Covered if the patient has (a) permanent nonfunction 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 provide sufficient nutrients to maintain weight and strength 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 judgment of the attending physician, substantiated in the medical record, is that the condition is of long and indefinite duration (ordinarily at least three months), the test of permanence is considered met. Enteral nutrition will be denied as non-covered in situations involving temporary impairments.

Indications for Home Enteral Therapy
The patient has a condition involving the gastrointestinal tract somewhere between the mouth and duodenum inclusive, which prevents adequate ingestion. This 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.).

• 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 not covered.
• The ordering physician is expected to see the patient within thirty (30) days prior to the initial certification or required recertification (not revised). If the physician did not see the patient within this time frame, he/she must document the reason why and describe what other monitoring methods were used to evaluate the patient's enteral nutrition needs (i.e., RN visits).

The claim must contain:

• A physician's written order or prescription including brand name of product, amount to be administered, duration/frequency of administration, and
• Sufficient medical documentation to permit an independent conclusion that enteral therapy is medically necessary (i.e., hospital records, clinical findings or the attending physician, etc.).

If the coverage requirements are met, all related supplies, equipment and nutrients are also covered, including IV poles and enteral nutrition preparation. No more than one month's supply of enteral nutrients, equipment or supplies are allowed for one month's prospective billing.

If a pump is ordered, the CMN must include sufficient medical documentation to justify medical necessity, i.e., that gravity feeding is not satisfactory due to aspiration, diarrhea, dumping syndrome, administration rate less than 100 ml/hr, blood glucose fluctuations, circulatory overloads. This information should be listed in Question #15 on the certificate of medical necessity.

Special nutrients require additional documentation on the CMN to establish medical necessity.

More than three nasogastric tubes, or one gastrostomy or jejunostomy tube every three months is rarely medically necessary. If enteral therapy is provided in the home by nonprofessionals who have received special training, these persons cannot be reimbursed for their supplies/services.