Enteral nutrition is covered for patients who have:
- Permanent nonfunctional or the structures that normally permit food to reach the small bowel, or
- Disease of the small bowel which impairs digestion and absorption of an oral diet, either of which requires tube feeding to provide sufficient nutrition to maintain weight and strength commensurate with the patient's overall health.
The patient's condition could be either anatomic (e.g. obstruction due to head and neck cancer or reconstructive surgery, etc.) Or due to motility disorder ( e.g., severe dysphagia following a stroke, etc.) Enteral nutrition is not covered for patients who have a functioning gastrointestinal tract whose need for nutrition is due to reasons such as anorexia, nausea associated with mood disorder, ESRD, etc.
The patient must require tube feeding to maintain weight and strength commensurate with the patient's overall health status. The patient must be unable to receive adequate nutrition 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 a prolonged infusion of enteral nutrients to overcome a problem with absorption.
The patient must have a permanent impairment. If the judgment of the attending physician, documented in the medical record, is that the condition is of long or indefinite duration (ordinarily at least 3 months), then the test of permanence has been met.