TPN Medicare Guidelines



Parenteral nutrition is covered for a beneficiary with permanent, severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the beneficiary’s general condition.

The beneficiary must have permanent impairment, defined as at least 3 months; parenteral nutrition will be denied as non-covered in situation involving temporary impairment.

Total caloric daily intake should be 20-35 kcal/kg/day.

Total protein daily intake should be 0.8-1.5 gm/kg/day.

Qualifying diagnosis with supporting objective documentation such as history & physical, radiology reports, operative reports, lab studies, progress notes, nutritional assessment, current weight documentation, and/or estimated daily calorie intake.

Parenteral nutrition is covered in any one of the following SEVERE GI CONDITIONS:
  1. The beneficiary has undergone massive small bowel resection within last 3 months leaving less than or equal to 5 feet of small bowel beyond the ligament of Treitz
  2. The beneficiary has short bowel syndrome that is severe enough that the beneficiary has net gastrointestinal fluid and electrolyte malabsorption such that on an oral intake of 2.5-3 liters/day, enteral losses exceed 50% of the oral/enteral intake and urine output is less than 1 liter/day
  3. The beneficiary requires bowel rest for =3 months and is receiving 20-35 kcal/kg/day intravenously for treatment of: symptomatic pancreatitis, OR severe exacerbation of regional enteritis, OR proximal enterocutaneous fistula where distal tube feeding isn't possible
  4. The beneficiary has complete mechanical small bowel obstruction where surgery is not an option
  5. The beneficiary is significantly malnourished (defined as both 10% weight loss within last 3 months and serum albumin =3.4 gm/dl) and has severe fat malabsorption (fecal fat >50% of oral/enteral intake on a diet of = 50 gm of fat/day as measured by a standard 72-hour fecal fat test)
  6. The beneficiary is significantly malnourished (defined as both 10% weight loss within last 3 months and serum albumin =3.4 gm/dl) and has severe motility disturbance of the small intestine and/or stomach which is unresponsive to prokinetic medication and is demonstrated either:
    • i. Scintigraphically (solid meal gastric emptying study demonstrates that the isotope fails to reach the right colon by 6 hours following ingestion), or
    • ii. Radiographically (barium or radiopaque pellets fail to reach the right colon by 6 hours following administration). These studies must be performed when the beneficiary is not acutely ill and is not on any medication which would decrease bowel motility.
Beneficiaries who do not meet criteria A-F above must have one of the MODERATE GI DISORDERS (a-f below) as well as documentation of all four items described following:
  • Modification of diet AND
  • Pharmacologic intervention AND criteria G and H below:
  • G. The beneficiary is malnourished (defined as both 10% weight loss within last 3 months and serum albumin =3.4 gm/dl), AND
  • H. The patient has undergone a trial of tube feeding which failed, as defined by Medicare policy. There is no exception to the requirement for documented tube feeding trial and failure.


  • MODERATE GI CONDITIONS:
    Each of the disorders below requires a failed trial of enteral nutrition by nasogastric or percutaneously-placed tube (H, above) before parenteral nutrition will be covered.
    1. Small bowel resection leaving > 5 feet of small bowel beyond the ligament of Treitz
    2. Short bowel syndrome less severe than is defined in B, Section 2
    3. Mild to moderate exacerbation of regional enteritis, or an enterocutaneous fistula
    4. Partial mechanical small bowel obstruction where surgery is not an option
    5. Nutrient malabsorption, with either one of the following:
      • i.) Moderate fat malabsorption diagnosed as defined in E, Section 2 with fecal fat of at least 25% of oral/enteral intake on a diet of at least 50 gm of fat/day, or
      • ii.) Diagnosis of malabsorption objectively confirmed by other methods (e.g., positive Sudan staining of stool for fecal fat, or positive d-xylose test for nutrient malabsorption, etc.)
    6. Motility disorders with either one of the following:
      • i.) Gastroparesis demonstrated by either of the following:
        • Radiographic or nuclear medicine studies as described in F (see Section 2) with the marker failing to reach the jejunum in 3-6 hours, or
        • Manometric motility studies that show poor gastric emptying, without response to prokinetic medication, or
      • ii.) Small bowel motility disorder which is unresponsive to prokinetic medication and demonstrated with a gastric-to-right colon transit time between 3 and 6 hours
    Parenteral nutrition is noncovered for the beneficiary with a functioning gastrointestinal tract whose need for parenteral nutrition is only due to any of the following conditions:
    • 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 dyspnea of severe pulmonary or cardiac disease
    • Side effect of medication
    • Renal failure and/or dialysis

    https://med.noridianmedicare.com/documents/2230703/7218263/Parenteral+Nutrition+LCD+and+PA/1b7429bc-6645-41dc-8167-88a15ffed946

    Revised: 3-13-18