DMERC Review of Initial PEN Certifications

In reviewing the claim and the supporting data on the CMN, the DMERC compares certain items, especially pertinent dates of treatment. For example, the start date of PEN coverage cannot precede the date of physician certification. The estimated duration of therapy must be contained on the CMN. This information is used to verify that the test of permanence is met. Once coverage is established, the estimated length of need at the start of PEN services will determine the recertification schedule. The information shown on the certification must support the need for PEN supplies as billed. A diagnosis must show a functional impairment that precludes the enteral patient from swallowing and the parenteral patient from absorbing nutrients.

Initial assigned claims with the following conditions are denied without development:

• Inappropriate or missing diagnosis or functional impairment;

• Estimated duration of therapy is less than 90 consecutive days;

• Duration of therapy is not listed;

• Supplies have not been provided;

• Supplies were provided prior to onset date of therapy; and

• Stamped physician's signature.

Unassigned claims are developed for missing or incomplete information.


A. Revised Certifications/Change in Prescription

A revised certification is required when:

• There is a change in the attending physician's orders in the category of nutrients and/or calories prescribed;

• There is a change by more than one liter in the daily volume of parenteral solutions;

• There is a change from home-mix to pre-mix or pre-mix to home-mix parenteral solutions;

• There is a change from enteral to parenteral or parenteral to enteral therapy; or

• There is a change in the method of infusion (e.g., from gravity-fed to pump-fed).

The PEN payments are not adjusted unless a revised or renewed certification documents the necessity for the change. Payment levels for the most current certification or recertification may not be changed unless a prescription change is documented by a new recertification.

The DMERC may adjust the recertification schedule as needed.