Medicare Home Parenteral Nutrition Coverage Criteria Changes – Steps in the Right Direction, but Still Falling Short

Authors: Nicole Jacobson, RD, CNSC; Jennifer Lachnicht, RD, CNSC; Deb Kohl, RD, CNSC; Jessica Younkman, RD, CNSC; Paige Paswaters, RD, CNSC, CP-FS; Christine Miller, PharmD – Soleo Health

Background

Home parenteral nutrition (HPN) is a costly and complex endeavor to navigate for the Medicare patient population. Specialty infusion clinicians act as advocates for patients prescribed HPN, as payor coverage can be difficult to navigate for this life-sustaining therapy. The updates to the local coverage determination (LCD) criteria for HPN enacted in 2021 were a welcome change after decades of outdated criteria.1,2 While improvement can be seen with ease of qualification under these new criteria, there are still shortcomings. Additionally, the rigidity of decades-long antiquated and strict guidelines that overlooked so many patients in need has left in its wake an entire generation of clinicians and infusion companies unsure of the new language and fearful of fully embracing the new criteria. The purpose of this study is to describe observations from one complex specialty infusion organization, exposing persistent gaps despite the 2021 LCD updates.

Case Study

A retrospective analysis of medical records was conducted on adult HPN Medicare beneficiaries referred to this complex specialty infusion organization between 01/01/2022-06/30/2023. It was determined if each patient met the 2021 LCD criteria as well as the American Society for Parenteral and Enteral Nutrition (ASPEN) 2017 consensus recommendations for parenteral nutrition (PN) appropriateness.1,2,3

Discussion

This study showcases the experiences from one complex specialty infusion organization and may not be reflective of the entire HPN population, yet it identifies 45 patients who were denied Medicare coverage for HPN that was clinically appropriate according to ASPEN consensus recommendations. Of the 45 patients, 28 did not meet the requirement of “permanent impairment” with a “long and indefinite” length of therapy. This statement implies non-coverage for temporary impairments of the gastrointestinal tract, creating the illusion that a patient can live without nutrition for longer than physiologically possible. Changing or removing the language within the LCD criteria around the length of need requirement would provide access to HPN for 62% of the 45 patients who did not qualify. Since many commercial insurances rely on LCD verbiage for their criteria as well, this not only affects the Medicare population, but would spread far and wide throughout the HPN community.

Conclusion

Based on the observations within this study, there is still room to improve the LCD criteria enacted in 2021. HPN was unable to be provided using LCD criteria to 36% of Medicare beneficiaries for whom, according to ASPEN consensus recommendations, it was clinically appropriate. The majority of patients who were denied Medicare coverage did not meet the LCD requirement for permanence. Further updates to the LCD criteria may seem unachievable given the time between the last update; however, advocacy efforts around this issue must continue in order to close the gaps further and help more patients access the HPN they clinically need.

References

  1. Centers for Medicare & Medicaid Services. Local coverage article for parenteral nutrition—policy article. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=58836&ver=20. Accessed August 17, 2023.
  2. Centers for Medicare & Medicaid Services. Local coverage article for parenteral nutrition—policy article. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=38953&ver=16. Accessed August 17, 2023.
  3. Worthington P, Balint J, Bechtold M, et al. When Is Parenteral Nutrition Appropriate? JPEN J Parenter Enteral Nutr. 2017 Mar;41(3):324-377. doi: 10.1177/0148607117695251. Epub 2017 Feb 1.

Authors of this presentation disclose the following concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation: Nothing to disclose.

Originally presented at ASPEN 2024 Nutrition Science & Practice Conference

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