S9367, Home infusion therapy, total parenteral nutrition (tpn); more than two liters
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For adults: documentation of involuntary weight loss of 10% in six months or 5% in one month (baseline weight and timeframe).
- For children: documentation of weight-for-length/height or sex percentile < 10th, inadequate weight gain, or significant decrease in usual growth percentile (growth charts/measurements).
- For neonates: documentation of birth weight < 1000 g.
- Clinical documentation supporting structural or functional bowel disease or other reason oral/tube feedings are inappropriate and that the GI tract is non-functioning for a period of time (operative notes, imaging, clinical assessments).
Key Coverage Criteria
- Initial use of home parenteral nutrition is consideredmedically necessarywhenallof the following criteria (A, B, and C) are met:
- The individual is malnourished or at risk for malnutrition as evidenced by:Adults:Loss of 10% or more of their ideal body weight within a 3 month period;orLoss of 20% of their usual body weight within a 3 month period;orSerum total protein level less than 6 g/dL;orSerum albumin level less than 3.4 g/dL;orNone of the conditions listed above (a-d) are present but one or more are considered inevitable given the individualâs expected course of illness.Children:Under the 10thpercentile of expected [...]
- Adults:Loss of 10% or more of their ideal body weight within a 3 month period;orLoss of 20% of their usual body weight within a 3 month period;orSerum total protein level less than 6 g/dL;orSerum albumin level less than 3.4 g/dL;orNone of the conditions listed above (a-d) are present but one or more are considered inevitable given the individualâs expected course of illness.
- Loss of 10% or more of their ideal body weight within a 3 month period;or
- Loss of 20% of their usual body weight within a 3 month period;or
- Serum total protein level less than 6 g/dL;or
8 Active Policies
ANTHEM-CG-MED-89, CG-MED-89 Home Parenteral Nutrition
ANTHEM-CG-MED-23, CG-MED-23 Home Health
AMBETTER-CP.MP.163, Total Parenteral Nutrition and Intradialytic Parenteral Nutrition
MED201.011, Nutritional Support
BCBSIL-MED201.011, Nutritional Support
Related Codes
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