B4187, Omegaven, 10 grams lipids
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- A completed Standard Written Order (SWO) must be communicated to the supplier before claim submission; for DMEPOS base items requiring WOPD, a signed WOPD must be received before delivery.
- Medical records must document the clinical diagnosis, the consideration/attempt/contraindication of enteral nutrition, and permanence of the impairment (see Policy Article).
- Treating practitioner evaluation within 30 days prior to initiation of parenteral nutrition must be documented, or the reason and alternate monitoring methods must be documented if not performed.
- Document medical necessity when prescribing calories outside 20–35 kcal/kg/day, protein outside 0.8–2.0 g/kg/day, dextrose concentration <10%, or lipids above product-specific FDA dosing.
Key Coverage Criteria
- Parenteral nutrition is covered when the beneficiary qualifies under the Medicare Prosthetic Device Benefit and the service is reasonable and necessary for the diagnosis or treatment of illness or injury.
- Parenteral nutrition is covered only when enteral nutrition (EN) has been considered and ruled out, tried and found ineffective, or EN exacerbates gastrointestinal tract dysfunction.
- Beneficiary must have either (a) a condition of the small intestine and/or its exocrine glands that significantly impairs nutrient absorption or (b) disease of the stomach and/or intestine that is a motility disorder impairing transport and absorption of nutrients.
- The beneficiary must have a permanent impairment causing the need for parenteral nutrition (see LCD-related Policy Article for permanence guidance).
- Related supplies, equipment, and nutrients are covered when the coverage requirements for parenteral nutritional therapy are met under the prosthetic device benefit.
- A daily total caloric intake of 20–35 kcal/kg/day is considered reasonable and necessary; medical necessity must be documented if prescribing calories outside this range.
8 Active Policies
ANTHEM-CG-MED-89, CG-MED-89 Home Parenteral Nutrition
ANTHEM-CG-MED-99, CG-MED-99 Intradialytic Parenteral Nutrition
L38953, Parenteral Nutrition
MED201.011, Nutritional Support
BCBSIL-MED201.011, Nutritional Support
Related Codes
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