CurrentAmbetter NevadaPolicy CP.MP.71

Clinical Policy: Long Term Care Placement

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Defines medical necessity criteria, intensity of service, admission and discharge criteria for long term care placement in nursing home settings (custodial care through specialized high-acuity services) for Ambetter Nevada members.

Policy Summary

PayerAmbetter Nevada

PolicyLong Term Care Placement

Policy CodePolicy CP.MP.71

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain and document a comprehensive geriatric assessment at admission and perform ongoing reassessments to determine and maintain the appropriate level of care.

SourceLink

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CurrentAmbetter NevadaPolicy CP.MP.71

Clinical Policy: Long Term Care Placement

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Policy Summary

PayerAmbetter Nevada

PolicyLong Term Care Placement

Policy CodePolicy CP.MP.71

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain and document a comprehensive geriatric assessment at admission and perform ongoing reassessments to determine and maintain the appropriate level of care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7placement categories

BMI ≥ 50bariatric BMI threshold

≥6 hrs/dayventilator threshold

90960-90962, 94004example CPT codes

Annualreview cadence

Coverage Criteria for Long Term Care Placement

Placement Categories

Covered when ANY of the following placement categories are met per their specific criteria:

Custodial/Non-Skilled Care (A)
- Placement levels: Placement level determined by number of ADLs requiring help and level of supervision/behavior management (Intermediate-Light: help with up to 2 ADLs; Intermediate-Moderate: 3–4 ADLs; Intermediate-Heavy: dependent on all 5 ADLs or constant supervision).
Dementia/Wandering Care (B): Diagnosis of dementia/organic brain syndrome/other cognitive impairment; failed adequate psychiatric evaluation/treatment; documentation of problematic wandering behavior that endangers self/others (specific wandering behaviors listed for residential and HCBS settings).
Dementia with Behaviors Care (C): Diagnosis of dementia/organic brain syndrome/other cognitive impairment; failed adequate psychiatric evaluation/treatment; documentation of problematic daily behaviors endangering self/others not manageable in traditional nursing facility or HCBS; requires two failed step-down attempts.
Dialysis Care (D): Member requires dialysis and cannot receive it outpatient due to medical condition (e.g., pericarditis, infection, GI bleed, confusion/dementia, hemodynamic instability) AND is unable to sit up for four hours or has a wound preventing outpatient dialysis or requires Hoyer lift for transfers.
Respiratory Care (E): Member requires three or more specified respiratory interventions in a 24-hour period performed by licensed facility staff (examples: tracheostomy care twice daily/as needed; tracheal suctioning every 4 hours/as needed; aerosol therapy with FIO2 ≥28%; chest physical therapy; CPAP/BIPAP; PSV on ventilator; mechanical ventilation <6 hours/day without weaning).
Ventilator Care (F): Either (a) requires mechanical ventilation ≥ six hours/day (acceptable modes include AC or SIMV) OR (b) requires < six hours/day and is undergoing weaning from ventilator.
Bariatric Care (G): Member has BMI ≥ 50 kg/m2 AND is unable to change position, ambulate, or transfer without hands-on assistance from three or more caregivers.BMI ≥ 50 kg/m2

Documentation and assessment: A comprehensive geriatric assessment at admission and ongoing reassessments are required to determine appropriate placement level and to document continued need for the selected placement category.

See OBRA/comprehensive assessment requirements.

Care that is solely custodial/non-skilled does not meet the criteria for skilled nursing, skilled rehabilitation, or the specialized placement categories described in this policy. Custodial care is assistance with activities of daily living (ADLs) or supervision for safety/behavior management (examples: bathing, dressing, toileting, transferring, eating) and may be provided by family members, health aides, or other unlicensed personnel when the member has reached maximum physical or mental function. Placement decisions should therefore focus on the specific placement criteria for skilled or specialized services rather than on ADL need alone.

Placement decisions must not be made solely on the basis of a diagnosis or a single functional limitation. The policy requires that a member meet the specific placement criteria for one of the defined categories (e.g., dementia with wandering/behaviors, dialysis, respiratory care, ventilator dependence, bariatric care) before higher-level skilled or specialized residential care is authorized. Basic custodial needs or a diagnosis alone do not establish medical necessity for a higher level of care.

All coverage determinations are subject to the member’s contract terms and applicable law. This clinical policy is a guide to medical necessity and does not guarantee payment. Coverage decisions remain subject to the terms, conditions, exclusions and limitations of the applicable evidence of coverage, certificate of coverage, policy or contract and to state and federal requirements and Health Plan administrative policies.

Admission Criteria for SNF/LTC

SNF/LTC Admission Criteria

Admission meets one category's placement criteria: Admission requires meeting the specified placement criteria for one of the categories (A–G), for example: dialysis when outpatient dialysis is not possible (pericarditis, infection, GI bleed, confusion/dementia, hemodynamic instability) with inability to sit for four hours or need for Hoyer lift; respiratory needs requiring three or more specified interventions in 24 hours; ventilator dependence thresholds; bariatric BMI and transfer dependence; or documented dementia-related wandering/behaviors after failed psychiatric evaluation/treatment.

Provider must document the specific placement category criteria that are met and relevant clinical findings.

Continued Stay Criteria for SNF/LTC

SNF/LTC Continued Stay Criteria

Continued placement in a skilled nursing facility or long-term care setting is covered when ALL of the following are met:

Ongoing need and reassessment: Ongoing assessment required to ensure appropriate level of care; continued stay supported while member continues to meet placement/intensity of service criteria and requires skilled or protective supervision beyond what can be provided at a lower level of care or home setting.

A comprehensive geriatric assessment at admission and ongoing reassessments are required to determine and maintain the appropriate level of care; changes in status should be communicated with the Health Plan Case Manager.

Documentation of continued skilled needs or protective supervision: Clinical documentation demonstrates continued need for skilled services provided by qualified staff (e.g., RNs, LPNs/LVNs, PT/OT/SLP) or need for protective supervision related to safety/behavior that cannot be managed in a lower level of care or home setting.

Include current assessment findings, treatment plan updates, and family/caregiver communications as part of the medical record.

Discharge Criteria for SNF/LTC

Discharge from a SNF/LTC setting is appropriate when the member no longer meets the placement criteria for the level of care and either can be safely managed at a lower level of care or requires a higher level of care than the facility provides. For custodial-level discharges, criteria include the member being independent or needing only limited assistance with ADLs that can be met by a home caregiver, the caregiver being willing and able to manage medications, transfers/ambulation and home therapy programs, a safe and accessible home environment, and prearranged equipment/devices. For dementia/dementia-with-behaviors units, discharge is appropriate when the member no longer meets the placement criteria or can be stepped down safely. For high-acuity categories (respiratory, ventilator, dialysis, bariatric), discharge follows the same principle: the member no longer meets the high-acuity placement criteria or requires a different level of care.

Referenced Procedure and CPT Codes

Referenced procedure codesCPT

90960	End-stage renal disease (ESRD) related services monthly, for patients 20 years of age or older, with four or more face to face visits by a physician or other qualified health care professional per month
90961	End-stage renal disease (ESRD) related services monthly, for patients 20 years of age or older, with two to three face to face visits by a physician or other qualified health care professional per month
90962	End-stage renal disease (ESRD) related services monthly, for patients 20 years of age or older, with one face to face visit by a physician or other qualified health care professional per month
94004	Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing, nursing facility, per day

Referenced CPT Codes (ESRD)CPT

90960

End-stage renal disease (ESRD) related services monthly, for patients 20 years of age or older, with four or more face to face visits by a physician or other qualified health care professional per month

Referenced CPT Codes (ESRD and Ventilation)CPT

90961	End-stage renal disease (ESRD) related services monthly, for patients 20 years of age or older, with two to three face to face visits by a physician or other qualified health care professional per month
90962	End-stage renal disease (ESRD) related services monthly, for patients 20 years of age or older, with one face to face visit by a physician or other qualified health care professional per month
94004	Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing, nursing facility, per day

inv-08: Bariatric BMI threshold — value display

Transfer dependence requirementUnable to change position, ambulate, or transfer without hands-on assistance from three or more caregivers

Intensity of service requirementRequires multidisciplinary services, nutritional counseling, therapies, medications, supplies and bariatric equipment as needed

inv-09: Ventilator dependence threshold — value display

Acceptable ventilator modesAssist control (AC) or Spontaneous Intermittent Mandatory Ventilation (SIMV)

Weaning exceptionMember requiring < six hours/day may qualify if actively undergoing ventilator weaning

Provider Responsibilities, Prior Authorization & Documentation

Note

Referenced procedure codes are informational examples

The policy references example CPT procedure codes (90960–90962 and 94004) for informational coding purposes only; these are included as examples and are not an exhaustive or prescriptive list.

90960–90962: ESRD monthly services (multiple face-to-face visit level descriptions).
94004: Ventilation assist and management, nursing facility, per day.

Prior Authorization

Verify coverage and prior authorization for referenced CPT codes

Verify member coverage and any required prior authorization with the plan before submitting claims for the referenced CPT codes; the document explicitly instructs providers to confirm coverage/prior authorization requirements.

Providers should verify coverage and prior authorization requirements with the plan for facility-related CPT codes such as 90960–90962 and 94004.
Codes referenced in the policy are for informational purposes and may require authorization per payer rules.

Key Definitions

inv-19: Custodial/Non-Skilled Care definition — assistance with ADLs and medication supervision

DefinitionCustodial (non-skilled) care: assistance with ADLs (walking, bathing, dressing, feeding, toileting) and supervision of medication that can normally be self-administered; may be provided by non-medical personnel

Primary purposeProvides hands-on help and/or supervision for safety or behavior management rather than skilled medical treatment

Placement decision basisDecision is not based on diagnosis or rehabilitation potential but on level of assistance/supervision required

Examples of ADLs consideredBathing, dressing, toileting, transferring, eating

inv-20: Medical necessity / Clinical policy purpose definition

Purpose of policy

Background

This policy addresses the spectrum of long term care placement from custodial/non-skilled care through specialized skilled residential care for complex medical needs such as dementia with wandering or behaviors, dialysis-dependent care, respiratory or ventilator management, and bariatric care. Skilled services require licensed clinical staff and ongoing evaluation. A comprehensive geriatric assessment at admission and periodic reassessments are required to determine and maintain the appropriate level of care; Medicare/Medicaid rules and waiver programs may affect eligibility and payment.

Coding Examples and Reference Notes

This policy references Current Procedural Terminology (CPT®) for informational coding guidance; referenced codes are not a guarantee of coverage and are included for example only. Providers should verify coding, coverage, and any prior authorization requirements with the plan before submitting claims.

Revision History

2026-01-26Annual reviewLatest

Annual review completed; references reviewed and updated; reviewed by external specialist.

2025-01-25Annual review

Annual review completed; references reviewed and updated; reviewed by external specialist.

2024-02-24Annual review

Policy Summary

PayerAmbetter Nevada

PolicyLong Term Care Placement

Policy CodePolicy CP.MP.71

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain and document a comprehensive geriatric assessment at admission and perform ongoing reassessments to determine and maintain the appropriate level of care.

SourceLink

On This Page

Member continues to meet specific placement category criteria:

Member continues to meet the intensity/placement criteria for one or more defined placement categories (e.g., ongoing dialysis that cannot be delivered outpatient; respiratory care requiring three or more specified interventions per 24 hours; ventilator dependence per policy thresholds; BMI and transfer dependence for bariatric placement; dementia with wandering or behaviors meeting policy criteria).

Refer to the placement category criteria (A–G) for the specific objective requirements (examples: mechanical ventilation ≥ six hours/day; BMI ≥ 50 kg/m2; respiratory interventions list).

Authorization, coding, and verification actions by provider: Provider must verify member coverage and obtain any required prior authorization for facility placement and for referenced CPT codes used in skilled care (examples cited for informational purposes: 90960-90962, 94004). Inclusion/exclusion of codes in this policy does not guarantee coverage; verify payer rules prior to claim submission.

Document authorizations and include relevant CPT codes on requests and claims per payer guidance; failure to obtain required authorizations or to meet placement criteria may result in denial or reclassification as custodial/non-skilled care.

Placement that no longer meets criteria: If the member no longer meets the placement/intensity criteria for skilled or specialized services, continued stay is not supported; such placement may be considered custodial/non-skilled and not medically necessary for higher level services.

Discharge planning should be initiated when criteria are no longer met; see discharge requirements for home caregiver readiness, safe home environment, and arranged equipment.

Documentation Required

Comprehensive geriatric assessment at admission and ongoing reassessment

Perform a comprehensive geriatric assessment at admission and conduct ongoing reassessments to determine and maintain the appropriate level of care; use assessment findings to inform the individualized treatment plan and share status changes with facility medical staff and the Health Plan Case Manager.

Complete the OBRA-required comprehensive assessment at time of admission to develop the treatment plan.
Document functional, physical, cognitive, emotional, and psychosocial status in the assessment.
Perform and document periodic ongoing assessments and family meetings to capture status changes.
Notify the Health Plan Case Manager of changes in the member's status that affect placement or level of care.

Step Therapy

Document failed psychiatric evaluation/treatment for dementia placements

For dementia-related placements, include documentation showing the member has failed to adequately improve with appropriate psychiatric evaluation and treatment attempts prior to admission to dementia/wandering or dementia-with-behaviors units.

Documentation must evidence failed adequate improvement after psychiatric evaluation and treatment attempts.
Required for both Dementia/Wandering Care and Dementia with Behaviors Care placement criteria.

Denial Risk

Avoid custodial placement when skilled/specialized criteria are required

If the member’s needs do not meet the defined placement criteria for skilled or specialized services, the placement may be considered custodial/non-skilled care and may not meet medical necessity for higher-level services.

Custodial care is assistance with ADLs or supervision and is not based on medical diagnosis alone.
Placements should be evaluated against the policy’s specified placement criteria to determine appropriate level of care.

Billing Rule

Code listing does not guarantee coverage — confirm current coding guidance

Inclusion or exclusion of any CPT codes in this policy does not guarantee coverage; providers must reference the most current professional coding guidance before claim submission.

Codes included are for informational purposes only and are not a determination of coverage.
Always confirm current coding guidance prior to submitting claims.

Documentation Required

Coverage decisions subject to plan terms and legal/regulatory requirements

Coverage and authorization decisions are subject to the member’s plan terms, evidence/certificate of coverage, state and federal requirements, and Health Plan administrative policies; this policy is a guide and not a guarantee of payment.

Providers must follow the plan’s evidence of coverage, certificate of coverage, contract terms, and applicable state/federal rules.
The Health Plan may change, amend, or withdraw this clinical policy at any time.

Documentation Required

Provide documentation to support placement determination (required action)

Ensure all required documentation and assessments are provided to support placement requests; where the source provides no additional specific provider action, treat this as a required verification step prior to admission.

Provide documentation that demonstrates the member meets the specific placement criteria applicable (A–G).
Share treatment plans and assessment results used to determine level of care.

Provides a guide to medical necessity to assist in making coverage decisions and administering benefits

Not a guaranteeDoes not constitute a contract or guarantee regarding payment or results

ScopeCoverage decisions remain subject to terms, conditions, exclusions and limitations of coverage documents and applicable state and federal requirements

Annual review completed; description for CPT 94004 edited; references reviewed and updated; reviewed by external specialist.

2023-04-23Annual review

Annual review completed; references reviewed and updated; edit to description for CPT 94004 and reviewed by external specialist noted.

2022-04-22Annual review

Annual review completed; references reviewed and updated; header terminology and custodial care definition edits; background on state waivers added; reviewed by specialist.

2021-04-21Revision

Replaced all instances of 'member' with 'member/enrollee'; references reviewed and updated.

2020-04-20Annual review

Annual review completed; coding reviewed and updated with new ICD-10 codes added and G30.1 changed to G30.0.

2019-05-19Revision

Deleted informational codes 94660, E0470, E0471, E0472.

2019-04-19Revision

References reviewed and updated; codes updated; specialist reviewed.

2018-04-18Revision

Minor wording changes for clarity; references reviewed and updated.

2014-05-14Approval

Policy approved by specialist (approval date recorded).

If revisions affect discharge criteria, the revision notes should reflect that discharge follows the policy principle that the member no longer meets the placement criteria and can either be safely managed at a lower level of care or requires a higher level of care. Documentation requirements (e.g., caregiver capability, safe home environment, arranged equipment) must be updated as applicable.

Admission criteria for SNF/LTC require meeting one of the placement categories (A–G). Examples include inability to receive outpatient dialysis due to medical instability or transfer limitations, respiratory needs requiring three or more interventions in 24 hours, ventilator dependence of ≥ six hours per day or active weaning, and bariatric criteria of BMI ≥ 50 kg/m2 with dependence on three or more caregivers for transfers. Revisions to admission criteria should be documented to preserve these thresholds and the requirement for comprehensive assessment at admission.