TPN Qualification Checklist for Medicare

TPN Qualification Checklist for Medicare

Core Coverage Criteria

1. Has an enteral trial failed? Yes    No   
2. Have pharmacological means been tried to treat the etiology of the malabsorption? Yes    No   

(e.g., pancreatic enzymes or bile salts, broad spectrum antibiotics for bacterial overgrowth, prokinetic medication for reduced motility, etc.)

IF THE ANSWER TO BOTH OF THE ABOVE WAS YES, THEN ONE OF THE FOLLOWING MUST BE A YES:

1. Has the patient undergone surgery within the past 3 months leaving ,5 feet of small bowel?  Yes    No   
2. Does the patient have short bowel syndrome that results in:
   1. Evidence of electrolyte malabsorption, AND
   2. GI fluid of 2.5-3L/day resulting in enteral losses that exceed 50% of the oral/enteral intake, AND
   3. Urine output of, 1L/day? Yes    No   
3. Does the patient require bowel rest for at least 3 months, AND is receiving intraveneously 20-35cal/kg/day for:
   1. Symptomatic pancreatitis with or without pancreatic pseudocyst, OR
   2. Sever exacerbation of regional enteritis, OR
   3. Proximal enterocutaneous fistula where tube feedings distal to the fistula are not possible? Yes    No   
4. Does the patient have a complete mechanical small bowel obstruction where surgery is not an option? Yes    No   
5. Is the patients malnourished as evidenced by:
   1. 10% weight loss over 3 months or less, AND
   2. Serum albumin < 3.4gm/DL, AND
   3. Severe fat malabsorption (fecal fat exceeds 50% of oral/enteral intake on a diet of at least 50 grams of fat/day as measure by a standard 72 hours fecal fat test), OR
   4. Severe stomach motility disturbance of the small intestine and/or stomach which is unresponsive to prokinetic medications and is demonstrated scintigraphically OR radiographically? (These studies must be performed when the patient is not acutely ill and is not on any medication which would decrease bowel motility). Yes    No   

IF THE ANSWER TO ALL OF 1-6 WAS NO, THEN THE PATIENT MUST MEET THE FOLLOWING:

Maintenance of weight and strength commensurate with the patient’s overall health must require intravenous nutrition and must not be possible utilizing the following approaches:

CORE MEDICAL POLICY:

1. Modifying the nutrient composition of the enteral diet (i.e., lactose free, gluten free, low in chain triglycerides, substitution with medium chain triglycerides, provision of protein as peptides or amino acids, etc.) AND
2. Utilizing pharmacological means to treat the etiology of the malabsorption (i.e., pancreatic enzymes or bile salts, broad spectrum antibiotics for bacterial overgrowth, prokinetic medication for reduced motility, etc.)

AND THE FOLLOWING SUPPORTING MEDICAL POLICY:

1. Is the patient malnourished as evidenced by 10% weight loss over 3 months or less and serum albumin , 3.4 gm/DL, AND
2. Has a disease and clinical condition been documented as being present and it has not responded to altering the manner of delivery of appropriated nutrients through a tube with the tip location in the stomach or jejunum? Yes    No   

• Documentation in the patient’s progress notes, surgical report or diagnostic report has to support the answer to this form.