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Issue Number - Name
0106-Parenteral Nutrition-Medical Necessity
Review Type
Complex
Claim Type
DME by Supplier; DME by Physician
Region and State
RAC 5
All States
Date Approved
09/11/2018

Description

This review will determine if Parenteral Nutrition is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied.

Affected Code(s)  

HCPCS MODIFIERS:
       
B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200

Applicable Policy References

Social Security Act, Section 1862(a)(1)(A) 
Social Security Act, Section 1861(s)(8)
42 CFR, Section 424.57(12)                                   
CMS NCD Manual, Chapter 1, Part 3, Section 180.2 (Rev. 173, Issued: 09-04-14, Effective: Upon Implementation of ICD-10
CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 120
CMS Pub. 100-08, Medicare Program Integrity Manual 3.3.2.4 
CMS Pub. 100-08, Medicare Program Integrity Manual 5.2.2
CMS Pub. 100-08, Medicare Program Integrity Manual 5.2.6
CMS Pub. 100-08, Medicare Program Integrity Manual 5.2.8 
CMS Pub. 100-08, Medicare Program Integrity Manual 5.3 
CMS Pub. 100-08, Medicare Program Integrity Manual 5.5.8
CMS Pub. 100-04, Medicare Claims Manual, Chapter 20 
LCD 33798, Effective date 10/01/2015, Revision 01/01/2017
Article 52515, Effective date 10/01/2015, Revision 01/01/2017
Article 55426, Effective date 01/01/2017, Revision 12/21/2017