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DESCRIPTIONParenteral nutritional support (PEN), also known as parenteral hyperalimentation, is used for patients with medical conditions that impair gastrointestinal absorption to a degree incompatible with life. It is also used for variable periods of time to bolster the nutritional status of severely malnourished patients with medical or surgical conditions. PEN involves percutaneous transvenous implantation of a central venous catheter into the vena cava or right atrium. A nutritionally adequate hypertonic solution consisting of glucose (sugar), amino acids (protein), electrolytes (sodium, potassium), vitamins and minerals, and sometimes fats is administered daily. An infusion pump is generally used to assure a steady flow of the solution either on a continuous (24-hour) or intermittent schedule. If intermittent, a heparin lock device and diluted heparin are used to prevent clotting inside the catheter.
Enteral nutrition support (EN) is used 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. The patient is at risk of severe malnutrition. EN involves administering non-sterile 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/day).
POLICYParticipating providers are required to follow the American Dietetic Association Medical Nutrition Therapy Protocols for Parenteral and Enteral Feeding Support.
Parenteral feeding support (PEN) in the home is considered medically necessary in the treatment of inanition associated with conditions resulting in impaired intestinal absorption, including the following conditions, but not limited to, any of the conditions listed in the "Code Reference" section.
The following criteria must be met prior to the initial implementation of parenteral feeding support (PEN):
Enteral feeding support (EN) in the home is considered medically necessary under the following conditions:
If 25% of estimated calories needed per day or less are being administered by PEN or EN, they are considered supplemental and benefits will be denied as not medically necessary.
Benefits will not be provided for nutritional substances when used:
Blenderized baby food and regular shelf food used with an enteral system are not eligible for benefits.
Nutrients and their method of administration for both PEN and EN must be specifically ordered by a physician.
Approved PEN or EN services (those that require a physician's prescription) may include, but are not limited to, the following:
POLICY GUIDELINESGlobal allowances for PEN and EN feeding support in the home include nursing services, cost of supplies, clinical pharmacy service, dietitian monitoring, supply delivery and administrative overhead.
Benefits may be provided for placement of central venous catheters and nasogastric, nasojejunostomy, gastrostomy or jejunostomy feeding tubes when policy guidelines have been met for PEN or EN.
The total cost of renting equipment should not exceed the purchase cost of the equipment.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY6/1994: Approved by Medical Policy Advisory Committee (MPAC) as Home Hyperalimentation
5/1999: MPAC reviewed, updated and renamed policy, HCPCS T0015, T0030, T0045, T0060 added
3/5/2002: Prior authorization deleted
3/12/2002: New 2002 HCPCS B4164, B4168, B4172, B4176, B4178, B4180, B4184, B4186, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9000, B9002, B9004, B9006, B9998, B9999 added
3/19/2002: Fifth digit required for 643.0X, review on an "Individual basis" for 577.0 and 643.0X has been deleted
5/2/2002: Type of Service and Place of Service deleted
5/28/2002: Code Reference section updated, CPT 99560, 99561, 99562 added, HCPCS B4081, B4082, B4083, B4086, S5520, S5522, S9123, S9124, S9340, S9341, S9342, S9343, S9364-S9368, S9374-S9379, S9524 added
8/26/2003: Code Reference section updated, CPT code 97802, 99341-99350, 99601, 99602 added, CPT code 99560, 99561, 99562 deletion dated of 6/30/2003 added, ICD-9 procedure code 99.15 added, ICD-9 diagnosis codes 530.3, 537.89, 560.9, 577.0, 643.0X, 750.3, 751.2, 756.79 listed separately, 643.0X fifth digit added, ICD-9 diagnosis code 141.0-141.9, 150.0-150.9, 151.0-151.9, 195.0, 197.8, 198.89, 210.0-210.9, 211.0, 211.1. 230.0-230.2, 232.4, 234.8, 235.0-235.2, 235.5, 238.8, 239.0, 239.8, 261, 783.21 added, HCPCS B4034, B4035, B4036, B4081, B4082, B4083, B4086, B4164, B4168, B4172, B4176, B4178, B4180, B4184, B4186, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9000, B9002, B9004, B9006, B9998, B9999, S9123, S9124, S9374-S9379, S9524 deleted, HCPCS S9364-S9368 listed separately, HCPCS G0108, G0109, S5517, S5518 added, HCPCS H0201, H0300, H0301, H0600 BCBSMS deletion date of 9/30/2003 added, HCPCS S5520, S5522 description revised, HCPCS T0015, T0030, T0045, T0060 “BCBSMS deletion date of 9/30/2003, see codes G0108-G0109 and 97802” added, Notes “**B4150 is the code used for all categories. Processors will recode any codes from B4151-B4156 to B4150” and “B4081-B4086 are included in the global service H0300 or H0301. B4081-B4086 will be bundled with either H0300 or H0301 on the claim” deleted, conditions moved from "Code Reference" section to "Policy" section
3/23/2005: Code Reference section reviewed, CPT code 97803, 97804 added covered codes, CPT 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 description revised, CPT 99560, 99561, 99562 deleted, HCPCS B4102, B4103, B4104, B4157, B4158, B4159, B4160, B4161, B4162, B4164, B4168, B4172, B4176, B4178, B4180, B4184, B4186, B4189, B4193, B4197, B4199, B4216, B5000, B5100, B5200 added covered codes, HCPCS B4151, B4156 description revised and deletion date of 12/31/2004 added, HCPCS B4152, B4153, B4154, B4155 description revised, HCPCS T0015, T0030, T0045, T0060 deleted, non-covered codes table added, HCPCS B4149 added non-covered codes
3/9/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy.
10/23/2006: Policy reviewed, no changes
9/20/2007: Code Reference section updated. ICD-9 2007 revisions added to policy
9/15/2008: Code reference section updated per the annual ICD-9 updates effective 10-1-2008
9/28/2009: Code reference section updated. New ICD-9 diagnosis codes 239.81, 239.89, 756.72 and 756.73 added to covered table. Deleted statement added to ICD9 diagnosis code 239.8.
4/29/2010: Policy statement clarified that benefits will not be provided for over-the-counter nutritional supplements or enteral nutrition.
3/26/2012: further policy clarification about nutritionals
08/31/2015: Medical policy revised to add ICD-10 codes. Removed ICD-9 procedure code 99.15, ICD-9 diagnosis code 239.8, and HCPCS codes B4151, B4156, B4184, and B4186 from the Code Reference section.
SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policy #1.02.01
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.
Not Medically Necessary Codes