Indications and Limitations of Coverage and/or Medical Necessity
Enteral nutrition is the provision of nutritional requirements through a tube into the stomach or small intestine.
Enteral nutrition is covered for a patient who has (a) permanent non-function or disease of the structures that normally permit food to reach the small bowel or (b) disease of the small bowel which impairs digestion and absorption of an oral diet, either of which requires tube feedings to commensurate with the patient's overall health status.
The patient must have a permanent impairment. Permanence does not require a determination that there is no possibility that the patient's condition may improve sometime in the future. If the judgement of the attending physician, substantiated in the medical record, is that the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is considered met. Enteral nutrition will be denied as non-covered in situations involving temporary impairments.
The patient's condition could be either anatomic (e.g., obstruction due to head and neck cancer or reconstructive surgery, etc.) or due to a motility disorder (e.g., severe dysphagia following a stroke, etc.). Enteral nutrition is non-covered for patients with a functioning gastrointestinal tract whose need for enteral nutrition is due to reasons such as anorexia or nausea associated with mood disorder, end-stage disease, etc.
The patient must require tube feedings to maintain weight and strength commensurate with the patient's overall health status. Adequate nutrition must not be possible by dietary adjustment and/or oral supplements. Coverage is possible for patients with partial impairments - e.g., a patient with dysphagia who can swallow small amounts of food or a patient with Crohn's disease who requires prolonged infusion of enteral nutrients to overcome a problem with absorption.
Enteral nutrition products that are administered orally and related supplies are noncovered.
If the coverage requirements for enteral nutrition are met, medically necessary nutrients, administration supplies, and equipment are covered.
No more than one month's supply of enteral nutrients, equipment or supplies is allowed for one month's prospective billing. Claims submitted retroactively, however, may include multiple months.
The ordering physician is expected to see the patient within 30 days prior to the initial certification. If the physician did not see the patient within this timeframe, he/she must document the reason why and describe what other monitoring methods were used to evaluate the patient's enteral nutrition needs.
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An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request.
A Certificate of Medical Necessity (CMN) which has been completed, signed, and dated by the treating physician must be kept on file by the supplier and made available to the DMERC on request. The CMN may act as a substitute for a written order if it contains all of the required elements of an order.
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