CurrentAmbetter NevadaPolicy CP.MP.91

Obstetrical Home Care Programs

Medical necessity criteria and coverage stance for obstetrical home health programs and services provided by home health vendors for pregnant and postpartum members/enrollees.

Policy Summary

PayerAmbetter Nevada

PolicyObstetrical Home Care Programs

Policy CodePolicy CP.MP.91

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document reassessment for home infusion or hydration therapy; conservative outpatient treatments must be tried and failed before home infusion authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Named program/service categories (A–F)

1–4Hydration volume (L)

up to 7dTypical course length

<14dPostpartum BP window

single courseAntenatal corticosteroid guidance

Medically Necessary and Not Medically Necessary Criteria

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Medically necessary services (A–F)

Obstetrical home health services are medically necessary when specific program criteria are met for the named service categories A–F.

A. Obstetrical Nurse Assessment: An obstetrical nurse assessment is medically necessary when provided with any of the services listed in B–F.

Supports any of the listed home services.

B. Metoclopramide or Ondansetron Infusion Therapy: Home visits for infusion therapy are medically necessary when all of the following are met: (1) home visits take place during the same period as the ordered infusion therapy; (2) member/enrollee has tried and failed conservative treatment including oral and/or rectal medications and/or other non-pharmacological treatments (see ACOG tiered approach); (3) if re-authorization is requested, the ordering provider has reassessed the member since the previous authorization and documented the need for continuation of infusion therapy.

See Background Table 1 (ACOG) for tiered approach; consider adverse effects and infection risk.

C. Hydration Therapy: Hydration therapy is medically necessary for close surveillance of dehydration (examples: hyperemesis gravidarum, malabsorption, or illnesses such as influenza or gastrointestinal virus that impair oral intake) when one to four liters are provided; a course of up to seven days at a time is considered medically necessary, with additional days as clinically indicated.1–4 liters; up to 7 days per course

Home visits must be ordered to coincide with the therapy period.

D. Diabetes in Pregnancy Clinical Management Programs: Program must include diabetic nutrition education and meet one of the following: (a) one visit for pregnant members with non–insulin-dependent diabetes managed by oral medication or dietary modification; (b) an initial course of visits up to seven days for insulin-dependent diabetes requiring insulin administration by any means; (c) an additional course(s) of visits up to seven days until the member is able to self-manage blood glucose and insulin administration.up to 7 days per course

Applies to gestational diabetes and pre-existing type 1 or type 2 diabetes.

E. Hypertensive Disorders of Pregnancy Program: Home visits are medically necessary for chronic or gestational hypertension and for management of preeclampsia without severe features when meeting one of the following: (1) One visit for gestational or chronic hypertension when either (a) elevated blood pressure without proteinuria is present, or (b) the member could benefit from education and surveillance (examples: prior hypertensive disorder, multiple gestation, diabetes); postpartum visit requests must be for <14 days postpartum; OR (2) An initial home visit with remote blood pressure monitoring and additional phone/virtual follow-up for preeclampsia without severe features when both (a) blood pressure criteria (≥140 mm Hg systolic or ≥90 mm Hg diastolic on two occasions at least four hours apart after 20 weeks) OR proteinuria criteria (≥300 mg/24 hr OR protein/creatinine ratio ≥0.3 OR dipstick ≥2+) are met, and (b) if request is for postpartum visits, member is <14 days postpartum. Note: Preeclampsia with severe features requires inpatient management.BP and proteinuria thresholds per definitions

ACOG supports ambulatory management for non-severe cases; severe features require hospital care.

F. Dietary Analysis: Dietary analysis is medically necessary for members with obesity, malnutrition, or prior bowel/bariatric surgery affecting nutrient absorption.

Medication infusion therapy (I.B.)

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

I.B Medication infusion therapy: Member/enrollee has tried and failed conservative treatment including medications by mouth and/or per rectum and/or other non-pharmacological treatments; home visits will take place during the period the infusion therapy is ordered to be administered; if re-authorization is requested, the ordering provider has reassessed the member since the previous authorization and documented the need for continuation of infusion therapy.

Exact local visit limits and additional specific criteria are located elsewhere in the full policy.

Preterm labor management

Preterm labor management recommendations

Preterm labor disposition: Decision to manage post-episode preterm labor as an inpatient versus outpatient should be individualized and made on a case-by-case basis, considering factors such as cervical dilation, vaginal bleeding, fetal status, and travel time to an appropriate level of care facility.

Policy notes limited evidence and recommends individualized clinical judgment.

Management of preterm prelabor rupture of membranes (PPROM) and ongoing preterm labor is not considered medically necessary when provided by home health vendors. The policy cites limited and insufficient evidence for safe outpatient/home management of PPROM and notes higher risks (including infection, placental abruption, and umbilical cord complications) that favor hospital-based surveillance. For preterm labor, available studies are underpowered and the decision to manage post-episode preterm labor should be individualized; however, routine home-based management by a home health vendor is not supported by the evidence and is therefore excluded from medically necessary home vendor services.

Cases of preeclampsia with severe features require inpatient management and are explicitly excluded from home-based management under this policy. Home visits and remote monitoring are described only for non-severe hypertensive disorders or preeclampsia without severe features; any presentation meeting severe criteria should be directed to hospital-level care.

Where there is a conflict between this clinical policy and state Medicaid coverage provisions, the state Medicaid provisions take precedence. Providers should consult the applicable state Medicaid manual and plan-level rules when making coverage or billing decisions for Medicaid members.

Administration of antenatal corticosteroids in the home setting is restricted: multiple repeat courses or intermittent betamethasone injections delivered via home health vendors are considered not medically necessary. The policy aligns with ACOG guidance that recommends a single course of corticosteroids, with rare, specific exceptions for a single repeat (‘rescue’) dose under narrowly defined clinical conditions.

Nursing visits for administration of 17‑hydroxyprogesterone caproate (Makena) have been removed from the policy following withdrawal of the product. As a result, Makena injections are no longer included among services to be provided by home health vendors under this policy.

Relevant HCPCS/CPT Codes and Clinical Thresholds

Home care skilled nursing and program HCPCSHCPCS

G0162	Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes
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)
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, per diem
S9213	Home management of preeclampsia, per diem
S9214	Home management of gestational diabetes, per diem

Home infusion and related HCPCSHCPCS

S9351	Home infusion therapy, continuous or intermittent antiemetic infusion therapy; per diem
S9353	Home infusion therapy, continuous insulin infusion therapy; per diem
S9374	Home infusion therapy, hydration therapy; one liter per day, per diem
S9375	Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day, per diem
S9376	Home infusion therapy, hydration therapy; more than two liters but no more than three liters per day, per diem
S9377	Home infusion therapy, hydration therapy; more than three liters per day, per diem
S9379	Home infusion therapy, infusion therapy, not otherwise classified; per diem
S9470	Nutritional counseling, dietitian visit
S9560	Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), per diem

Home infusion CPT-like codesCPT

99601	Home infusion/specialty drug administration, per visit (up to 2 hours)
99602	Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour

Coding guidance notemixed

No codes listed

Blood pressure threshold for preeclampsia without severe features

BP threshold≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on two occasions at least four hours apart after 20 weeks gestation

TimingNew‑onset hypertension occurring after 20 weeks gestation

Measurement frequencyBlood pressures must be confirmed on two occasions at least four hours apart

Context of useApplies to diagnosis of preeclampsia without severe features when combined with proteinuria criteria or as isolated elevated BP without proteinuria

Proteinuria thresholds

24‑hour urine protein≥ 300 mg per 24‑hour urine collection (or extrapolated from a timed collection)

Protein/creatinine ratioProtein/creatinine ratio ≥ 0.3

Urine dipstickDipstick reading of ≥ 2+ (30 mg/dL)

Authorization, Documentation, and Clinical Responsibilities

Prior Authorization

Prior Authorization Required

Authorization is required for listed home health, infusion, and skilled nursing services (including metoclopramide or ondansetron infusion therapy and hydration therapy). Providers must obtain prior authorization per plan requirements before initiating these services.

Affected services include home infusion visits, hydration therapy (1–4 liters, courses up to seven days), obstetrical nurse assessment when provided with other home services, diabetes and hypertension home management programs, dietary analysis, and other listed home care services.

Documentation Required

Verify Plan-Level Requirements

Providers must verify plan-level administrative requirements prior to delivering services. This includes checking member eligibility, benefit coverage, prior authorization processes, claim submission rules, and any state-specific Medicaid provisions that may supersede this policy.

Confirm effective date and plan-specific requirements (e.g., network, referral, authorization forms).
If state Medicaid provisions conflict with this policy, follow the state Medicaid manual.

Denial Risk

Not Medically Necessary Services

Certain services are designated not medically necessary when provided in the home setting. Do not seek authorization for or provide these home-based services as medically necessary under this policy: multiple repeat courses of betamethasone, multiple gestation management via home program, continuous heparin infusion therapy, member-administered nonstress/fetal monitoring, PPROM management, preterm labor management, and 17-hydroxyprogesterone caproate (Makena) injections.

See policy list of Not Medically Necessary services for complete exclusions.

Billing Rule

Coding Inclusion Is Not a Coverage Guarantee

Inclusion or exclusion of procedure, HCPCS, CPT, or other codes in this policy is provided for informational purposes only and does not guarantee coverage. Providers should reference the most current professional coding guidance and the member's coverage documents when submitting claims.

Coding references are informational; verify code applicability and coverage prior to billing.

Documentation Required

Re-authorization Documentation Required

If re-authorization for infusion therapy (e.g., metoclopramide or ondansetron) is requested, the ordering provider must have reassessed the member since the prior authorization and documented ongoing clinical need for continuation of infusion therapy.

Documentation must be in the medical record and available upon request.
Re-assessment should address response to prior therapy, adverse events, and rationale for continued home infusion.

Step Therapy

Stepwise Treatment Required Before Home Infusion

A stepwise, tiered approach is required before home infusion is authorized for nausea/vomiting in pregnancy. Per ACOG guidance, providers should first employ prevention and conservative measures (e.g., prenatal vitamin optimization, ginger, P6 acupressure), then first-line oral pharmacotherapy such as pyridoxine ± doxylamine, before considering rectal or parenteral routes and home infusion when oral/rectal options are not tolerated or have failed.

Document trials of nonpharmacologic therapies and oral/rectal medications prior to requesting home infusion.
Table 1 (ACOG tiered approach) is referenced in Background and should guide step-therapy decisions.

Note

Provider Clinical Responsibility

Providers remain responsible for exercising professional medical judgment in each case. This policy is a guideline for medical necessity determinations and does not replace clinical judgment or the member's coverage documents. Providers are accountable for the medical advice and treatment they provide.

This policy does not constitute medical advice and is not a contract or guarantee of payment.
When state Medicaid rules conflict with this policy, state rules take precedence.

Key Clinical Definitions

Gestational diabetes mellitus (GDM) — Definition and screening approach

DefinitionGestational diabetes mellitus (GDM) is carbohydrate intolerance that develops in pregnancy

Screening approachTwo‑step approach: 1) one‑hour 50‑gram screening oral glucose tolerance test (no fasting required); 2) if screen‑positive, proceed to a three‑hour 100‑gram diagnostic oral GTT after an overnight fast

Associated risksIncreased risk of preeclampsia, cesarean delivery, future diabetes; offspring risks include macrosomia and neonatal hypoglycemia

Preeclampsia without severe features — Definition

DefinitionNew‑onset hypertension after 20 weeks gestation with BP ≥140/90 on two occasions at least four hours apart in a previously normotensive member/enrollee

Proteinuria requirementPreeclampsia without severe features requires proteinuria by defined laboratory thresholds (≥300 mg/24‑hr OR protein/creatinine ≥0.3 OR dipstick ≥2+) or elevated BP criteria

Care setting guidanceInitial home visit with remote BP monitoring and virtual follow‑up is acceptable for preeclampsia without severe features; preeclampsia with severe features requires inpatient management

Preterm labor management — Disposition guidance

PrincipleDecision to manage post‑episode preterm labor as inpatient versus outpatient should be individualized

Clinical factors to considerCervical dilation, vaginal bleeding, fetal status

Logistical factors to considerTravel time to an appropriate level of care facility and access to timely escalation of care

OpenPayer

Obstetrical Home Care Programs

Medically Necessary and Not Medically Necessary Criteria

Relevant HCPCS/CPT Codes and Clinical Thresholds

Authorization, Documentation, and Clinical Responsibilities

Context and Rationale

Key Clinical Definitions