ModifiedAmbetter GeorgiaPolicy CP.MP.91

Obstetrical Home Care Programs

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This policy establishes medical necessity criteria for obstetrical home health services provided by vendors to pregnant and postpartum members/enrollees, including infusion, hydration, diabetes, hypertension, nurse assessment, and dietary services. It also identifies obstetrical home care services that are not medically necessary.

Policy Summary

PayerAmbetter Georgia

PolicyObstetrical Home Care Programs

Policy CodePolicy CP.MP.91

Change TypeModified

Effective DateNov 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionFor infusion therapy reauthorization, reassess the member and document the continued need for therapy.

SourceLink

POLICY UPDATE CHANGES

Medication infusion therapy was added as medically necessary when conservative treatments, including oral or rectal medications and nonpharmacologic treatments, have been tried and failed.

Reauthorization for infusion therapy requires reassessment by the ordering provider and documentation of the need for continued therapy.

Diabetes home management criteria were expanded to include pre-existing type 1 and type 2 diabetes and to require diabetic nutrition education within the program.

Hypertension home management criteria were clarified to include chronic hypertension, prior postpartum hypertension, and remote blood pressure monitoring during virtual follow-up.

Criteria for nursing visits to administer hydroxyprogesterone caproate (Makena) were removed.

Postpartum home or virtual visit criteria were added for members less than 14 days postpartum.

The initial hypertensive-disorder visit requirement was revised to one initial home or virtual visit, with additional telephone or virtual follow-up as needed.

Up to 7 daysHydration therapy course

<14 daysPostpartum visit window

≥140/90Preeclampsia blood pressure

Twice weeklyBlood pressure monitoring

4New HCPCS codes

Covered and Non-Covered Obstetrical Home Care Services

Obstetrical Nurse Assessment

Covered when provided with at least one service listed in sections B through F.

ONE of the following services

Metoclopramide or ondansetron infusion therapy.
Hydration therapy.
Diabetes of pregnancy clinical management program.
Management of hypertensive disorders in pregnancy and postpartum.
Dietary analysis.

Metoclopramide or Ondansetron Infusion Therapy

Home visits for medication infusion therapy are considered medically necessary when ALL of the following criteria are met:

ALL of the following

Home visits will take place during the same period as the infusion therapy is ordered to be administered.
The member/enrollee has tried and failed conservative treatment, including medications by mouth and/or per rectum and/or other non-pharmacological treatments.
If re-authorization is requested, the ordering provider has reassessed the member/enrollee since the previous authorization and documented the need for continuation of infusion therapy.
See Table 1 in Background for recommendations from ACOG.

Hydration Therapy — One to Four Liters

Hydration therapy is medically necessary for members/enrollees who could benefit from close surveillance for the onset of dehydration.

ALL of the following

A qualifying condition or clinical circumstance
- Hyperemesis gravidarum.
- Malabsorption.
- A diagnosis, such as influenza or a gastrointestinal virus, that impairs the member/enrollee's ability to maintain fluid and/or food in the system.
- Another clinical circumstance in which the member/enrollee could benefit from close surveillance for the onset of dehydration.
The requested course is up to seven days at a time.
Additional days may be granted as clinically indicated.

Diabetes of Pregnancy Clinical Management Programs

Diabetes of pregnancy clinical management is medically necessary when ANY one of the following pathways is met. The program applies to gestational diabetes and pre-existing type I or type II diabetes.

ANY of the following pathways

Nutrition education and non-insulin-dependent diabetes
- The program includes diabetic nutrition education.
- The pregnant member/enrollee has non-insulin-dependent diabetes managed by oral medications or dietary modifications.
  One visit is medically necessary.
Nutrition education and initial insulin-dependent diabetes course
- The program includes diabetic nutrition education.
- The pregnant member/enrollee has insulin-dependent diabetes requiring insulin administration by any means.
  An initial course of visits for up to seven days is medically necessary.
Nutrition education and additional insulin-dependent diabetes course
- The program includes diabetic nutrition education.
- The pregnant member/enrollee has insulin-dependent diabetes requiring insulin administration by any means.
- The member/enrollee requires additional visits until able to self-manage blood sugar and insulin administration.
  Each additional course may be up to seven days.

Management of Hypertensive Disorders in Pregnancy and Postpartum

Home visits for management of hypertensive disorders of pregnancy, including chronic hypertension, gestational hypertension, and preeclampsia without severe features, are medically necessary when ANY one of the following pathways is met.

ANY of the following pathways

Gestational or chronic hypertension pathway
- The member/enrollee is diagnosed with gestational or chronic hypertension.
- ONE of the following clinical findings or risk circumstances
  - Elevated blood pressure without proteinuria.
  - The member/enrollee could benefit from education and surveillance for potential onset of hypertension, including circumstances such as a hypertensive disorder affecting a previous pregnancy or postpartum period, multiple gestations, or diabetes.
- The request is for one initial home or virtual visit, with additional telephone or virtual follow-up as needed.
- Postpartum timing requirement
  - The request is not for postpartum visits.
  - If the request is for postpartum visits, the member/enrollee is less than 14 days postpartum.
Preeclampsia without severe features pathway
- The member/enrollee is diagnosed with preeclampsia without severe features.
- ONE of the following diagnostic findings
  - Blood pressure is ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on two occasions at least four hours apart after 20 weeks' gestation in a member/enrollee with previously normal blood pressure.
  - Proteinuria demonstrated by ONE or more of the following
    At least 300 mg per 24-hour urine collection, or this amount extrapolated from a timed collection.
    Protein/creatinine ratio ≥ 0.3 mg.
    Dipstick reading ≥ 2+ (30 mg/dL).
- The request is for an initial home visit with additional telephone or virtual follow-up as needed, including remote blood pressure monitoring.
- Postpartum timing requirement
  - The request is not for postpartum visits.
  - If the request is for postpartum visits, the member/enrollee is less than 14 days postpartum.

Dietary Analysis

A dietary analysis is medically necessary when the member/enrollee has ANY of the following qualifying nutritional conditions:

ANY of the following

Obesity.
Malnutrition.
Prior bowel or bariatric surgery affecting nutrient absorption.

Medication Infusion Therapy

Medication infusion therapy is considered medically necessary when ALL of the following criteria are met:

ALL of the following

Home visits occur during the same period as the medication infusion therapy is ordered to be administered.
The member/enrollee has tried and failed conservative treatment, including medications by mouth and/or per rectum and/or other non-pharmacological treatments.
For a re-authorization request, the ordering provider has reassessed the member/enrollee since the previous authorization and documented the need for continuation of infusion therapy.

Gestational Hypertension and Preeclampsia Without Severe Features — Home Management

Home management may be considered for gestational hypertension or preeclampsia without severe features when the member/enrollee requires frequent fetal and maternal evaluation and meets the applicable pathway below.

ONE qualifying home-management pathway

Gestational or chronic hypertension
- Diagnosis of gestational or chronic hypertension.
- ONE of the following
  - Elevated blood pressure without proteinuria.
  - The member/enrollee could benefit from education and surveillance for potential onset of hypertension, such as with a hypertensive disorder affecting a previous pregnancy or postpartum period, multiple gestations, or diabetes.
- One initial home or virtual visit, with additional telephone or virtual follow-up as needed.
- For postpartum visits, the member/enrollee is less than 14 days postpartum.
Preeclampsia without severe features
- Preeclampsia without severe features.
- ONE of the following
  - Blood pressure ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on two occasions at least four hours apart after 20 weeks' gestation in a member/enrollee with previously normal blood pressure.
  - Proteinuria demonstrated by ONE or more of the following
    ≥ 300 mg per 24-hour urine collection, or this amount extrapolated from a timed collection.
    Protein/creatinine ratio ≥ 0.3 mg.
    Dipstick reading ≥ 2+ (30 mg/dL).
- An initial home visit with additional telephone or virtual follow-up as needed, including remote blood pressure monitoring.
- For postpartum visits, the member/enrollee is less than 14 days postpartum.

Diabetes in Pregnancy — Home-Management Program

The diabetes in pregnancy home-management program is medically necessary when it includes diabetic nutrition education and follows a qualifying management pathway.

Required program component

The program includes diabetic nutrition education.
ONE qualifying diabetes-management pathway
- One visit for a pregnant member/enrollee with non-insulin-dependent diabetes managed by oral medications or dietary modifications.
- An initial course of visits for up to seven days for a pregnant member/enrollee with insulin-dependent diabetes requiring insulin administration by any means.
- One or more additional courses of visits, each up to seven days, for a pregnant member/enrollee with insulin-dependent diabetes requiring insulin administration by any means until the member/enrollee is able to self-manage blood sugar and insulin administration.

Preterm Labor Management

The decision to manage an individual with preterm labor as an inpatient or outpatient should be made on a case-by-case basis.

Individualized decision factors

The clinician evaluates cervical dilation.
The clinician evaluates vaginal bleeding.
The clinician evaluates fetal status.
The clinician evaluates travel time to the appropriate level-of-care facility.

The following services provided by a home health vendor are considered not medically necessary: betamethasone therapy via multiple repeat courses or intermittent injections; multiple gestation management (refer to the individual program for the identified risk factor); continuous heparin infusion therapy; member/enrollee-administered nonstress testing or fetal heart rate monitoring; preterm labor management; preterm prelabor rupture of membranes (PPROM) management; and 17-hydroxyprogesterone caproate (Makena) injections.

Preeclampsia with severe features should be managed through inpatient care. Hospitalization is recommended for individuals with severe features and for individuals in whom adherence to frequent evaluation may be a concern.

Betamethasone therapy via intermittent injections is not medically necessary. ACOG recommends a single course of corticosteroids in appropriate clinical circumstances and does not recommend multiple repeated weekly injections because of their association with lower birthweight and head circumference. A single repeat or rescue course may be clinically indicated in limited circumstances, but repeated weekly administration is not recommended.

Home management of preterm prelabor rupture of membranes (PPROM) is not medically necessary. Evidence is insufficient to establish the safety of home care, and the risks of sudden infection, placental abruption, and umbilical cord compression make hospital surveillance the appropriate management choice.

17-hydroxyprogesterone caproate (Makena) injections are not medically necessary. The FDA withdrew approval of Makena and its generics in 2023 after the required confirmatory study did not verify the proposed clinical benefit.

Home management is not appropriate for preeclampsia with severe features or when the member/enrollee cannot comply with frequent maternal and fetal evaluation. Hospitalization is recommended in these circumstances.

Services provided by a home health vendor are explicitly considered not medically necessary when they involve betamethasone therapy via multiple repeat courses or intermittent injections, multiple gestation management, continuous heparin infusion therapy, member/enrollee-administered nonstress testing or fetal heart rate monitoring, preterm labor management, PPROM management, or 17-hydroxyprogesterone caproate (Makena) injections.

Betamethasone therapy provided by intermittent injections is subject to a policy treatment limitation and is not medically necessary when delivered as multiple repeat courses or routine weekly injections.

Management of preterm prelabor rupture of membranes (PPROM) in the home setting is subject to a policy limitation and is not medically necessary. Hospital surveillance is the appropriate management setting because of the risks associated with infection, placental abruption, and umbilical cord compression.

17-hydroxyprogesterone caproate (Makena) injections are subject to a policy limitation and are not medically necessary following the FDA withdrawal of approval in 2023.

Billing Codes and Clinical Thresholds

Home obstetrical care and nursing HCPCS codesHCPCS

G0162	Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential nonskilled care achieves its purpose in the home health or hospice setting).
G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes.
S9123	Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500 to 99602 can be used).
S9140	Diabetic management program, follow up-visit to non-MD provider.
S9145	Insulin pump initiation, instruction in initial use of pump (pump not included).
S9211	Home management of gestational hypertension, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code).
S9213	Home management of preeclampsia, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code).

Additional HCPCS codeHCPCS

S9560

Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all

CPT CodesCPT

99601	Home infusion/specialty drug administration, per visit (up to two hours).
99602	Home infusion/specialty drug administration, per visit (up to two hours); each additional hour (List separately in addition to code for primary procedure).

HCPCS codes added during the 02/24 coding updateHCPCS

G0162
G0299
S9145
S9351

Preeclampsia blood pressure

Systolic threshold≥140 mm Hg

Diastolic threshold≥90 mm Hg

Timing and confirmationPresent on two occasions at least four hours apart after 20 weeks gestation in a member/enrollee with previously normal blood pressure

Preeclampsia proteinuria

24-hour urine collection≥300 mg per 24-hour urine collection, or the equivalent extrapolated from a timed collection

Protein/creatinine ratio≥0.3 mg

Dipstick reading≥2+ (30 mg/dL)

Postpartum hypertension visits

Postpartum eligibilityMember/enrollee is less than 14 days postpartum

Visit typeOne initial home or virtual visit, with additional phone or virtual follow-up as needed

Applicable conditionsPostpartum visits may be requested for management of chronic or gestational hypertension or preeclampsia without severe features

Hydration therapy duration

Hydration volumeOne to four liters

Standard courseUp to 7 days at a time

Additional treatmentAdditional days may be granted as clinically indicated

Blood pressure monitoring

Blood pressure monitoringTwice weekly

PopulationIndividuals with gestational hypertension or preeclampsia without severe features

Care settingMonitoring is part of ambulatory management requiring frequent fetal and maternal evaluation

Fetal movement monitoring

Fetal movement monitoringDaily self-monitoring

PopulationIndividuals with gestational hypertension or preeclampsia without severe features

Evaluation planDaily fetal-movement monitoring is included in frequent fetal and maternal evaluation

Platelet count and liver enzyme assessment

Platelet count assessmentWeekly

Liver enzyme assessmentWeekly

PopulationIndividuals with gestational hypertension or preeclampsia without severe features

Single corticosteroid course for PPROM

Corticosteroid courseSingle course recommended for individuals with preterm premature rupture of membranes

Lower gestational-age limit24 0/7 weeks

Upper gestational-age limit33 6/7 weeks

Methylprednisolone duration

Initial methylprednisolone regimen16 mg every eight hours, orally or intravenously for three days

TaperTaper over two weeks to the lowest effective dose

Maximum suggested total durationLimit total duration of use to six weeks if beneficial

Authorization, Documentation, and Denial Risks

Documentation Required

Nurse Assessment Must Accompany a Qualifying Service

An obstetrical nurse assessment is medically necessary only when provided with one of the listed qualifying services in sections B through F.

Qualifying paired services: metoclopramide or ondansetron infusion therapy; hydration therapy; diabetes in pregnancy clinical management; hypertensive-disorders-of-pregnancy program; or dietary analysis.

Prior Authorization

Infusion Visits Must Match the Ordered Administration Period

Home visits for metoclopramide or ondansetron infusion therapy are medically necessary only when the visit occurs during the same period in which the infusion is ordered to be administered and the applicable clinical requirements are met.

Document that the home visit overlaps the ordered infusion-administration period.
Document failed conservative treatment and, when applicable, reassessment for continuation.

Prior Authorization

Hydration Therapy Authorization

Hydration therapy of one to four liters is medically necessary for members who could benefit from close surveillance for the onset of dehydration. Document the qualifying circumstance and requested course.

Examples include hyperemesis gravidarum; malabsorption; or influenza/GI virus impairing the ability to maintain fluids or food.
A course of up to seven days at a time is covered; additional days require clinical indication.

Unsupported block type: prior_auth

Step Therapy

Conservative Treatment Must Fail First

Before requesting medication infusion therapy, document that conservative treatment was tried and failed, including medications administered by mouth and/or per rectum and/or other nonpharmacologic treatments.

Identify the treatments attempted, duration or course when available, response, and reason they were unsuccessful.
Failure of conservative treatment is a required infusion-therapy criterion.

Step Therapy

Stepwise Hyperemesis Treatment

Use a stepwise approach for hyperemesis treatment, progressing from nonpharmacologic measures to first-line medication therapy and then to additional agents or infusion options when symptoms persist.

First line: convert the prenatal vitamin to folic acid alone; ginger capsules 250 mg four times daily; and consider P6 acupressure wrist bands.
Next: vitamin B6 alone or with doxylamine, using the listed oral dosing options.
If symptoms persist: add an oral, rectal, or as-needed antiemetic such as dimenhydrinate, diphenhydramine, prochlorperazine, or promethazine.
If symptoms persist without dehydration, consider oral or intramuscular metoclopramide or oral ondansetron. If dehydration exists, consider intravenous dimenhydrinate or intravenous metoclopramide as specified.

Documentation Required

Document Reassessment for Continued Infusion

For continued infusion therapy, the ordering provider must reassess the member since the previous authorization and document why infusion remains necessary.

Include the reassessment date, current symptoms and response, ongoing clinical need, and requested continuation period.
A reauthorization request without documented reassessment and continued need may be denied.

Documentation Required

Document Preeclampsia Findings and Postpartum Status

Document the findings supporting home management of hypertension or preeclampsia without severe features, including qualifying blood-pressure or proteinuria findings and postpartum timing when applicable.

For gestational or chronic hypertension, document elevated blood pressure without proteinuria or the qualifying risk/education and surveillance need.
For preeclampsia without severe features, document blood pressure of at least 140/90 on two occasions at least four hours apart after 20 weeks and/or qualifying proteinuria.
For postpartum requests, document that the member is less than 14 days postpartum.

Documentation Required

Document Diabetes Program Needs

For diabetes-in-pregnancy clinical management, document the diabetes category, insulin requirement, requested course, and required program components.

The program must include diabetic nutrition education.
For non-insulin-dependent diabetes managed with oral medication or dietary modification: request one visit.
For insulin-dependent diabetes: request an initial course of up to seven days and additional courses of up to seven days until the member can self-manage blood sugar and insulin administration.

Documentation Required

Hypertensive Disorder Monitoring

For hypertensive disorders, document the maternal and fetal surveillance plan required for outpatient management.

ACOG-referenced monitoring includes blood pressure twice weekly, daily self-monitoring of fetal movement, and weekly platelet counts and liver enzymes for gestational hypertension or preeclampsia without severe features.
Remote blood-pressure monitoring is required for the preeclampsia home-visit pathway.

Documentation Required

Infusion Reauthorization Documentation

A reauthorization request must show reassessment since the prior authorization and a documented continued need for infusion therapy.

Attach or reference the ordering provider's interval reassessment.
Explain the ongoing symptoms or clinical findings supporting additional infusion visits.

Documentation Required

Preterm Labor Disposition Assessment

Before pursuing a home pathway for preterm labor concerns, document the disposition assessment, including cervical dilation, bleeding, fetal status, and whether travel to an appropriate facility is safe and feasible.

Home-vendor preterm labor management is listed as not medically necessary.
Escalate when findings require facility-based evaluation or monitoring.

Denial Risk

Services Explicitly Considered Not Medically Necessary

The policy considers several home-health vendor services not medically necessary. Verify the requested service against the exclusion list before submitting authorization or billing.

Betamethasone therapy via multiple repeat courses or intermittent injections.
Multiple gestation management; continuous heparin infusion therapy; and member/enrollee-administered nonstress testing or fetal heart-rate monitoring.
Preterm prelabor rupture of membranes management; preterm labor management; and 17-hydroxyprogesterone caproate (Makena) injections.

Denial Risk

Severe Preeclampsia Requires Inpatient Management

Preeclampsia with severe features should be managed through inpatient care rather than the covered home-care pathway.

Do not request home visits as a substitute for inpatient management when severe features are present.

Denial Risk

Infusion Therapy Criteria Not Met

Infusion therapy may be denied when the required criteria are not documented or are not met.

No documented failed conservative treatment, including oral and/or rectal medication or nonpharmacologic treatment.
Home visits do not occur during the ordered infusion-administration period.
For reauthorization, the ordering provider did not reassess the member or document continued need.
The requested therapy lacks documented medical necessity or otherwise fails the policy requirements.

Denial Risk

Intermittent Betamethasone Injections

Intermittent betamethasone injections and multiple repeat courses are not medically necessary through a home-health vendor. This exclusion is distinct from a clinically supported single antenatal corticosteroid course.

ACOG supports a single course in qualifying PPROM circumstances, including 24 0/7 through 33 6/7 weeks, high risk of preterm birth within seven days, and a prior course more than 14 days earlier.
A rescue course may be considered as early as seven days after the prior dose when clinically indicated; repeated weekly administration is not supported.

Denial Risk

PPROM Requires Hospital Surveillance

PPROM management is not medically necessary in the home setting under this policy. Hospital surveillance is the appropriate management choice because of risks including sudden infection, placental abruption, and umbilical-cord compression.

Do not authorize home PPROM management as an alternative to hospital care.
The evidence is insufficient to establish the safety of home management.

Denial Risk

Makena Injections Not Covered

17-hydroxyprogesterone caproate (Makena) injections are not medically necessary under the home obstetrical-care policy.

The FDA withdrew approval of Makena and its generics in 2023 after the confirmatory study failed to verify the proposed clinical benefit.

Denial Risk

Severe Features or Unreliable Monitoring Require Hospitalization

Hospitalization is recommended for hypertensive disorders with severe features and for members who may not reliably adhere to the required frequent outpatient evaluation.

Home care is intended for gestational hypertension or preeclampsia without severe features requiring frequent maternal and fetal evaluation.
Consider inpatient management when adherence to frequent evaluation is a concern.

Obstetrical Home Care Programs

Obstetrical home care programs support high-risk pregnancies through risk assessment, education, case management, and home-based services. Depending on the member’s clinical needs, covered services may include provider care, diagnostic services, treatments, devices, and actionable information that supports care decisions. For nausea and vomiting in pregnancy, care generally follows a tiered approach beginning with prevention and nonpharmacologic or first-line pharmacologic treatment before alternative administration routes or infusion therapy are considered.

Key Clinical Definitions

Gestational diabetes mellitus (GDM)

DefinitionA pregnancy-related condition involving carbohydrate intolerance that can develop during pregnancy

Maternal risksIncreased risk of preeclampsia, cesarean section, and developing diabetes later in life

Neonatal risksIncreased risk of macrosomia, neonatal hypoglycemia, hyperbilirubinemia, shoulder dystocia, and birth trauma

Ambulatory management

Eligible conditionGestational hypertension or preeclampsia without severe features

Required evaluationFrequent fetal and maternal evaluation

Outpatient reliabilityHome management is appropriate only when adherence to frequent evaluation can be reliably performed; hospitalization is recommended when adherence may be a concern

PPROM

DefinitionPreterm prelabor rupture of membranes

Management settingHospital surveillance is the appropriate management choice

Relevant risksIncreased risk of sudden infection, placental abruption, and umbilical cord compression

Policy Summary

PayerAmbetter Georgia

PolicyObstetrical Home Care Programs

Policy CodePolicy CP.MP.91

Change TypeModified

Effective DateNov 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionFor infusion therapy reauthorization, reassess the member and document the continued need for therapy.

SourceLink

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Obstetrical Home Care Programs

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Covered and Non-Covered Obstetrical Home Care Services

Obstetrical Nurse Assessment

Covered when provided with at least one service listed in sections B through F.

ONE of the following services

Metoclopramide or ondansetron infusion therapy.
Hydration therapy.
Diabetes of pregnancy clinical management program.
Management of hypertensive disorders in pregnancy and postpartum.
Dietary analysis.

Metoclopramide or Ondansetron Infusion Therapy

Home visits for medication infusion therapy are considered medically necessary when ALL of the following criteria are met:

ALL of the following

Home visits will take place during the same period as the infusion therapy is ordered to be administered.
The member/enrollee has tried and failed conservative treatment, including medications by mouth and/or per rectum and/or other non-pharmacological treatments.
If re-authorization is requested, the ordering provider has reassessed the member/enrollee since the previous authorization and documented the need for continuation of infusion therapy.
See Table 1 in Background for recommendations from ACOG.

Hydration Therapy — One to Four Liters

Hydration therapy is medically necessary for members/enrollees who could benefit from close surveillance for the onset of dehydration.

ALL of the following

A qualifying condition or clinical circumstance
- Hyperemesis gravidarum.
- Malabsorption.
- A diagnosis, such as influenza or a gastrointestinal virus, that impairs the member/enrollee's ability to maintain fluid and/or food in the system.
- Another clinical circumstance in which the member/enrollee could benefit from close surveillance for the onset of dehydration.
The requested course is up to seven days at a time.
Additional days may be granted as clinically indicated.

Diabetes of Pregnancy Clinical Management Programs

ANY of the following pathways

Nutrition education and non-insulin-dependent diabetes
- The program includes diabetic nutrition education.
- The pregnant member/enrollee has non-insulin-dependent diabetes managed by oral medications or dietary modifications.
  One visit is medically necessary.
Nutrition education and initial insulin-dependent diabetes course
- The program includes diabetic nutrition education.
- The pregnant member/enrollee has insulin-dependent diabetes requiring insulin administration by any means.
  An initial course of visits for up to seven days is medically necessary.
Nutrition education and additional insulin-dependent diabetes course
- The program includes diabetic nutrition education.
- The pregnant member/enrollee has insulin-dependent diabetes requiring insulin administration by any means.
- The member/enrollee requires additional visits until able to self-manage blood sugar and insulin administration.
  Each additional course may be up to seven days.

Management of Hypertensive Disorders in Pregnancy and Postpartum

ANY of the following pathways

Gestational or chronic hypertension pathway
- The member/enrollee is diagnosed with gestational or chronic hypertension.
- ONE of the following clinical findings or risk circumstances
  - Elevated blood pressure without proteinuria.
  - The member/enrollee could benefit from education and surveillance for potential onset of hypertension, including circumstances such as a hypertensive disorder affecting a previous pregnancy or postpartum period, multiple gestations, or diabetes.
- The request is for one initial home or virtual visit, with additional telephone or virtual follow-up as needed.
- Postpartum timing requirement
  - The request is not for postpartum visits.
  - If the request is for postpartum visits, the member/enrollee is less than 14 days postpartum.
Preeclampsia without severe features pathway
- The member/enrollee is diagnosed with preeclampsia without severe features.
- ONE of the following diagnostic findings
  - Blood pressure is ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on two occasions at least four hours apart after 20 weeks' gestation in a member/enrollee with previously normal blood pressure.
  - Proteinuria demonstrated by ONE or more of the following
    At least 300 mg per 24-hour urine collection, or this amount extrapolated from a timed collection.
    Protein/creatinine ratio ≥ 0.3 mg.
    Dipstick reading ≥ 2+ (30 mg/dL).
- The request is for an initial home visit with additional telephone or virtual follow-up as needed, including remote blood pressure monitoring.
- Postpartum timing requirement
  - The request is not for postpartum visits.
  - If the request is for postpartum visits, the member/enrollee is less than 14 days postpartum.

Dietary Analysis

A dietary analysis is medically necessary when the member/enrollee has ANY of the following qualifying nutritional conditions:

ANY of the following

Obesity.
Malnutrition.
Prior bowel or bariatric surgery affecting nutrient absorption.

Medication Infusion Therapy

Medication infusion therapy is considered medically necessary when ALL of the following criteria are met:

ALL of the following

Home visits occur during the same period as the medication infusion therapy is ordered to be administered.
The member/enrollee has tried and failed conservative treatment, including medications by mouth and/or per rectum and/or other non-pharmacological treatments.
For a re-authorization request, the ordering provider has reassessed the member/enrollee since the previous authorization and documented the need for continuation of infusion therapy.

Gestational Hypertension and Preeclampsia Without Severe Features — Home Management

ONE qualifying home-management pathway

Gestational or chronic hypertension
- Diagnosis of gestational or chronic hypertension.
- ONE of the following
  - Elevated blood pressure without proteinuria.
  - The member/enrollee could benefit from education and surveillance for potential onset of hypertension, such as with a hypertensive disorder affecting a previous pregnancy or postpartum period, multiple gestations, or diabetes.
- One initial home or virtual visit, with additional telephone or virtual follow-up as needed.
- For postpartum visits, the member/enrollee is less than 14 days postpartum.
Preeclampsia without severe features
- Preeclampsia without severe features.
- ONE of the following
  - Blood pressure ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on two occasions at least four hours apart after 20 weeks' gestation in a member/enrollee with previously normal blood pressure.
  - Proteinuria demonstrated by ONE or more of the following
    ≥ 300 mg per 24-hour urine collection, or this amount extrapolated from a timed collection.
    Protein/creatinine ratio ≥ 0.3 mg.
    Dipstick reading ≥ 2+ (30 mg/dL).
- An initial home visit with additional telephone or virtual follow-up as needed, including remote blood pressure monitoring.
- For postpartum visits, the member/enrollee is less than 14 days postpartum.

Diabetes in Pregnancy — Home-Management Program

The diabetes in pregnancy home-management program is medically necessary when it includes diabetic nutrition education and follows a qualifying management pathway.

Required program component

The program includes diabetic nutrition education.
ONE qualifying diabetes-management pathway
- One visit for a pregnant member/enrollee with non-insulin-dependent diabetes managed by oral medications or dietary modifications.
- An initial course of visits for up to seven days for a pregnant member/enrollee with insulin-dependent diabetes requiring insulin administration by any means.
- One or more additional courses of visits, each up to seven days, for a pregnant member/enrollee with insulin-dependent diabetes requiring insulin administration by any means until the member/enrollee is able to self-manage blood sugar and insulin administration.

Preterm Labor Management

The decision to manage an individual with preterm labor as an inpatient or outpatient should be made on a case-by-case basis.

Individualized decision factors

The clinician evaluates cervical dilation.
The clinician evaluates vaginal bleeding.
The clinician evaluates fetal status.
The clinician evaluates travel time to the appropriate level-of-care facility.

17-hydroxyprogesterone caproate (Makena) injections are subject to a policy limitation and are not medically necessary following the FDA withdrawal of approval in 2023.

Billing Codes and Clinical Thresholds

Home obstetrical care and nursing HCPCS codesHCPCS

G0162	Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential nonskilled care achieves its purpose in the home health or hospice setting).
G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes.
S9123	Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500 to 99602 can be used).
S9140	Diabetic management program, follow up-visit to non-MD provider.
S9145	Insulin pump initiation, instruction in initial use of pump (pump not included).
S9211	Home management of gestational hypertension, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code).
S9213	Home management of preeclampsia, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code).

Additional HCPCS codeHCPCS

S9560

Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all

CPT CodesCPT

99601	Home infusion/specialty drug administration, per visit (up to two hours).
99602	Home infusion/specialty drug administration, per visit (up to two hours); each additional hour (List separately in addition to code for primary procedure).

HCPCS codes added during the 02/24 coding updateHCPCS

G0162
G0299
S9145
S9351

Preeclampsia blood pressure

Systolic threshold≥140 mm Hg

Diastolic threshold≥90 mm Hg

Timing and confirmationPresent on two occasions at least four hours apart after 20 weeks gestation in a member/enrollee with previously normal blood pressure

Preeclampsia proteinuria

24-hour urine collection≥300 mg per 24-hour urine collection, or the equivalent extrapolated from a timed collection

Protein/creatinine ratio≥0.3 mg

Dipstick reading≥2+ (30 mg/dL)

Postpartum hypertension visits

Postpartum eligibilityMember/enrollee is less than 14 days postpartum

Visit typeOne initial home or virtual visit, with additional phone or virtual follow-up as needed

Applicable conditionsPostpartum visits may be requested for management of chronic or gestational hypertension or preeclampsia without severe features

Hydration therapy duration

Hydration volumeOne to four liters

Standard courseUp to 7 days at a time

Additional treatmentAdditional days may be granted as clinically indicated

Blood pressure monitoring

Blood pressure monitoringTwice weekly

PopulationIndividuals with gestational hypertension or preeclampsia without severe features

Care settingMonitoring is part of ambulatory management requiring frequent fetal and maternal evaluation

Fetal movement monitoring

Fetal movement monitoringDaily self-monitoring

PopulationIndividuals with gestational hypertension or preeclampsia without severe features

Evaluation planDaily fetal-movement monitoring is included in frequent fetal and maternal evaluation

Platelet count and liver enzyme assessment

Platelet count assessmentWeekly

Liver enzyme assessmentWeekly

PopulationIndividuals with gestational hypertension or preeclampsia without severe features

Single corticosteroid course for PPROM

Corticosteroid courseSingle course recommended for individuals with preterm premature rupture of membranes

Lower gestational-age limit24 0/7 weeks

Upper gestational-age limit33 6/7 weeks

Methylprednisolone duration

Initial methylprednisolone regimen16 mg every eight hours, orally or intravenously for three days

TaperTaper over two weeks to the lowest effective dose

Maximum suggested total durationLimit total duration of use to six weeks if beneficial

Authorization, Documentation, and Denial Risks

Documentation Required

Nurse Assessment Must Accompany a Qualifying Service

An obstetrical nurse assessment is medically necessary only when provided with one of the listed qualifying services in sections B through F.

Qualifying paired services: metoclopramide or ondansetron infusion therapy; hydration therapy; diabetes in pregnancy clinical management; hypertensive-disorders-of-pregnancy program; or dietary analysis.

Prior Authorization

Infusion Visits Must Match the Ordered Administration Period

Document that the home visit overlaps the ordered infusion-administration period.
Document failed conservative treatment and, when applicable, reassessment for continuation.

Prior Authorization

Hydration Therapy Authorization

Examples include hyperemesis gravidarum; malabsorption; or influenza/GI virus impairing the ability to maintain fluids or food.
A course of up to seven days at a time is covered; additional days require clinical indication.

Unsupported block type: prior_auth

Step Therapy

Conservative Treatment Must Fail First

Identify the treatments attempted, duration or course when available, response, and reason they were unsuccessful.
Failure of conservative treatment is a required infusion-therapy criterion.

Step Therapy

Stepwise Hyperemesis Treatment

Use a stepwise approach for hyperemesis treatment, progressing from nonpharmacologic measures to first-line medication therapy and then to additional agents or infusion options when symptoms persist.

First line: convert the prenatal vitamin to folic acid alone; ginger capsules 250 mg four times daily; and consider P6 acupressure wrist bands.
Next: vitamin B6 alone or with doxylamine, using the listed oral dosing options.
If symptoms persist: add an oral, rectal, or as-needed antiemetic such as dimenhydrinate, diphenhydramine, prochlorperazine, or promethazine.
If symptoms persist without dehydration, consider oral or intramuscular metoclopramide or oral ondansetron. If dehydration exists, consider intravenous dimenhydrinate or intravenous metoclopramide as specified.

Documentation Required

Document Reassessment for Continued Infusion

For continued infusion therapy, the ordering provider must reassess the member since the previous authorization and document why infusion remains necessary.

Include the reassessment date, current symptoms and response, ongoing clinical need, and requested continuation period.
A reauthorization request without documented reassessment and continued need may be denied.

Documentation Required

Document Preeclampsia Findings and Postpartum Status

For gestational or chronic hypertension, document elevated blood pressure without proteinuria or the qualifying risk/education and surveillance need.
For preeclampsia without severe features, document blood pressure of at least 140/90 on two occasions at least four hours apart after 20 weeks and/or qualifying proteinuria.
For postpartum requests, document that the member is less than 14 days postpartum.

Documentation Required

Document Diabetes Program Needs

For diabetes-in-pregnancy clinical management, document the diabetes category, insulin requirement, requested course, and required program components.

The program must include diabetic nutrition education.
For non-insulin-dependent diabetes managed with oral medication or dietary modification: request one visit.
For insulin-dependent diabetes: request an initial course of up to seven days and additional courses of up to seven days until the member can self-manage blood sugar and insulin administration.

Documentation Required

Hypertensive Disorder Monitoring

For hypertensive disorders, document the maternal and fetal surveillance plan required for outpatient management.

ACOG-referenced monitoring includes blood pressure twice weekly, daily self-monitoring of fetal movement, and weekly platelet counts and liver enzymes for gestational hypertension or preeclampsia without severe features.
Remote blood-pressure monitoring is required for the preeclampsia home-visit pathway.

Documentation Required

Infusion Reauthorization Documentation

A reauthorization request must show reassessment since the prior authorization and a documented continued need for infusion therapy.

Attach or reference the ordering provider's interval reassessment.
Explain the ongoing symptoms or clinical findings supporting additional infusion visits.

Documentation Required

Preterm Labor Disposition Assessment

Home-vendor preterm labor management is listed as not medically necessary.
Escalate when findings require facility-based evaluation or monitoring.

Denial Risk

Services Explicitly Considered Not Medically Necessary

The policy considers several home-health vendor services not medically necessary. Verify the requested service against the exclusion list before submitting authorization or billing.

Betamethasone therapy via multiple repeat courses or intermittent injections.
Multiple gestation management; continuous heparin infusion therapy; and member/enrollee-administered nonstress testing or fetal heart-rate monitoring.
Preterm prelabor rupture of membranes management; preterm labor management; and 17-hydroxyprogesterone caproate (Makena) injections.

Denial Risk

Severe Preeclampsia Requires Inpatient Management

Preeclampsia with severe features should be managed through inpatient care rather than the covered home-care pathway.

Do not request home visits as a substitute for inpatient management when severe features are present.

Denial Risk

Infusion Therapy Criteria Not Met

Infusion therapy may be denied when the required criteria are not documented or are not met.

No documented failed conservative treatment, including oral and/or rectal medication or nonpharmacologic treatment.
Home visits do not occur during the ordered infusion-administration period.
For reauthorization, the ordering provider did not reassess the member or document continued need.
The requested therapy lacks documented medical necessity or otherwise fails the policy requirements.

Denial Risk

Intermittent Betamethasone Injections

ACOG supports a single course in qualifying PPROM circumstances, including 24 0/7 through 33 6/7 weeks, high risk of preterm birth within seven days, and a prior course more than 14 days earlier.
A rescue course may be considered as early as seven days after the prior dose when clinically indicated; repeated weekly administration is not supported.

Denial Risk

PPROM Requires Hospital Surveillance

Do not authorize home PPROM management as an alternative to hospital care.
The evidence is insufficient to establish the safety of home management.

Denial Risk

Makena Injections Not Covered

17-hydroxyprogesterone caproate (Makena) injections are not medically necessary under the home obstetrical-care policy.

The FDA withdrew approval of Makena and its generics in 2023 after the confirmatory study failed to verify the proposed clinical benefit.

Denial Risk

Severe Features or Unreliable Monitoring Require Hospitalization

Hospitalization is recommended for hypertensive disorders with severe features and for members who may not reliably adhere to the required frequent outpatient evaluation.

Home care is intended for gestational hypertension or preeclampsia without severe features requiring frequent maternal and fetal evaluation.
Consider inpatient management when adherence to frequent evaluation is a concern.

Obstetrical Home Care Programs

Key Clinical Definitions

Gestational diabetes mellitus (GDM)

DefinitionA pregnancy-related condition involving carbohydrate intolerance that can develop during pregnancy

Maternal risksIncreased risk of preeclampsia, cesarean section, and developing diabetes later in life

Neonatal risksIncreased risk of macrosomia, neonatal hypoglycemia, hyperbilirubinemia, shoulder dystocia, and birth trauma

Ambulatory management

Eligible conditionGestational hypertension or preeclampsia without severe features

Required evaluationFrequent fetal and maternal evaluation

Outpatient reliabilityHome management is appropriate only when adherence to frequent evaluation can be reliably performed; hospitalization is recommended when adherence may be a concern

PPROM

DefinitionPreterm prelabor rupture of membranes

Management settingHospital surveillance is the appropriate management choice

Relevant risksIncreased risk of sudden infection, placental abruption, and umbilical cord compression