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DESCRIPTIONProtein calorie malnutrition, typically assessed by measurements of serum albumin, occurs in an estimated 25%-40% those undergoing dialysis and is associated with increased morbidity and mortality. For example, the risk of death is increased more than 10-fold in those whose serum albumin levels are less than 2.5g/dl, and those with a serum albumin near the normal range (i.e., between 3.5 to 3.9g/dl) have a mortality rate twice as high as those with albumin greater than 4.0 g/dl. In patients receiving chronic dialysis, the National Kidney Foundation currently recommends a daily protein intake of >1.2 g/kg in patients undergoing hemodialysis and >1.3 g/kg in patients undergoing peritoneal dialysis. Intradialytic parenteral nutrition, infusion hyperalimentation fluids at the time of either hemodialysis or peritoneal dialysis, has been investigated as a technique to treat protein calorie malnutrition in an effort to decrease the associated morbidity and mortality.
POLICYIntradialytic parenteral nutrition may be considered medically necessary when it is offered as an alternative to a regularly scheduled regimen of total parenteral nutrition only in those patients who would be considered candidates for total parenteral nutrition (TPN), i.e. a severe pathology of the alimentary tract that does not allow absorption for sufficient nutrients to maintain weight and strength commensurate with the patient's general condition.
Intradialytic parenteral nutrition is considered not medically necessary in those patients who would be considered a candidate for TPN, but for whom the intradialytic parenteral nutrition is not offered as an alternative to TPN, but in addition to regularly scheduled infusions to TPN.
Intradialytic parenteral nutrition is considered investigational in those patients who would not otherwise be considered candidates for TPN.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY5/18/2006: Approved by Medical Policy Advisory Committee (MPAC)
7/11/2008: Policy reviewed, no changes
04/13/2010: Policy description updated. Policy statement unchanged.
08/02/2011: Policy reviewed; no changes.
07/17/2012: Policy reviewed; no changes.
10/21/2013: Policy reviewed; no changes.
SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.44
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.