Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 08.00.18m


Attachment:C

Policy #:08.00.18m

Description:Caloric Requirements

Title:Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk


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.



This attachment contains several calculations for the energy requirements for individuals.

CALORIC REQUIREMENTS IN CHILDREN

SAMPLE ESTIMATED ENERGY REQUIREMENTS FOR HEALTHY BOYS AND GIRLS OF MEDIAN WEIGHT AND HEIGHT (FOR AGE AT 50TH PERCENTILE)

Age
Boys - estimated energy requirements (kcal/kg/day)
Girls - estimated energy requirements (kcal/kg/day)
0–2 mo
107
104
3 mo
95
95
4–35 mo
82
82
Boys
Girls
Median Weight, Boys (kg) Sedentary * (kcal/kg/d) Active * (kcal/kg/d) Median Weight, Girls (kg) Sedentary * (kcal/kg/d) Active *(kcal/kg/d)
3 yr
14.3
80
104
13.9
76
100
4 yr
16.2
74
97
15.8
70
93
5 yr
18.4
68
90
17.9
65
87
6 yr
20.7
63
84
20.2
61
81
7 yr
23.1
59
80
22.8
56
75
8 yr
25.6
56
75
25.6
52
71
9 yr
28.6
53
71
29.0
48
65
10 yr
31.9
49
67
32.9
44
60
11 yr
35.9
46
63
37.2
41
56
12 yr
40.5
44
60
41.6
38
52
13 yr
45.6
42
57
45.8
36
50
14 yr
51.0
40
55
49.4
34
47
15 yr
56.3
39
54
52.0
33
45
16 yr
60.9
38
52
53.9
32
44
17 yr
64.6
36
50
55.1
31
43
18 yr
67.2
35
49
56.2
30
42
* See definition of sedentary and active Physical Activity Level (PAL) below for further information.
    References for Caloric Requirements in Children:

    Engorn B, Flerlage J. The Harriet Lane Handbook. 20th ed. Philadelphia, PA: Elsevier Saunders; 2015.

    Otten JJ, Hellwig JP, Meyers LD, eds. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements . Washington, DC: National Academies Press, 2006.

*PHYSICAL ACTIVITY LEVELS (PAL) IN CHILDREN AND ADULTS:

Physical Activity Coefficients (PA Values) for Use in EER Equations
Sedentary
(PAL* 1.0–1.39)
Low Active
(PAL* 1.4–1.59)
Active
(PAL* 1.6–1.89)
Very Active
(PAL* 1.9–2.5)
Typical daily living
activities (e.g., household tasks, walking to the bus)
Typical daily living
activities PLUS 30-60 minutes of daily moderate activity (e.g., walking 5-7 km/h)
Typical daily living
activities PLUS at least 60 minutes of daily moderate activity
Typical daily living
activities PLUS at least 60 minutes of daily moderate activity PLUS an additional 60 minutes of vigorous activity or 120 minutes of moderate activity
Boys 3–18 y1.001.131.261.42
Girls 3–18 y1.001.161.311.56
Men 19 y +1.001.111.251.48
Women 19 y +1.001.121.271.45
    References for Caloric Requirements in Children:

    Coulston A, Boushey CJ, Ferruzzi MG. Nutrition in the Prevention and Treatment of Disease, 3rd Ed. 2013.

    Engorn B, Flerlage J. The Harriet Lane Handbook. 20th ed. Philadelphia, PA: Elsevier Saunders; 2015.

    Escott-Stump S. Nutrition and Diagnosis - Related Care, 7th Ed. 2012. Wolters Kluwer/Lippincott Williams & Wilkins. Philadelphia, PA.

    Otten JJ, Hellwig JP, Meyers LD, eds. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements . Washington, DC: National Academies Press, 2006.

CALORIC REQUIREMENTS IN CHILDREN AND ADULTS:

1. Equations based on the following sources: Coulston 2013, Escott-Stump (2012), Otten (2006)

Infants and Young Children
Estimated Energy Requirement (EER) (kcal/day) = Total Energy Expenditure + Energy Deposition
0–3 months EERa = (89 X weight [kg] –100) + 175
4–6 months EER = (89 X weight [kg] –100) + 56
7–12 months EER = (89 X weight [kg] –100) + 22
13–35 months EER = (89 X weight [kg] –100) + 20

Children and Adolescents 3–18 years
Estimated Energy Requirement (EER) (kcal/day) = Total Energy Expenditure + Energy Deposition
Boys
3–8 years EER = 88.5 – (61.9 X age [y]) + PAL* X [(26.7 X weight [kg]) + (903 X height [m])] + 20
9–18 years EER = 88.5 – (61.9 X age [y]) + PAL X [(26.7 X weight [kg]) + (903 X height [m])] + 25
Girls
3–8 years EER = 135.3 – (30.8 X age [y]) + PAL X [(10.0 X weight [kg]) + (934 X height [m])] + 20
9–18 years EER = 135.3 – (30.8 X age [y]) + PAL X [(10.0 X weight [kg]) + (934 X height [m])] + 25

Adults 19 years and older
Estimated Energy Requirement (EER) (kcal/day) = Total Energy Expenditure
Men EER = 662 – (9.53 X age [y]) + PAL* X [(15.91 X weight [kg]) + (539.6 X height [m])]
Women EER = 354 – (6.91 X age [y]) + PAL X [(9.36 X weight [kg]) + (726 X height [m])]

Pregnancy
Estimated Energy Requirement (EER) (kcal/day) = Nonpregnant EER + Pregnancy Energy Deposition
1st trimester EER = Nonpregnant EER + 0
2nd trimester EER = Nonpregnant EER + 340
3rd trimester EER = Nonpregnant EER + 452

Lactation
Estimated Energy Requirement (EER) (kcal/day) = Nonpregnant EER + Milk Energy Output – Weight Loss
0–6 months postpartum EER = Nonpregnant EER + 500 – 170
7–12 months postpartum EER = Nonpregnant EER + 400 – 0
    NOTE: These equations provide an estimate of energy requirement. Relative body weight (i.e., loss, stable, gain) is the preferred indicator of energy adequacy.
    * See definition of sedentary and active Physical Activity Level (PAL) above for further information.

    References for Caloric Requirements in Children and Adults:

    Coulston A, Boushey CJ, Ferruzzi MG. Nutrition in the Prevention and Treatment of Disease, 3rd Ed. 2013.

    Escott-Stump S. Nutrition and Diagnosis - Related Care, 7th Ed. 2012. Wolters Kluwer/Lippincott Williams & Wilkins. Philadelphia, PA.

    Otten JJ, Hellwig JP, Meyers LD, eds. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements . Washington, DC: National Academies Press, 2006.


2. Harris-Benedict Equations (1919):

REE = Resting Energy Expenditure

Women: REE (kcal/day) = 655 + 9.56 (weight in kg) + 1.85 (height in cm) - 4.68 (age in years)

Men: REE (kcal/day) = 66.5 + 13.75 (weight in kg) + 5 (height in cm) - 6.76 (age in years)
    References for Caloric Requirements in Children and Adults:

    Coulston A, Boushey CJ, Ferruzzi MG. Nutrition in the Prevention and Treatment of Disease, 3rd Ed. 2013.

    Harris JA, Benedict FG. A Biometric Study of Basal Metabolism in Man. Washington, DC: Carnegie Institution, 1919.

3. Harris–Benedict Equations revised by Mifflin and St Jeor (1990):

REE = Resting Energy Expenditure.
Note: REE is usually multiplied by PAL*

Females: REE = 10 X weight (kg) + 6.25 X height (cm) – 5 X age (y) – 161

Males: REE = 10 X weight (kg) + 6.25 X height (cm) – 5 X age (y) + 5

CALORIC REQUIREMENTS IN ADULTS:

Short methods for calculating energy needs:

1. Energy Needs Based on Level of Activity or Illness:

Level of Activity or Illness
GoalLowModerateHigh
Lose weight15 kcal/kg20 kcal/kg25 kcal/kg
Maintain weight20 kcal/kg25 kcal/kg30 kcal/kg
Gain weight25 kcal/kg30 kcal/kg35 kcal/kg

2. Energy Needs Based on Gender:
Note: weight in lbs.

Men or active women15 kcal/lb
Most women, sedentary men, adults over 55 years13 kcal/lb
Sedentary women, obese adults10 kcal/lb
Pregnant women
1st trimester13-15 kcal/lb
2nd and 3rd trimester16-17 kcal/lb
Lactating women15-17 kcal/lb

References for Caloric Requirements Adults:

    Escott-Stump S. Nutrition and Diagnosis - Related Care, 7th Ed. 2012. Wolters Kluwer/Lippincott Williams & Wilkins. Philadelphia, PA.


Version Effective Date: 01/01/2019
Version Issued Date: 12/31/2018
Version Reissued Date: 10/23/2019

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