On average, approximately 34,000 patients in the United States receive parenteral nutrition (PN) each year1 for critical ailments. For patients 65+ who are on Medicare, the worst news that a physician or case manager has to deliver is, “I’m sorry, you don’t meet the Medicare criteria for home parenteral nutrition.”

For over 20 years, parenteral nutrition has fallen under the prosthetic device benefit under Medicare Part B. There are seven gastrointestinal conditions (GI) that are considered by Medicare before providing coverage. And when it can be proven that a patient permanently (beyond three months) cannot absorb nutrients that are needed to maintain their weight and strength, is when Medicare may cover the accessories or supplies that are needed for long-term home infusion therapy. Patients with short bowel syndrome, GI fistulas, bowel obstructions, acute pancreatitis, and/or nutritional complications from cancer are typical candidates. It goes without saying that the nutritional mix of protein, carbohydrate, fat, minerals and electrolytes, vitamins and other trace elements and are received through parenteral nutrition can reduce complications, and even more so, reduce the risk of rehospitalization. As a result, regardless of insurance coverage or not, if there is any possibility that a patient may require parenteral nutrition (PN) at home after being discharged, the planning and documentation process needs to start immediately. By starting right away, it ensures that the physician, case manager, infusion provider, as well as the patient, are aware of what is required to attempt to secure coverage.

Understanding what Medicare covers and does not cover will ensure speed, efficiency, and uninterrupted quality of care on behalf of the patient. Utilize and implement the guidelines and quick-reference chart below to maximize effectiveness.

Medicare Does Not Cover Parenteral Nutrition For

Patients with a functioning gastrointestinal tract whose need for parenteral nutrition is only due to any of the following conditions:

  • Swallowing disorder
  • Temporary defect in gastric emptying such as a metabolic or electrolyte disorder
  • Psychological disorder impairing food intake such as depression
  • Metabolic disorder inducing anorexia such as cancer
  • Physical disorder impairing food intake such as the dyspnea of severe pulmonary or cardiac disease
  • Side effect of a medication
  • Renal failure or dialysis

Medicare DOES Cover Parenteral Nutrition

(Parenteral Nutrition is approved on an individual, case-by-case basis initially and at periodic intervals of no more than three months by a Medicare Administrative Contractor (A/B MAC (B)) medical consultant or specially trained staff. It is expected that the patient’s medical records will reflect the need for the care provided. These records are not routinely submitted but must be available upon request.)

7 Gastrointestinal Conditions for Medicare Consideration

  1. Severe Short Bowel Resection: Surgery within the past three months, leaving less than 5 feet of small bowel beyond the ligament of the Treitz.
  2. Severe Short Bowel Syndrome: The patient has a short bowel syndrome that is severe enough that the patient has significant gastrointestinal fluid and electrolyte malabsorption.
  3. Bowel Rest for at Least 3 Months: The patient requires bowel rest for at least three months for treatment of:
    1. Symptomatic pancreatitis with/without pancreatic pseudocyst
    2. Severe exacerbation of regional enteritis
    3. A proximal enterocutaneous fistula where tube feeding distal to the fistula isn’t possible.
  4. Complete Mechanical Small Bowel Obstruction: The patient has complete mechanical small bowel obstruction where surgery is not an option.
  5. Malabsorption and Malnutrition: The patient is significantly malnourished (10% weight loss over three months or less and serum albumin less than or equal to 3.4 gm/dl) and has severe fat malabsorption.
  6. Motility Disturbance and Malnutrition: The patient is significantly malnourished (10% weight loss over 3 months or less and serum albumin less than or equal to 3.4 gm/dl) and has severe motility disturbance of the small intestine or stomach which is unresponsive to prokinetic medication.
  7. Malnourished and Proven Condition: The patient is malnourished (10% weight loss over three months or less serum albumin less than or equal to 3.4 gm/dl) and disease and the clinical condition has been documented as being present and it has not responded to altering the manner of delivery of appropriate nutrients (e.g., slow infusion of nutrients through a tube with the tip located in the stomach or jejunum).

The information provided is meant to be a guide for your information only. Each health care provider’s office is responsible for providing accurate information to ContinuumRx for verifying codes, coverage and payment policies used for individual patients to ensure that they are exact and appropriate for the services and items provided.

Contact a ContinuumRx Medicare qualifying expert or trained clinician to assess your patient’s eligibility.

1 Trends in Parenteral Nutrition, By Kristi L. King, MPH, RDN, CNSC, LD, Today’s Dietitian Vol. 21, No. 1, P. 36, January 2019.

home infusion

Currently, Medicare only covers certain home infusion drugs and biologicals administered intravenously, or subcutaneously, while commercial payors cover patients for an expansive array of intravenous and subcutaneous drugs. Lifting Medicare regulations, will ensure that Medicare enrollees in need of home infusion therapy can receive the care they need in a more comfortable environment and at a more reasonable cost to the federal government. This would provide increased access to care for patients with immune diseases, cancer, serious infections, heart failure, and other conditions that might otherwise force patients to receive their care in a more expensive and less convenient hospital, outpatient clinic, or skilled facility. This legislation is vital to home infusion patients, allowing them to safely receive treatment in the setting they overwhelmingly prefer—their homes.

“Home infusion providers have the capacity to treat hundreds-of-thousands of patients as hospitals and nursing facilities are being pushed to capacity,” said National Home Infusion Association (NHIA) Board Chair Logan Davis, PharmD, MBA. “Regardless of any change in policy, the home infusion community is working with health care providers to bring their resources to bare and keep the most vulnerable patients at home. While this can be a challenge for patients in traditional Medicare — where coverage is limited — the home infusion community is committed to playing a vital role in addressing this public health emergency.”

As per the NHIA, more than 160 hospitals, patient groups, and other stakeholders are calling on Medicare to lift restrictions on home infusion. They have announced their support for concept legislation that would: 

  • Cover Home Infusion Equipment, Supplies, and Professional Services.
  • Adequately Reimburse Providers.
  • Maintain Current Drug and Home Health Reimbursement.

“Our focus has always been to improve post-acute care coordination and care management, to help reduce gaps in patient care, and to enhance the overall patient experience,” said Keith Hartman, RPH, COO of ContinuumRx. “As a response to the pandemic, we have seen the rapid shift from moving care out of the hospital to home, are experiencing and measuring the success rates, and foresee that this is the model for the future. By lifting the current Medicare restrictions the door is opened to offer a higher quality of care and reduction in rehospitalization rates.”

ContinuumRx is committed to to doing our part to #FlattenTheCure, #DeliverHope, and heighten a patient’s quality of care while providing solutions to your staff and patients that require home infusion therapy. Our priority is to work with your team to identify patients that can be moved to the safety of their home not only to decrease their risk of hospitalization/re-hospitalization, but also to free up hospital beds for COVID-19 needs. 

We are actively monitoring the CDC guidelines related to the coronavirus (COVID-19) outbreak and updating our plans, policies, and guidelines as needed. We continue to accept and service new patients and operate under the highest standards.

ContinuumRx is dedicated to these guidelines to protect our healthcare providers and patients:

General Guidelines:

  • Complying with existing standard operating procedures (SOPs) and disaster emergency plans, and updating as needed for PPE modifications, social distancing, and compounding procedures.
  • Establish remote working capabilities for pharmacy staff where possible.

Patient Guidelines:

  • Providing bedside education and instruction via FaceTime, Zoom and Skype: 
    • For resumption of patient care 
    • For patients that are teachable remotely
    • Patient and caregiver education via video library
  • Requiring patients to wear face masks.
  • Maintain social distancing.
  • Comply with local health department screening, patient contact, and reporting requirements.

Patient Delivery:

  • Employ delivery strategies that limit patient/employee exposure:
    • Leave packages at the patient’s home and call the patient to alert them to delivery.
    • Utilize photo confirmation rather than obtain signatures.
    • Use common courier services (UPS, FedEx) whenever possible.
    • Do not allow courier or shipping personnel into your household.

Nursing Staff:

  • Limit nursing time in the home.
  • Medical-grade masks, gowns, and shoe covers.
  • Hand sanitizer upon initial entry and during glove change processes.
  • Instruct patients to have supplies needed for procedures ready prior to the nurse entering the home.
  • Nursing bags are prohibited in the patient’s home.
  • Limit non-disposable supplies taken into home.
  • Use disposable supplies, such as BP cuffs, stethoscopes and thermometer when possible.
  • Complete non-physical assessment telephonically.
  • Complete all documentation outside the home.
  • Patient Screening Tool to Identify COVID-19 Patients.
  • COVID-19 testing recommendations.
  • Isolation guidelines when employees develop symptoms.
  • Quarantine guidelines when exposure is suspected.
  • Return to work guidelines per CDC Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19.

We will continue to implement innovative ways to maintain the same level of service that you expect as we all work together during this difficult time.