In the United States insurance reimbursement for nutrition services may be a key factor in determining what can be provided for the patients. Each insurance company is likely to have slightly different requirements. Medicare requirements also change over time and must be verified at the time of care.
In Lillie's case her main insurance is Medicare. The entire regulation involved in receiving enteral or parenteral nutrition are covered under the National Coverage Determination (NCD) for Enteral and Parenteral Nutrition Therapy (180.2) and Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services,” §120.
However here are information from the key parts of the determination that apply to this case:
- Patients must have a chronic illness or trauma that cannot be sustained through oral feeding and rely on enteral nutrition
- Coverage of nutrition therapy as a Part B benefit is provided under the prosthetic device benefit provision. This provision requires that the patient impairment must be a "permanenty inoperative internal body organ or function. Enteral nutrition therapy is not normally covered for temporary impairments. Howeve the definition of "Permanent" does not necessarily mean for the rest of the patient's life. It does mean that the impairment will be of long and indefinite duration, the test of permanence is considered met.
- Enteral Nutrition is considered reasonable and necessary for a patient with a functioning gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition.
- However, claims for Part B coverage must be approved on an individual, case-by-case basis; contain a physician’s written order or prescription and sufficient medical documentation (e.g., hospital records, clinical findings from the attending physician) to permit an independent conclusion that the patient’s condition meets the requirements of the prosthetic device benefit and that the enteral nutrition therapy is medically necessary. Allowed claims are to be reviewed at periodic intervals of no more than 3 months.
- If the claim involves a pump, it must be supported by sufficient medical documentation to establish that the pump is medically necessary, i.e., gravity feeding is not satisfactory due to aspiration, diarrhea, dumping syndrome.
Updated November 11, 2018