Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Nutrition (IPN)
Policy #:MA08.008d

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

TOTAL PARENTERAL NUTRITION

MEDICALLY NECESSARY
Total parenteral nutrition (TPN) is considered medically necessary and, therefore, covered when both of the following indications are met:
  • The individual has a permanently impaired* (non-functioning) gastrointestinal tract resulting in insufficient absorption of nutrients to maintain adequate strength and weight.
  • The individual failed a tube trial of enteral nutrition through an enteral feeding tube by meeting at least one of the following:
    • A concerted effort was made to place an enteral feeding tube or is contraindicated
    • A trial with enteral nutrition was made, with appropriate attention to dilution, rate, and alternative formulas to address side effects of diarrhea. (See the Guideline Section for more information on Enteral Feeding Tube Trials.)
AND EITHER:
  • The individual meets one of the following conditions, which are considered to be severe enough that the individual would not be able to maintain weight and strength on only oral intake or through an enteral feeding tube:
    • The individual has undergone a recent (within the past 3 months) massive small bowel resection leaving less than or equal to 5 feet of small bowel beyond the ligament of Treitz, or
    • The individual has a short bowel syndrome that is severe enough that the individual 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 less than 1 liter/day, or
    • The individual requires bowel rest for at least 3 months and is receiving intravenously 20-35 cal/kg/day for treatment of symptomatic pancreatitis with/without pancreatic pseudocyst, severe exacerbation of regional enteritis, or a proximal enterocutaneous fistula where tube feeding distal to the fistula isn't possible, or
    • The individual has complete mechanical small bowel obstruction where surgery is not an option, or
    • The individual is significantly malnourished (10% weight loss over 3 months or less and serum albumin less than or equal to 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 gm of fat/day as measured by a standard 72 hour fecal fat test), or
    • The individual is significantly malnourished (10% weight loss over 3 months or less and serum albumin less than or equal to 3.4 gm/dl) and has a severe motility disturbance of the small intestine and/or stomach which is ***unresponsive to prokinetic medication and is demonstrated by either:
      • Scintigraphically (solid meal gastric emptying study demonstrates that the isotope fails to reach the right colon by 6 hours following ingestion), or
      • Radiographically (barium or radiopaque pellets fail to reach the right colon by 6 hours following administration). These studies must be performed when the individual is not acutely ill and is not on any medication that would decrease bowel motility.
    • The individual has severe Hyperemesis Gravidarum.
OR:
  • The individual meets All of the following criteria:
    • Maintenance of weight and strength commensurate with the individual’s overall health status requires intravenous nutrition and is not possible by utilizing both of the following approaches:
      • 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
      • 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.).
    • The individual is malnourished (10% weight loss over 3 months or less and serum albumin less than or equal to 3.4 gm/dL).
    • 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 an enteral feeding tube with the tip located in the stomach or jejunum).

*A permanent impairment, is defined as a permanence that does not require a determination that there is no possibility that the individual's condition may improve sometime in the future. If the judgment of the professional provider, 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.

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

NOT MEDICALLY NECESSARY
Total parenteral nutrition is considered not medically necessary, and therefore, not covered for individuals who do not meet the above criteria.

Parenteral nutrition is considered not medically necessary, and therefore, not covered for individuals with a functioning gastrointestinal tract whose need for parenteral nutrition is only required because of any of the following conditions, such as, but not limited to:
  • Swallowing disorder
  • Temporary defect in gastric emptying, such as a metabolic or electrolyte disorder
  • Psychological disorder impairing food intake, such as depression
  • Metabolic disorder inducing anorexia, such as cancer
  • Physical disorder impairing food intake, such as the dyspnea of severe pulmonary or cardiac disease
  • Side effect of a medication
  • Renal failure and/or dialysis

SPECIAL FORMULATIONS OF PARENTERAL NUTRITION

MEDICALLY NECESSARY
Parenteral nutrition solutions containing little or no amino acids and/or carbohydrates is considered medically necessary, and therefore covered, for any of the following indications:
  • The individual has undergone recent (within the past 3 months) massive small bowel resection leaving less than or equal to 5 feet of small bowel beyond the ligament of Treitz, or
  • The individual has a short bowel syndrome that is severe enough that the individual 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 less than 1 liter/day, or
  • The individual has complete mechanical small bowel obstruction where surgery is not an option.

INTRADIALYTIC PARENTERAL NUTRITION

MEDICALLY NECESSARY
Intradialytic parenteral nutrition (IDPN) is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • When it is infused as an alternative to a regularly scheduled regimen of TPN in individuals who meet the medical necessity criteria for TPN

For individuals with a functional gastrointestinal tract, IDPN is not covered under the medical benefit (Part B); however, IDPN, in members with a functional gastrointestinal tract, may be considered for coverage under the Pharmacy Benefit (Part D), if such a benefit exists.

INTRAPERITONEAL NUTRITION

MEDICALLY NECESSARY
Intraperitoneal nutrition (IPN) is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has a documented comprehensive nutritional assessment and dietary counseling
  • In spite of enteral nutrition via tube feeding, or adequate oral nutrition, the individual has evidence of protein or energy malnutrition as defined by any of the following:
    • Evidence of protein intake <1.2g/Kg or calories<25 Kcal/Kg
    • Evidence of weight loss 10-20% of usual body weight within 3-6 months
    • Serum Albumin Levels <3.4 g/l (3 months average)
  • The individual has evidence of adequate dialysis therapy

ASSOCIATED SERVICES

When an infusion therapy service is covered, all associated services (e.g., solutions, additives, equipment and/or supplies, nursing) are considered covered and eligible for reimbursement.

When an infusion therapy service is noncovered, all associated services (e.g., solutions, equipment and/or supplies, nursing) are considered noncovered and ineligible for reimbursement.

REQUIRED DOCUMENTATION

NON-FUNCTIONING GASTROINTESTINAL TRACT
  • A total caloric daily intake (parenteral, enteral and oral) of 20-35 cal/kg/day is considered sufficient to achieve or maintain appropriate body weight. The ordering professional provider must document in the medical record the medical necessity for a caloric intake outside this range for the individual.
  • The ordering professional provider must document the medical necessity for protein orders outside of the range of 0.8-1.5 gm/kg/day, dextrose concentration less than 10%, or lipid use greater than 1500 grams (150 units of service of code B4185) per month.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.
Policy Guidelines

ENTERAL FEEDING TUBE TRIAL
  • For gastroparesis, tube placement must be post-pylorus, preferably in the jejunum.

EXAMPLES OF A FAILED ENTERAL FEEDING TUBE TRIAL
  • An individual who has had documented placement of a tube in the post-pyloric area continues to have problems with vomiting and on radiographic recheck the tube has returned to the stomach.
  • After an attempt of sufficient time (5-6 hours) to get a tube into the jejunum, the tube does not progress and remains in the stomach or duodenum.
  • An attempt of enteral tube feeding with a very slow drip was made. It was initially tolerated well but vomiting occurred when the rate was increased.
  • After placement of the tube in the jejunum and 1-2 days of enteral tube feeding, the individual has vomiting and distension.
  • A tube is placed appropriately and remains in place. Enteral nutrition is initiated and the concentration and rate are increased gradually. Over the course of 3-4 weeks, attempts to increase the rate and/or concentration and/or to alter the formula to reach the targeted intake are unsuccessful, with increase in diarrhea, bloating or other limiting symptoms, and the individual is unable to meet the needed nutritional goals (stabilize at desired weight or gain weight as needed).

CONDITIONS REQUIRING A FAILED ENTERAL TUBE FEEDING TRIAL
The following are some examples of moderate abnormalities which would require a failed trial of enteral tube feeding before parenteral nutrition would be covered:
  • Moderate fat malabsorption: fecal fat exceeds 25% of oral/enteral intake on a diet of at least 50 gm of fat/day as measured by a standard 72 hour fecal fat test.
  • Diagnosis of malabsorption with objective confirmation by methods other than 72 hour fecal fat test (e.g., Sudan stain of stool, d-xylose test, etc.)
  • Gastroparesis that has been demonstrated (a) radiographically or scintigraphically as described above with the isotope or pellets failing to reach the jejunum in 3-6 hours, or (b) by manometric motility studies with results consistent with an abnormal gastric emptying, and which is unresponsive to prokinetic medication
  • A small bowel motility disturbance which is unresponsive to prokinetic medication, demonstrated with a gastric to right colon transit time between 3-6 hours.
  • Small bowel resection leaving greater than 5 feet of small bowel beyond the ligament of Treitz
  • Short bowel syndrome that is not severe.
  • Mild to moderate exacerbation of regional enteritis or an enterocutaneous fistula.
  • Partial mechanical small bowel obstruction where surgery is not an option.

MEDICARE DETERMINATION

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, total parenteral nutrition (TPN), intradialytic nutrition (IDPN), and intraperitoneal nutrition (IPN) are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

For individuals with a functional gastrointestinal tract, IDPN is not covered under the medical benefit (Part B); however, IDPN, in members with a functional gastrointestinal tract, may be considered for coverage under the Pharmacy Benefit (Part D), if such a benefit exists.

Description

Parenteral nutrition is the provision of nutritional requirements intravenously or can also be given during hemodialysis or peritoneal dialysis.

TOTAL PARENTERAL NUTRITION (TPN)

Total parenteral nutrition (TPN), also known as parenteral hyperalimentation, is used for individuals with medical conditions that impair gastrointestinal absorption. It is also used for variable periods of time to bolster the nutritional status of severely malnourished individuals with medical or surgical conditions. TPN given intravenously, 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 ensure a steady flow of the solution.

INTRADIALYTIC PARENTERAL NUTRITION (IDPN)

Intradialytic parenteral nutrition (IDPN) is the infusion of an intravenous nutritional formula of hyperalimentation, such as amino acids, glucose, and sometimes, lipids, during dialysis, to treat protein calorie malnutrition in an effort to decrease the associated morbidity and mortality experienced in patients with renal failure.

INTRAPERITONEAL NUTRITION (IPN)

Intraperitoneal nutrition also called is the provision of nutrients through the peritoneum. Amino acid-based dialysis solution has shown that the amino acids absorbed during one exchange quantitatively exceed the daily losses of proteins and amino acids. The supplementary amino acids are well tolerated and can induce protein anabolism in many malnourished PD individuals. Peritoneal dialysis (PD) is a common form of home dialysis treatment among individuals with end-stage renal disease (ESRD). A mixture of minerals and sugar dissolved in water (dialysis solution), travels through a dialysis catheter into your belly. The sugar—called dextrose—draws wastes, chemicals, and extra water from the tiny blood vessels in your peritoneal membrane into the dialysis solution. After several hours, the used solution is drained from your abdomen through the tube, taking the wastes from your blood with it. Then your abdomen is refilled with fresh dialysis solution, and the cycle is repeated. The process of draining and refilling is called an exchange.
References

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered Medical and Other Health Services. [CMS Website]. 120 - Prosthetic Devices (Rev. 256, 01-01-19) Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf . Accessed May 29, 2019.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Enteral and Parenteral Nutritional Therapy (180.2). effective date: 7/11/1984. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=242&ncdver=1&DocID=180.2&bc=gAAAABAAAAAA&. Accessed May 29, 2019.

Herrell HE. Nausea and vomiting of pregnancy. Am Fam Physician. 2014;89(12):965-70.

KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 update. Executive summary. Am J Kidney Dis 2009; 53(3 Suppl 2):S11-104. Available at: https://www.kidney.org/sites/default/files/docs/cpgpednutr2008.pdf . Accessed May 29, 2019.

Noridian. Local Coverage Determination (LCD). L33798: Parenteral Nutrition. Original effective: 10/01/2015. Revised effective: 01/01/17. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Parenteral+Nutrition+LCD+and+PA/1b7429bc-6645-41dc-8167-88a15ffed946. Accessed May 29, 2019.

Noridian. Parenteral Nutrition - Policy Article - (A52515) Original effective: 10/01/2015. Revised Effective: .01/01/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52515&ver=24&Date=01%2f01%2f2019&DocID=A52515&SearchType=Advanced&bc=JAAAABAAAAAA&
Accessed May 29. 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



THE FOLLOWING CODES REPRESENT HOME INFUSION THERAPY:

S9364 Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem (do not use with home infusion codes S9365-S9368 using daily volume scales)

S9365 Home infusion therapy, total parenteral nutrition (TPN); 1 liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem

S9366 Home infusion therapy, total parenteral nutrition (TPN); more than 1 liter but no more than 2 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem

S9367 Home infusion therapy, total parenteral nutrition (TPN); more than 2 liters but no more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem

S9368 Home infusion therapy, total parenteral nutrition (TPN); more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem

THE FOLLOWING CODES REPRESENT PARENTERAL NUTRITION SOLUTIONS:

B4164 Parenteral nutrition solution; carbohydrates (dextrose), 50 % or less (500 ml = 1 unit) - home mix

B4168 Parenteral nutrition solution; amino acid, 3.5 %, (500 ml = 1 unit) - home mix

B4172 Parenteral nutrition solution; amino acid, 5.5 % through 7 %, (500 ml = 1 unit) - home mix

B4176 Parenteral nutrition solution; amino acid, 7 % through 8.5 %, (500 ml = 1 unit) - home mix

B4178 Parenteral nutrition solution; amino acid, greater than 8.5 % (500 ml = 1 unit) - home mix

B4180 Parenteral nutrition solution; carbohydrates (dextrose), greater than 50 % (500 ml = 1 unit) - home mix

B4185 Parenteral nutrition solution, not otherwise specified, 10 grams lipids

B4189 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein-premix

B4193 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 52 to 73 grams of protein-premix

B4197 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength 74 to 100 grams of protein-premix

B4199 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix

B4216 Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) - home mix, per day

THE FOLLOWING CODES REPRESENT SPECIALIZED NUTRITION SOLUTIONS:

B5000 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal-aminosyn-rf, nephramine, renamine-premix

B5100 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, hepatamine-premix

B5200 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids-freamine-hbc-premix

THE FOLLOWING CODE REPRESENTS PARENTERAL NUTRITION SOLUTIONS CONTAINING LESS THAN 10 GRAMS OF PROTEIN PER DAY:

B9999 NOC for parenteral supplies

THE FOLLOWING CODES REPRESENT PARENTERAL NUTRITION EQUIPMENT AND SUPPLIES:
B4220 Parenteral nutrition supply kit; premix, per day

B4222 Parenteral nutrition supply kit; home mix, per day

B4224 Parenteral nutrition administration kit, per day

B9004 Parenteral nutrition infusion pump, portable

B9006 Parenteral nutrition infusion pump, stationary



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References




Policy History

MA08.008d
01/01/2020This version of the policy will become effective 01/01/2020. The following HCPCS code B4185 has a revised narrative.


MA08.008c
07/17/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Nutrition (IPN).
11/21/2018This policy became effective 9/21/2016. It has been reviewed and reissued to communicate the Company’s continuing position on Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN).
06/21/2017This policy has been reissued in accordance with the Company's annual review process.
09/21/2016The policy criteria was expanded regarding Specialized Formulations, to include coverage of solutions such as Proplete. Updates were made to the Coding Table to allow for billing by eligible participating home infusion companies.

MA08.008b
01/29/2016 The intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits.

MA08.008a
01/01/2016 The following HCPCS narratives have been revised in this policy effective 1/1/2016.

B5000
FROM: Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - Amirosyn RF, nephramine, renamine - premix
TO: Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal-aminosyn-rf, nephramine, renamine-premix

B5100
FROM: Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic - Freamine HBC, HepatAmine - premix
TO: Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, hepatamine-premix

B5200
FROM: Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress - branch chain amino acids – premix

TO: Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids-freamine-hbc-premix

MA08.008
01/01/2015This is a new policy.




Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A