CG-MED-89 Home Parenteral Nutrition

This policy addresses home parenteral nutrition (HPN), i.e., intravenous nutrition administered at home. Initial HPN is covered when all plan criteria are met, including documented malnutrition or high risk: for adults, ≥10% loss of ideal body weight or ≥20% loss of usual body weight within 3 months, serum total protein <6 g/dL, serum albumin <3.4 g/dL, or anticipated malnutrition; for children, weight-for-length/height or weight-for-sex below the 10th percentile (−1.28 z) or BMI below the 5th percentile. Initial or continuing HPN is not covered when these criteria are not met.

"Initial use of home parenteral nutrition is consideredmedically necessarywhenallof the following criteria (A, B, and C) are met:"

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