Description:
Total parenteral nutrition (TPN), 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. TPN 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.

Policy:
TPN is considered MEDICALLY NECESSARY in the treatment of inanition associated with conditions resulting in impaired intestinal absorption, including such conditions, but not limited to, any of the following:

• Crohn’s disease
• Obstruction secondary to stricture or neoplasm of the esophagus or stomach; loss of the swallowing mechanism due to a central nervous system disorder, where the risk of aspiration is great
• Short bowel syndrome secondary to massive small bowel resection
• Malabsorption due to enterocolic, enterovesical or enterocutaneous fistulas (TPN being temporary until the fistula is repaired)
• Motility disorder (pseudo-obstruction)
• Newborn infants with catastrophic gastrointestinal anomalies such as tracheoesophageal fistula, gastroschisis, omphalocele or massive intestinal atresia
• Infants and young children who fail to thrive due to systemic disease or secondarily to intestinal insufficiency associated with short bowel syndrome, malabsorption or chronic idiopathic diarrhea
• Patients with prolonged paralytic ileus following major surgery or multiple injuries

All of the following criteria must be met before the initial implementation of TPN:

• The patient must be in a stage of wasting as indicative of the following:
• Weight is significantly less than normal body weight for a patient’s height and age in comparison with pre-illness weight. 
• Blood urea nitrogen (BUN) is below 10 mg (but this is not a good marker in patients receiving dialysis due to protein catabolism).
• The patient can receive no more than 30 percent of his/her caloric needs orally or the patient cannot benefit from tube feedings as a result of a malabsorptive disorder.

Policy Guidelines:
In general, a daily caloric intake of 2,000 – 2,200 calories is sufficient to maintain body weight. If 750 calories per day or less are being administered by TPN, are considered supplemental, and benefits should be denied as NOT MEDICALLY NECESSARY.

Nutrients and their manner of administration for TPN  must be specifically ordered by a physician and be preapproved on an individual consideration basis.

Approved TPN services (those that require a physician’s prescription) may include, but are not limited to, the following:

• Cost of nutrients and solutions, cost of rental or purchase of an infusion pump and heparin lock
• Supplies and equipment necessary for the proper functioning and effective use of a TPN or EN system (e.g., catheters, dressings, IV stand, needles, filters, extension tubing and concentrated nutrients)
• Home visits by a physician
• Home visits by a registered nurse (RN) or licensed practical nurse (LPN) under the order and supervision of a physician, which meet guidelines for home care benefits. Skilled nursing services may include injection of drugs (IV or IM) and drawing of blood

Benefit Application:
BlueCard^®/National Account Issues
Benefits may be provided for placement of central venous catheters and gastrostomy or jejunostomy feeding tubes when policy guidelines have been met for TPN.

The total cost of renting equipment should not exceed the purchase cost of the equipment.

Benefits are usually not provided for nutritional substances when used:

• To increase protein or caloric intake in addition to the patient’s daily diet.
• In patients with a stable nutritional status, in whom only short-term parenteral nutrition might be required (i.e., for less than two weeks).
• For routine pre- and/or postoperative care.
• For over-the-counter enteral nutrition.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines. 

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward     

06/28/2024 Interim review, removing enteral nutrition from this policy. Creating new Enteral Nutrition policy. 

06/19/2024 Annual review. No changes to policy intent. 

01012024  NEW POLICY