List 5 requirements for Medicare coverage of home parenteral nutrition (HPN) under the Prosthetic device act?

• A. Documented evidence of inability to tolerate feeding through the enteral route; Patients with <= 5 feet of small bowel beyond the ligament of Treitz; GI losses exceeding 50% of oral intake (2.5-3 liters per day in and > 1.25 to 1.5 L/day out); Bowel rest is required for at least 90 days; 20-35 calories per kilogram per day is prescribed
• B. Documented evidence of inability to tolerate feeding through the enteral route only
• C. GI losses exceeding 10% of oral intake only
• D. Bowel rest for 30 days and a fixed lipid prescription

Answer: (A)

Medicare coverage for home parenteral nutrition under the Prosthetic Device Act is based on demonstrating intestinal failure and the necessity of a prosthetic approach to nutrition. The five criteria together establish that parenteral support is required because the gut cannot meet the patient’s needs and the patient has a high likelihood of needing ongoing PN.

First, there must be documented evidence that the patient cannot tolerate feeding through the enteral route. If the gut cannot absorb or process nutrients, parenteral nutrition becomes essential.

Second, the patient should have very limited small-bowel length—specifically, there is ≤ about 5 feet of small intestine beyond the ligament of Treitz. This reflects severe short-bowel syndrome with a high risk of ongoing malabsorption and dependence on PN.

Third, gastrointestinal losses must exceed half of the oral intake, indicating substantial ongoing losses that prevent meeting needs through the gut alone.

Fourth, bowel rest is required for a prolonged period, at least 90 days. This helps confirm that the gut is not functioning well enough to reestablish adequate nutrition through enteral feeding in the near term.

Fifth, the prescribed energy delivery should be within a typical PN range of 20–35 kcal per kilogram per day, ensuring sufficient calories to maintain or achieve nutritional status while on PN.

Together, these criteria distinguish patients who genuinely need home parenteral nutrition as a prosthetic support from those who might not meet the level of necessity. The other options lack one or more of these essential elements, making them incomplete.