Does S9366 require prior authorization?

Yes, S9366 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for S9366?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`S9366`, Home infusion therapy, total parenteral nutrition (tpn); more than one liter

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For adults: documentation of involuntary weight loss of 10% in six months or 5% in one month (baseline weight and timeframe).
For children: documentation of weight-for-length/height or sex percentile < 10th, inadequate weight gain, or significant decrease in usual growth percentile (growth charts/measurements).

For neonates: documentation of birth weight < 1000 g.

Clinical documentation supporting structural or functional bowel disease or other reason oral/tube feedings are inappropriate and that the GI tract is non-functioning for a period of time (operative notes, imaging, clinical assessments).

Clinical documentation of inadequate oral intake >1 week and that enteral feedings exacerbate symptoms (worsening abdominal pain, ascites, or fistulous output) for pancreatitis cases.

Documentation of the qualifying diagnosis (necrotizing enterocolitis or small bowel ischemia) when used for those conditions.

Key Coverage Criteria

Initial use of home parenteral nutrition is consideredmedically necessarywhenallof the following criteria (A, B, and C) are met:
The individual is malnourished or at risk for malnutrition as evidenced by:Adults:Loss of 10% or more of their ideal body weight within a 3 month period;orLoss of 20% of their usual body weight within a 3 month period;orSerum total protein level less than 6 g/dL;orSerum albumin level less than 3.4 g/dL;orNone of the conditions listed above (a-d) are present but one or more are considered inevitable given the individualâs expected course of illness.Children:Under the 10thpercentile of expected [...]
Adults:Loss of 10% or more of their ideal body weight within a 3 month period;orLoss of 20% of their usual body weight within a 3 month period;orSerum total protein level less than 6 g/dL;orSerum albumin level less than 3.4 g/dL;orNone of the conditions listed above (a-d) are present but one or more are considered inevitable given the individualâs expected course of illness.
Loss of 10% or more of their ideal body weight within a 3 month period;or
Loss of 20% of their usual body weight within a 3 month period;or
Serum total protein level less than 6 g/dL;or

8 Active Policies

ANTHEM-CG-MED-89, Home Parenteral Nutrition

ANTHEM-CG-MED-23, Home Health

EVICORE-HPLAN-CIGNA_MEDICARE-7E679040BEBB, Cigna Medicare Advantage Home Health Code List - Effective 01/01/2025

AMBETTER-CP.MP.163, Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

BCBSIL-MED201.011, Nutritional Support

BCBSMT-MED201.011, Nutritional Support

BCBSNM-MED201.011, Nutritional Support

BCBSOK-MED201.011, Nutritional Support

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S9366, Home infusion therapy, total parenteral nutrition (tpn); more than one liter