Intradialytic Parenteral Nutrition Form

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Intradialytic Parenteral Nutrition - Medical Policy

 Effective: September 1, 2025

Policy Number: UM1007POL

Approval Date: 6/24/2025

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Intradialytic parenteral nutrition (IDPN) is the infusion of an intravenous formula of hyperalimentation, such as amino acids, glucose, and lipids, during dialysis, to treat protein calorie malnutrition in an effort to decrease the associated morbidity and mortality experienced in patients with renal failure.

Protein calorie malnutrition occurs in an estimated 25%–40% of those undergoing dialysis. The cause of malnutrition in dialysis patients is often multifactorial and may include, from being under dialysis, chronic inflammation, protein loss in the dialysate solution (particularly in peritoneal dialysis), untreated metabolic acidosis, and decreased oral intake.

The clinical evaluation of malnutrition is multifactorial but typically includes measurement of serum albumin. Serum albumin levels correlate with nutritional status but are imperfect measures of nutrition because they can be affected by multiple other disease states. Protein calorie malnutrition is associated with increased morbidity and mortality. For example, the risk of death is increased more than 10-fold in those whose serum albumin levels are less than 2.5 g/dl, and those with a serum albumin near the normal range (i.e., between 3.5 to 3.9 g/dl) have a mortality rate twice as high as those with albumin greater than 4.0 g/dl.

In patients receiving chronic dialysis, the National Kidney Foundation currently recommends a daily protein intake of 1.2 g/kg or more in patients undergoing hemodialysis and 1.3 g/kg or more in patients undergoing peritoneal dialysis. When malnutrition is present, a stepwise approach to treatment is generally used, beginning with dietary counseling and diet modifications, followed by oral nutritional supplements, and then by enteral nutrition supplements or parenteral nutritional supplements if needed. Intradialytic parenteral nutrition (IDPN), which refers to infusion of hyperalimentation fluids at the time of either hemodialysis or peritoneal dialysis, has been investigated as a technique to treat protein calorie malnutrition in an effort to decrease the associated morbidity and mortality. IDPN solutions are similar to those used for total parenteral nutrition (TPN). A typical solution contains 10% amino acids and 40% to 50% glucose, 10% to 20% lipids, or a mixture of carbohydrate or lipids, depending on patient needs. In hemodialysis, the IDPN infusion is administered through the venous port of the dialysis tubing, typically, 30 minutes after dialysis has begun, and continued throughout the remainder of a dialysis session.

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 Line of Business

Commercial:

• Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:

• Refer to criteria under the Policy section in this medical policy.

• There are no MassHealth guidelines for Intradialytic Parenteral Nutrition.

Medicare:

• Refer to criteria under the Policy section in this medical policy.

• Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for Intradialytic Parenteral Nutrition.

Policy

I. Intradialytic Parenteral Nutrition (IDPN) may be considered MEDICALLY NECESSARY for initial 3 months trial when the following criteria are met:
A) The patient is currently receiving dialysis for End Stage Renal Disease; AND
B) The patient has weight loss of > 10% of ideal body weight over three months or less, or of > 20% of usual body weight; OR has an album in less than 3.4 g/dl and a prealbumin less than 30 mg/dl; AND
C) The patient has an adequate dialysis prescription (single pool KT/V of at least 1.25) and their acidosis has been corrected (serum tC02 of greater than or equal to 22 mmol/l); AND

D) The patient cannot tolerate full nutrition with an oral supplement but can consume at least 50% of their necessary caloric and protein intake (e.g. diabetic gastroparesis); OR the patient has failed or is unable to tolerate adequate nasogastric tube feedings or PEG tube feedings with enteral nutritional supplements.

II. Intradialytic Parenteral Nutrition (IDPN) may be considered MEDICALLY NECESSARY for continuation after initial 3 months trial when the following criteria are met:

A) There is demonstration of a significant rise in the prealbumin level to greater than 30 mg/dl; AND

B) Continued documented compliance with criteria noted above (I).

C) Approval will be for 9 months after the initial trial with patient reevaluated for continued need
after 9 months.

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III. Intradialytic Parenteral Nutrition (IDPN) may be considered MEDICALLY NECESSARY for continuation after first year when ALL of the following criteria are met:

A) Continuous dependence on dialysis; AND,

B) Positive clinical response to therapy; AND,

C) Member has NOT experienced a drug-related adverse event or toxicity associated with IDPN treatment.

III. Intradialytic Parenteral Nutrition is NOT COVERED for the following indications:

A) Intradialytic parenteral nutrition is considered NOT MEDICALLY NECESSARY when offered in addition to regularly scheduled infusions of TPN.

B) In patients who cannot tolerate any oral feedings, TPN is the appropriate therapy and IDPN is considered INVESTIGATIONAL as a single therapy.

C) Intradialytic parenteral nutrition is considered NOT MEDICALLY NECESSARY when discontinuation of IDPN may be reasonable if ONE of the following criteria is met:

1. Member tolerates adequate oral or enteral nutrition, OR
2. Protein and/or nutrition status does not improve after 6 months on IDPN; OR

3. Reasonable sustained improvement in protein and nutrition status as indicated by a serum albumin greater than > 4.0 g/dl AND BMI greater than or equal to 18.5 kg/m2.

   Policy Guidelines and Definitions

   Policy Guidelines:

   • This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, requesting physician should be consulted.
   • Evidence for individuals undergoing hemodialysis who receive IDPN includes multiple RCTs, observational studies, and systematic reviews. Relevant outcomes are overall survival, change in disease status, morbid events, health status measures, quality of life, treatment-related mortality and treatment-related morbidity. Published systematic reviews, which include randomized controlled trials but could not pool data, have concluded that current evidence does not demonstrate benefits in patient outcomes with the use of intradialytic parenteral nutrition for those who would not otherwise qualify for total parenteral nutrition. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

   Coding Guidance

   Code
   Description
   Auth Required? B4164 Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix No B4168 Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix No

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Code
Description
Auth Required? B4172 Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix No B4176 Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix No B4178 Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml = 1 unit) - home mix No B4180 Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix No B4185 Parenteral nutrition solution, not otherwise specified, 10 grams lipids No B4189 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix No B4193 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix No B4197 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix No B4199 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix No B4216 Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes), home mix, per day No B4220 Parenteral nutrition supply kit; premix, per day No B4222 Parenteral nutrition supply kit; home mix, per day No B4224 Parenteral nutrition administration kit, per day No B5000 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal-aminosyn-rf, nephramine, renamine-premix No B5100 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, hepatamine-premix No B5200 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids-freamine-hbc-premix No

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Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

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The beneficial effects of intradialytic parenteral nutrition in hemodialysis patients with protein energy wasting: a prospective randomized controlled trial Kittiskulnam et al. PMID: 35296793, PMCID: PMC8927103, DOI: 10.1038/s41598-022-08726-8 The beneficial effects of intradialytic parenteral nutrition in hemodialysis patients with protein energy wasting: a prospective randomized controlled trial - PubMed

Intradialytic parenteral nutrition in maintenance hemodialysis patients suffering from protein-energy wasting. Results of a multicenter, open, prospective, randomized trial Tobias A Marsen, Justinus Beer, Helmut Mann, German IDPN-Trial group PMID: 26708726, DOI: 10.1016/j.clnu.2015.11.016 https://pubmed.ncbi.nlm.nih.gov/26708726/

Effectiveness of Intradialytic Parenteral Nutrition in Treating Protein-Energy Wasting in Hemodialysis: A Rapid Systematic Review Journal of Renal Nutrition, Volume 29, Issue 5, September 2019, Pages 361-369. Effectiveness of Intradialytic Parenteral Nutrition in Treating Protein-Energy Wasting in Hemodialysis: A Rapid Systematic Review - ScienceDirect

Evidence Brief: Use of Intradialytic Parenteral Nutrition (IDPN) to Treat Malnutrition in Hemodialysis Patients Evidence Brief: Use of Intradialytic Parenteral Nutrition (IDPN) to Treat Malnutrition in Hemodialysis Patients - NCBI Bookshelf

Revisiting Intradialytic Parenteral Nutrition: How Can We Apply the Evidence in Clinical Practice? Advances in Kidney Disease and Health, Volume 30, Issue 6, November 2023, Pages 502-507. Revisiting Intradialytic Parenteral Nutrition: How Can We Apply the Evidence in Clinical Practice? - ScienceDirect

American Society for Parenteral and Enteral Nutrition (ASPEN). Clinical Guidelines: Nutrition support in adults acute and chronic renal failure. July 2010. https://aspenjournals.onlinelibrary.wiley.com/doi/pdf/10.1177/0148607110374577

Cano NJ, Fouque D, Roth H, Aparicio M, Azar R, Canaud B, Chauveau P, Combe C, Laville M, Leverve XM, French Study Group for Nutrition in Dialysis. Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study. J Am Soc Nephrol. 2007 Sep; 18(9):2583-91.
http://jasn.asnjournals.org/content/18/9/2583.long

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 7/2024 New Policy.

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Date Update 05/2025 No criteria changes. Removed Prior Authorization from all procedure codes.
References updated.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.