the medical record, is that the condition is of long and indefinite duration - ordinarily at least 3 months - the test of permanence is considered met).
4. A total daily caloric intake (parenteral, enteral and oral) is 20-35 cal/kg/day.

Parenteral nutrition is covered in any one of the following situations when all the above criteria is met and one of the below A-F criteria is met:

1. The patient has undergone recent (within the past 3 months) massive small bowel resection leaving less than five (5) feet of small bowel beyond the ligament of Trietz.
2. The patient has short bowel syndrome severe enough that the patient has net gastrointestinal fluid and electrolyte malabsorption such that on an oral intake of 2.5 - 3L / day the enteral losses exceed 50% of the oral / enteral intake and urine output is < 1 liter / day.
3. The patient requires bowel rest for at least 3 months and is receiving intravenously 20 - 35 cal/kg/day for treatment of symptomatic pancreatitis with or without pancreatic pseudocyst, severe exacerbation of regional enteritis, or a proximal enterocutaneous fistula where tube feedings distal to the fistula isn't possible.
4. The patient has a complete mechanical small bowel obstruction where surgery isn't an option.
5. The patient is significantly malnourished (10% weight loss over 3 months or less serum albumin < 3.4 gm/DL) and has very severe fat malabsorption (fecal fat exceeds 50% of oral / enteral intake on a diet of at least 50 grams of fat/day as measured by a standard 72 hour fecal fat test).
6. The patient significantly malnourished as (10% weight loss over 3 months or less and serum albumin < 3.4 gm/DL) and has severe motility disturbance of the small intestine and / or stomach which is unresponsive to prokinetic medication and is demonstrated either:
   4. scintigraphically (solid meal gastric emptying study demonstrates that the isotope fails to reach the right colon by 6 hours following ingestion), or
   5. radiographically (barium or radiopaque pellets fail to reach the right colon by 6 hours following administration).

   These studies must be performed when the patient is not acutely ill and is not on any medication which would decrease bowel motility.

   Unresponsiveness to prokinetic medication is defined as the presence of daily symptoms of nausea and vomiting while taking maximal doses.

   For criteria A-F above, the conditions are deemed to be severe enough that the patients would not be able to maintain weight and strength on only oral intake or tube enteral nutrition.

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

   Maintenance of weight and strength commensurate with the patients overall health status must require intravenous nutrition and must not be possible utilizing all of the following approaches:

   1. Modifying the nutrient composition of the enteral diet (i.e. 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. Utilizing pharmacological means to treat the etiology of the malabsorption (i.e. pancreatic enzymes or bile salts, broad spectrum antibiotics for bacterial overgrowth, prokinetic medication for reduced motility, etc.)
7. The patient is malnourished (10% weight loss over 3 months or less and serum albumin < 3.4 gm/DL), AND
8. The patient has a disease or clinical condition that has been documented as being present and it hasn't responded to alteration of the manner of delivery of appropriate nutrients (e.g. slow infusion through a tube with the tip located in the stomach or jejunum)

View and Print the TPN qualification checklist^*

Return to Top »