Description

Home Health Care
Home health care services are for an essentially homebound member in a personal residence. Home health care must be provided by, or through, a community home health agency on a part-time visiting basis and according to a physician-prescribed course of treatment. Prior authorization of care is based on an established home health care treatment plan before being eligible for benefits. Please refer to the Schedule of Benefits to see what benefit limitations apply. Home health care includes: 

1. Services by a registered nurse (RN) or licensed practical nurse (LPN).
2. Physical, speech and occupational therapy (benefit period maximum applies).
3. Services provided by a home health aide or medical social worker.
4. Nutritional guidance.
5. Diagnostic services.
6. Administration of prescription drugs.
7. Medical and surgical supplies.
8. Oxygen and its use.
9. Durable medical equipment (a separate prior authorization isn’t needed when we approve the entire home health care plan).

Policy
Medically Necessary:
Home health services are considered MEDICALLY NECESSARY when all of the following criteria 1 through 4 are met:

1. The individual is confined to the home:

• Ongoing receipt of outpatient kidney dialysis
• The individual’s overall physical/medical condition poses a serious and significant impediment to receiving intermittent or occasional, skilled, medically necessary services outside the home setting. This includes those who are bedridden and those who are non-bedridden but whose medical condition is such that they meet all other criteria for home health services. In general, the condition of these individuals should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort
• If the individual does in fact leave the home, the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. The following are examples of acceptable medical and non-medical absences (these examples are not all-inclusive and are provided as a means to illustrate the kinds of infrequent or unique events an individual may attend):
  • Medical absences to receive health care treatment, including, but not limited to:
    • Receipt of outpatient chemotherapy or radiation therapy.
    • Participation in psychosocial or medical treatment in an adult day-care program that is licensed or certified by a state, or accredited, to furnish adult day-care services.
  • Non-medical absences:
    • To attend a funeral, religious service or graduation
    • An occasional trip to the barber, a walk around the block
    • Other infrequent or unique event (for example, a family reunion or other such occurrence)

Note: Any absence of an individual from the home attributable to the need to receive health care treatment of the types described above shall not disqualify an individual from being considered to be confined to the home. Any other absence from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. It is expected that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment. However, occasional absences from the home for nonmedical purposes, as described above, would not necessitate a finding that one is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the individual has the capacity to obtain the health care provided outside rather than in the home.

2. The service must be prescribed by the attending physician, health care provider practicing within the scope of license, or the primary care physician in coordination with the attending physician as part of a written plan of care.
3. The service(s) is so inherently complex that it can be safely and effectively performed only by:
   • Qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, licensed social-workers, licensed mental health professionals, and speech pathologists, or audiologists.
   • The home health services are provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation and/or skilled licensed mental health professional personnel to assure safety and to achieve the desired result.
4. The primary care physician, health care provider practicing within the scope of license, or attending physician in coordination with the primary care physician should review the treatment plan at least once every 30 days to assess the continued need for skilled intervention.

Home Infusion (IVTX)
Certain extended home infusion treatments are considered MEDICALLY NECESSARY because they are more appropriately performed in the home setting, even if the member is not homebound. The optimal location for these treatments is dependent upon a number of factors, including the toxicity of the medication, the individual’s previous response to the treatment, the monitoring required for safe administration, and the individual’s underlying medical condition. Examples of infusion treatments sometimes performed in the home setting include, but are not limited to, the following:

1. Intravenous gamma globulin
2. Intravenous hydration for a variety of conditions
3. Infusions for pain control
4. Some chemotherapy regimens

Other conditions for which intermittent intravenous infusions of medications provided in the home setting are considered MEDICALLY NECESSARY, either because of the complexity of the underlying condition, or the infusion itself include, but are not limited to, the following:

1. Infections requiring a prolonged treatment course
2. Coagulation disorders
3. Enzyme deficiency states
4. Pain management

Not Medically Necessary
Home health services are considered NOT MEDICALLY NECESSARY when:

1. The treatment plan provided by the primary care physician does not demonstrate the continued need for skilled intervention.
2. Goals have been achieved per plan of care. 

Home Wound Care
Wound care must be performed in accordance with accepted standards for medical and surgical treatment of wounds. Wound care provided by a nurse in the home setting is considered MEDICALLY NECESSARY for these circumstances:

1. The individual is confined to the home (see home health services policy section above for homebound status criteria)
2. Wound types:
   • Surgical wound that must be left open to heal by secondary intention
   • Infected open wound related to trauma or surgery
   • Wounds with biofilm
   • Wounds associated with autoimmune, metabolic, and vascular or pressure ulcers
   • Open or closed wounds complicated by necrotic tissue and/or eschar
3. Documentation must include:
   • Wound location, size, depth and stage by description.
   • Presence or absence of obvious signs of infection.
   • Presence or absence of necrotic, devitalized, or non-viable tissue.
   • For continued visits: Medical record must contain all of the above plus documentation of wound’s response to treatment.
4. Appropriate control of complicating factors such as pressure (e.g., off-loading, padding, and appropriate footwear), infection, vascular insufficiency, metabolic derangement and/or nutritional deficiency.
5. Care required is too complex to be performed primarily by the patient and/or the patient’s caregiver. (e.g., packing required, wet-to-dry dressings, wound vac)

Home Therapy (Physical, Occupational, Speech)

All home therapy services require a plan of care. The plan of care should be should be updated and/or evaluated as the patient’s condition changes and should have recertification from the physician at least every 30 days.

Plan of Care
The plan of care should include:

• Specific statements of long- and short-term goals.
• Measurable objectives.
• A reasonable estimate of when the goals will be reached.
• The specific modalities and exercises to be used in treatment.
• The frequency and duration of treatment.

Physical therapy services in the home must meet all of the following criteria:

• The individual is confined to the home (see home health services policy section above for homebound status criteria).
• Services must meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies or prior therapeutic intervention.
• Services must achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time.
• They must provide specific, effective and reasonable treatment for the patient’s diagnosis and physical condition.
• They must be delivered by a qualified provider of physical therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure.
• They must require the judgment, knowledge and skills of a qualified provider of physical therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient.

Augmented soft tissue mobilization is investigational/unproven therefore considered NOT MEDICALLY NECESSARY because it has not been proven to be more effective than standard soft tissue mobilization. There is no reliable evidence that outcomes of soft tissue mobilization (myofascial release) are improved with the use of handheld tools (so-called "augmented soft tissue mobilization").

Kinesio taping/taping is investigational/unproven therefore considered NOT MEDICALLY NECESSARY for all conditions because its clinical value has not been established.

MEDEK therapy is investigational/unproven therefore considered NOT MEDICALLY NECESSARY because its clinical value has not been established.

Hands-free ultrasound and low-frequency sound (infrasound) are investigational/unproven therefore considered NOT MEDICALLY NECESSARY because their clinical values have not been established.

Hivamat therapy (deep oscillation therapy) is investigational/unproven and therefore considered NOT MEDICALLY NECESSARY because its clinical value has not been established.

Speech therapy sessions in the home must meet ALL of the following criteria:

• The individual is confined to the home (see home health services policy section above for homebound status criteria).
• Sessions must treat the needs of a patient who suffers from communication impairment or swallowing disorder due to disease, trauma, congenital anomalies or prior therapeutic intervention.
• Sessions must achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable time period.
• They must provide specific, effective and reasonable treatment for the patient’s diagnosis and physical condition.
• They must be delivered by a qualified, licensed provider of speech therapy services.
• They require the judgment, knowledge and skills of a qualified provider of speech therapy services due to the complexity and sophistication and the physical condition of the patient.

Speech therapy services are generally NOT COVERED for the following conditions:

• Psychological speech delay
• Behavioral problems
• Attention disorders
• Conceptual handicap
• Mental retardation
• Stammering, stuttering

Occupational therapy services in the home must meet all of the following criteria:

• The individual is confined to the home (see home health services policy section above for homebound status criteria).
• Services must meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies or prior therapeutic intervention.
• They must achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time.
• They must provide specific, effective and reasonable treatment for the patient’s diagnosis and physical condition.
• They must be delivered by a qualified provider of occupational therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure.
• They require the judgment, knowledge and skills of a qualified provider of occupational therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient.

Non-Skilled Services:
There are certain types of treatments that do not generally require the skills of a licensed, qualified OT provider and are therefore NOT MEDICALLY NECESSARY. Such services may include:

• Passive range of motion (ROM) treatment, which is not related to the restoration of a specific loss of function.
• Services that maintain function by using routine, repetitive and reinforced procedures (e.g., daily feeding program once the adaptive procedures are in place).

Coding Section 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward     

07/10/2024 Interim review to add code G0155

06/27/2024 Removed language regarding pandemic  

06/19/2024 Annual review. No changes to policy intent. 

01/01/2024 NEW POLICY