Home IV Therapy is Medically Necessary for This Patient
This patient with type 2 short bowel syndrome from multiple Crohn's resections and documented chronic intestinal failure requiring home parenteral support since 2019 has an absolute medical necessity for the prescribed 800 mL IV fluid regimen containing magnesium sulfate (64 mEq), potassium chloride (75 mEq), sodium phosphate (75 mEq), and Infuvite Adult multivitamins administered four days weekly. The September 2025 deterioration when therapy was discontinued provides objective clinical evidence of ongoing dependence. 1
Guideline-Based Justification for Parenteral Support
The fundamental treatment aim in short bowel syndrome is to provide the nutrition, water, and electrolytes necessary to maintain health with normal body weight, while reducing complications and achieving good quality of life. 2 International guidelines explicitly state that patients with jejunostomy and less than 100 cm of remaining jejunum require parenteral saline, and those with less than 75 cm require both parenteral nutrition and saline in the long term. 2
Home parenteral nutrition and specialized IV fluids are standard care—not experimental—for patients with chronic intestinal failure who cannot maintain adequate hydration, electrolyte balance, or nutritional status through oral or enteral routes alone. 1 The European Society for Clinical Nutrition and Metabolism recommends home parenteral nutrition for patients with chronic insufficient dietary intake and/or uncontrollable malabsorption. 1
Medical Necessity of Each Component
Magnesium Sulfate (64 mEq)
Hypomagnesemia is common in jejunostomy patients and requires treatment with intravenous magnesium supplements when oral supplementation is inadequate. 2 Magnesium supplementation via the parenteral route is medically necessary for patients with documented chronic hypomagnesemia secondary to short bowel syndrome. 1 Without this replacement, severe hypomagnesemia causes cardiac arrhythmias, neuromuscular dysfunction, and refractory hypokalemia. 1
Potassium Chloride (75 mEq)
Parenteral potassium supplementation is medically necessary for short bowel syndrome patients experiencing hypokalemia from sodium depletion and secondary hyperaldosteronism. 1 Fluid and electrolyte losses dominate the clinical picture in jejunostomy patients, and adaptation does not occur, meaning requirements do not reduce with time. 2 Severe hypokalemia can precipitate life-threatening cardiac arrhythmias. 1
Sodium Phosphate (75 mEq)
Parenteral phosphate supplementation is medically necessary to prevent and treat hypophosphatemia in patients receiving specialized IV fluids. 1 Complete parenteral therapy must include adequate amounts of all essential nutrients, including electrolytes and minerals, tailored to the individual patient's clinical and intestinal status. 2
Infuvite Adult (Intravenous Multivitamins)
The American Gastroenterological Association explicitly states that patients receiving home parenteral nutrition must add vitamins to their solutions prior to infusion, making multivitamins an integral component of the therapy rather than an optional supplement. 1 Complete parenteral nutrition must include the 35 essential nutrients (electrolytes, minerals, vitamins, and trace metals), and amounts should be tailored according to the clinical and intestinal status of individual patients. 2
Patients with short bowel syndrome require supplementation of both water-soluble and fat-soluble vitamins, as micronutrient deficiency is a recognized complication of malabsorption. 1 Do not consider parenteral multivitamins as optional or "complementary" therapy—they are a required component of parenteral nutrition formulations that must be added before infusion. 1 Oral vitamin supplementation cannot substitute for parenteral vitamins in patients with severe malabsorption from short bowel syndrome, as absorption is inadequate. 1
Water-soluble vitamins have very low toxicity, and the rationale for providing higher doses than the minimum calculated requirement IV is that many patients have higher vitamin requirements due to malnutrition, baseline vitamin deficiencies, and metabolic changes secondary to illness, with increased excretion of water-soluble vitamins when provided IV. 2
Duration and Monitoring Justification
The requested 12-month authorization period is appropriate for a patient with chronic intestinal failure requiring ongoing parenteral support. 1 Stable patients with chronic intestinal failure on home parenteral nutrition can be monitored as infrequently as 3 times per year with office visits and laboratory testing. 1 Clinical monitoring every 1-3 months with laboratory assessment is standard practice. 1
Do not require repeated short-term authorizations for chronic intestinal failure, as this condition is permanent and the patient has already demonstrated dependence on parenteral support. 1 This patient has been on therapy since November 2019 and deteriorated when attempting discontinuation in September 2025, providing objective evidence of ongoing need. 1
Clinical Consequences Without Treatment
Without continuation of specialized IV fluid therapy, this patient will experience recurrent severe dehydration, electrolyte derangements, malnutrition, and likely require emergency department visits and hospitalizations. 1 Severe hypomagnesemia can cause cardiac arrhythmias, neuromuscular dysfunction, and refractory hypokalemia. 1 Patients with short bowel syndrome who become dehydrated should have rapid access to medical expertise for advice, clinics, or inpatient treatment. 2
The goal of home parenteral support is to keep patients stable at home rather than in the hospital, reducing complications resulting from the underlying disease, intestinal failure, and nutritional/fluid support while achieving good quality of life. 2 Nutrition support teams that specialize in chronic intestinal failure are a prerequisite for running such home parenteral nutrition programs, and long-term health outcome improvement has been demonstrated. 2
All Components and Supplies Are Medically Necessary
All components including the multivitamins and supplies are medically necessary to safely deliver the therapy. 1 The infusion pump and 10-hour delivery schedule allow for safe administration of the complete formulation while maintaining the patient's quality of life. 2 Patients should be taught proper storage and handling of parenteral nutrition solutions and supplies as part of comprehensive home therapy training. 3