Evidence of Medical Necessity for Parenteral and Enteral Nutrition (PEN) Therapy

The PEN coverage is determined by information provided by the treating physician and the PEN supplier. A completed certification of medical necessity (CMN) must accompany and support initial claims for PEN to establish whether coverage criteria are met and to ensure that the PEN therapy provided is consistent with the attending or ordering physician's prescription. Contractors ensure that the CMN contains pertinent information from the treating physician. Uniform specific medical data facilitate the review and promote consistency in coverage determinations and timelier claims processing.

The medical and prescription information on a PEN CMN can be most appropriately completed by the treating physician or from information in the patient's records by an employee of the physician for the physician's review and signature. Although PEN suppliers sometimes may assist in providing the PEN services, they cannot complete the CMN since they do not have the same access to patient information needed to properly enter medical or prescription information. Contractors use appropriate professional relations issuances, training sessions, and meetings to ensure that all persons and PEN suppliers are aware of this limitation of their role.

When properly completed, the PEN CMN includes the elements of a prescription as well as other data needed to determine whether Medicare coverage is possible. This practice will facilitate prompt delivery of PEN services and timely submittal of the related claim.