Indications and Limitations of Coverage
This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.
Covered As Prosthetic Device
There are patients who, because of chronic illness or trauma, cannot be sustained through oral feeding. These people must rely on either ENTERAL or parenteral NUTRITIONal THERAPY, depending upon the particular nature of their medical condition.
Coverage of NUTRITIONal THERAPY as a Part B benefit is provided under the prosthetic device benefit provision which requires that the patient must have a permanently inoperative internal body organ or function thereof. Therefore, ENTERAL and parenteral NUTRITIONal THERAPY are normally not covered under Part B in situations involving temporary impairments.
Coverage of such THERAPY, however, does not require a medical judgment that the impairment giving rise to the THERAPY will persist throughout the patient’s remaining years. If the medical record, including the judgment of the attending physician, indicates that the impairment will be of long and indefinite duration, the test of permanence is considered met.
If the coverage requirements for ENTERAL or parenteral NUTRITIONal THERAPY are met under the prosthetic device benefit provision, related supplies, equipment and nutrients are also covered under the conditions in the following paragraphs and the Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services,” §120.
Parenteral NUTRITION THERAPY Daily parenteral NUTRITION is considered reasonable and necessary for a patient with severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient’s general condition.
Since the alimentary tract of such a patient does not function adequately, an indwelling catheter is placed percutaneously in the subclavian vein and then advanced into the superior vena cava where intravenous infusion of nutrients is given for part of the day. The catheter is then plugged by the patient until the next infusion. Following a period of hospitalization, which is required to initiate parenteral NUTRITION and to train the patient in catheter care, solution preparation, and infusion technique, the parenteral NUTRITION can be provided safely and effectively in the patient’s home by nonprofessional persons who have undergone special training. However, such persons cannot be paid for their services, nor is payment available for any services furnished by non-physician professionals except as services furnished incident to a physician’s service.
For parenteral NUTRITION THERAPY to be covered under Part B, the claim must contain a physician’s written order or prescription and sufficient medical documentation to permit an independent conclusion that the requirements of the prosthetic device benefit are met and that parenteral NUTRITION THERAPY is medically necessary. An example of a condition that typically qualifies for coverage is a massive small bowel resection resulting in severe NUTRITIONal deficiency in spite of adequate oral intake. However, coverage of parenteral NUTRITION THERAPY for this and any other condition must be approved on an individual, case-by-case basis initially and at periodic intervals of no more than three months by the Medicare Administrative Contractor (A/B MAC (B)) medical consultant or specially trained staff, relying on such medical and other documentation as the A/B MAC (B) may require. If the claim involves an infusion pump, sufficient evidence must be provided to support a determination of medical necessity for the pump. Program payment for the pump is based on the reasonable charge for the simplest model that meets the medical needs of the patient as established by medical documentation.
Nutrient solutions for parenteral THERAPY are routinely covered. However, Medicare pays for no more than one month’s supply of nutrients at any one time. Payment for the nutrients is based on the reasonable charge for the solution components unless the medical record, including a signed statement from the attending physician, establishes that the beneficiary, due to his/her physical or mental state, is unable to safely or effectively mix the solution and there is no family member or other person who can do so. Payment will be on the basis of the reasonable charge for more expensive premixed solutions only under the latter circumstances.
ENTERAL NUTRITION THERAPY
ENTERAL NUTRITION is considered reasonable and necessary for a patient with a functioning gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition. ENTERAL THERAPY may be given by nasogastric, jejunostomy, or gastrostomy tubes and can be provided safely and effectively in the home by nonprofessional persons who have undergone special training. However, such persons cannot be paid for their services, nor is payment available for any services furnished by non-physician professionals except as services furnished incident to a physician’s service.
Typical examples of conditions that qualify for coverage are head and neck cancer with reconstructive surgery and central nervous system disease leading to interference with the neuromuscular mechanisms of ingestion of such severity that the beneficiary cannot be maintained with oral feeding. However, claims for Part B coverage of ENTERAL NUTRITION THERAPY for these and any other conditions must be approved on an individual, case-by-case basis. Each claim must contain a physician’s written order or prescription and sufficient medical documentation (e.g., hospital records, clinical findings from the attending physician) to permit an independent conclusion that the patient’s condition meets the requirements of the prosthetic device benefit and that ENTERAL NUTRITION THERAPY is medically necessary. Allowed claims are to be reviewed at periodic intervals of no more than 3 months by the A/B MAC (B) medical consultant or specially trained staff, and additional medical documentation considered necessary is to be obtained as part of this review.
Medicare pays for no more than one month’s supply of ENTERAL nutrients at any one time. If the claim involves a pump, it must be supported by sufficient medical documentation to establish that the pump is medically necessary, i.e., gravity feeding is not satisfactory due to aspiration, diarrhea, dumping syndrome. Program payment for the pump is based on the reasonable charge for the simplest model that meets the medical needs of the patient as established by medical documentation.
Some patients require supplementation of their daily protein and caloric intake. NUTRITIONal supplements are often given as a medicine between meals to boost protein-caloric intake or the mainstay of a daily NUTRITIONal plan. NUTRITIONal supplementation is not covered under Medicare Part B.