This document addresses parenteral nutrition given in the home setting.

Clinical Indications

Medically Necessary:

Initial use of home parenteral nutrition is considered medically necessary when all of the following criteria (A, B, and C) are met:

1. The individual is malnourished or at risk for malnutrition as evidenced by:
   1. Adults:
      1. Loss of 10% or more of their ideal body weight within a 3 month period; or
      2. Loss of 20% of their usual body weight within a 3 month period; or
      3. Serum total protein level less than 6 g/dL; or
      4. Serum albumin level less than 3.4 g/dL; or
      5. None of the conditions listed above (a-d) are present but one or more are considered inevitable given the individual’s expected course of illness.
   2. Children:
      1. Under the 10^th percentile of expected weight for length/height, or weight for sex (–1.28 z score); or
      2. Under the 5^th percentile of expected body mass index.
         and
2. The individual has a condition that prevents adequate nutritional supplementation using the enteral route (for example, impaired gastrointestinal digestion, absorption, or motility);
   and
3. Home parenteral nutrition can be safely administered including documentation of the following:
   1. Metabolic stability with normal serum sodium, potassium, phosphate, and magnesium levels and serum glucose less than 160 mg/dL; and
   2. Completion of training for the individual or their designated caregiver in the safe preparation and administration of parenteral nutrition; and
   3. A nutrition care plan including the nutritional prescription.

Continuing use of home parenteral nutrition will be reviewed every 6 months and is considered medically necessary when all of the following criteria are met:

1. A physician certifies that the criteria for initial treatment (A, B, and C above) continue to be met; and
2. A physician certifies that there has been benefit from the treatment; and
3. An updated nutrition care plan is provided.

Not Medically Necessary:

Initial use of home parenteral nutrition is considered not medically necessary when the above criteria have not been met.

Continuing use of home parenteral nutrition is considered not medically necessary when the above criteria have not been met.