How does Medicare define eligibility for coverage of home enteral nutrition?

How does Medicare define eligibility for coverage of home enteral nutrition?

• A. It covers any patient needing tube feeding, regardless of underlying condition.
• B. It covers patients with permanent non-function or disease of structures that normally permit food to reach the small bowel, or a disease of the small bowel that impairs digestion and absorption, requiring tube feeding to maintain weight and strength; the condition could be anatomic or motility disorder.
• C. It covers only patients with cancer of the GI tract.
• D. It requires that the patient be unable to receive any oral nutrition for at least 6 months.

Answer: (B)

Medicare bases home enteral nutrition coverage on a permanent impairment of the GI tract that prevents adequate oral intake or normal digestion and absorption, such that tube feeding at home is medically necessary to maintain weight and strength. This can come from anatomic problems that block food from reaching the small bowel or from motility or small-bowel diseases that impair digestion/absorption. The condition may be structural or functional, but the key is permanence and the need for tube feeding to support nutrition at home. It isn’t simply any patient who needs a tube, it isn’t limited to GI cancers, and there isn’t a strict six-month minimum of oral non-feasibility—coverage depends on the permanent, medically necessary condition that requires enteral feeding.

Medicare bases home enteral nutrition coverage on a permanent impairment of the GI tract that prevents adequate oral intake or normal digestion and absorption, such that tube feeding at home is medically necessary to maintain weight and strength. This can come from anatomic problems that block food from reaching the small bowel or from motility or small-bowel diseases that impair digestion/absorption. The condition may be structural or functional, but the key is permanence and the need for tube feeding to support nutrition at home. It isn’t simply any patient who needs a tube, it isn’t limited to GI cancers, and there isn’t a strict six-month minimum of oral non-feasibility—coverage depends on the permanent, medically necessary condition that requires enteral feeding.