CurrentAmeriHealth Caritas LouisianaPolicy ILO.01

Remote Patient Monitoring

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This policy governs AmeriHealth Caritas Louisiana's In Lieu Of coverage for remote patient monitoring for eligible Louisiana Medicaid managed-care members, including eligibility, authorization, provider responsibilities, billing, service duration, and reporting.

Policy Summary

PayerAmeriHealth Caritas Louisiana

PolicyRemote Patient Monitoring

Policy CodePolicy ILO.01

Change TypeNo material change

Effective DateN/A

Last ReviewJul 1, 2025

Next Review DateJun 1, 2027

Key ActionConfirm ACLA authorization through the eligible-member roster before enrolling a member in RPM.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Adult and pregnancy-related eligibility pathways

99453One-time RPM setup and education code

30 days

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CurrentAmeriHealth Caritas LouisianaPolicy ILO.01

Remote Patient Monitoring

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Policy Summary

PayerAmeriHealth Caritas Louisiana

PolicyRemote Patient Monitoring

Policy CodePolicy ILO.01

Change TypeNo material change

Effective DateN/A

Last ReviewJul 1, 2025

Next Review DateJun 1, 2027

Key ActionConfirm ACLA authorization through the eligible-member roster before enrolling a member in RPM.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Adult and pregnancy-related eligibility pathways

99453One-time RPM setup and education code

30 days

Ongoing device supply and monitoring interval

6-12 monthsAdult anticipated service duration

9 monthsPregnancy anticipated service duration

>140/90 or HbA1c >9.0%Poor-control eligibility thresholds

Coverage Criteria

Eligible Member Populations

Remote patient monitoring is medically appropriate and approved when ALL of the following criteria are met:

ALL of the following

The member has access to a smartphone or tablet.
ONE of the following eligible member pathways
- Adult member with hypertension and a potentially preventable admission (PPA), potentially preventable readmission (PPR), or potentially preventable ED visit (PPV) event within the last 18 months.
- Adult member with diabetes and a PPA, PPR, or PPV event within the last 18 months.
- Adult member with poorly controlled hypertension (greater than 140/90) and at risk for a PPA, PPR, or PPV event.
- Adult member with poorly controlled diabetes (HbA1c greater than 9.0%) and at risk for a PPA, PPR, or PPV event.
- Pregnant woman with hypertensive disorders and/or insulin-dependent diabetes.

Authorization, Ordering, and Supervision

Coverage requires ACLA authorization and compliance with the following ordering, referral, and supervision requirements:

ALL of the following

The member is enrolled in AmeriHealth Caritas Louisiana and authorized to participate in the RPM program by ACLA.
ONE of the following enrollment pathways
- AmeriHealth Caritas Louisiana identifies the member for enrollment and notifies the member's provider.
- The member's primary care provider requests enrollment.
ACLA provides a roster of eligible members to the RPM provider.
RPM services are ordered by a physician or other qualified health professional.

Billing Frequency and Anticipated Duration

Billing and duration requirements are as follows:

ALL of the following

CPT 99453 is billed once for initial setup of the remote monitoring equipment, including patient education on connected-device use and measurement best practices.
CPT 99453 is reimbursable once per episode of care, or every 9 months during pregnancy.
CPT 99454 or CPT 99199 is billed every 30 days for ongoing monitoring and the provider's leased or purchased device costs.
Providers may use either CPT 99454 or CPT 99199 for the same member, but not both.
Anticipated length of service
- Adult member with hypertension or diabetes.No greater than 6–12 months

Providers may use either CPT 99454 or CPT 99199 for ongoing monitoring, but may not bill CPT 99454 and CPT 99199 together for the same member.

Coding and Reimbursement

Initial setup and educationCPTCovered

99453

Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.

Device supply and daily recording or programmed alert transmissionCPTCovered

99454

Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.

Alternative unlisted reimbursement codeCPTCovered

99199

Unlisted special service, procedure, or report- This code with appropriate modifiers may be used as an alternative reimbursement CPT code for systems that have conflict with use of 99453 and/or 99454.

Poorly controlled hypertension

Eligibility threshold>140/90

Applicable populationAdult members with poorly controlled hypertension

Utilization riskMember is at risk for a potentially preventable admission, readmission, or emergency department visit

Poorly controlled diabetes

Eligibility thresholdHbA1c >9.0%

Applicable populationAdult members with poorly controlled diabetes

Provider Responsibilities and Billing Safeguards

Prior Authorization

ACLA Roster Authorization Required

Verify that each member is on the AmeriHealth Caritas Louisiana (ACLA) roster before enrolling or billing for RPM. ACLA authorizes participation by providing the RPM provider with a roster of eligible members; a provider notification or PCP enrollment request does not replace roster authorization.

Confirm the member appears on the ACLA roster of eligible RPM participants.
Do not treat a provider notification or PCP request for enrollment as authorization unless ACLA has authorized the member’s participation.

Documentation Required

Deliver and Support RPM Services

Contact the member to offer RPM, coordinate enrollment, and deliver the required equipment. Educate the member on device use, monitoring procedures, measurement timing, and program best practices; monitor results under the agreed parameters, contact the member about results outside those parameters, and provide ongoing education and engagement to support continued participation.

Background

Remote patient monitoring (RPM) uses digital technologies and noninvasive devices to collect physiologic and other health data at the member’s location and securely transmit it to a provider or monitoring entity for assessment, recommendations, and intervention. This policy focuses on blood pressure and cardiovascular monitoring for members with hypertension and blood glucose monitoring for members with diabetes. Targeted populations include adults with suboptimal disease control or recent or anticipated potentially preventable utilization, as well as pregnancies complicated by hypertensive disorders and/or diabetes.

Definitions

Remote patient monitoring (RPM)

Data collectionDigital technologies and non-invasive devices collect medical and other health data from an individual in one location

Secure transmissionThe information is electronically transmitted securely to a health care provider or other monitoring entity in a different location

Clinical useThe receiving provider or monitoring entity assesses the information and provides recommendations and interventions

Device requirementsRPM devices include non-invasive devices that measure or detect physiologic parameters and devices that wirelessly transmit medical information

In Lieu Of (ILO) service

Service typeA medically appropriate and cost-effective alternative to an MCO Covered Service or Setting

Policy Summary

PayerAmeriHealth Caritas Louisiana

PolicyRemote Patient Monitoring

Policy CodePolicy ILO.01

Change TypeNo material change

Effective DateN/A

Last ReviewJul 1, 2025

Next Review DateJun 1, 2027

Key ActionConfirm ACLA authorization through the eligible-member roster before enrolling a member in RPM.

SourceLink

On This Page

If RPM services are delivered by auxiliary personnel, including contracted employees, they are provided under the supervision of the billing physician or qualified health professional.

Pregnant member, including prenatal and postpartum periods.No greater than 9 months

Member is at risk for a potentially preventable admission, readmission, or emergency department visit

Expected improved blood pressure control

Expected blood pressure resultImproved BP control (<140/90)

Applicable populationMembers participating in the In Lieu Of remote patient monitoring program

Related outcomeReduced emergency department utilization and preventable hospitalizations for hypertension and diabetes

Expected improved blood glucose control

Expected blood glucose resultImproved blood glucose control, as measured by Hgb A1c (<9.0%)

Applicable populationMembers participating in the In Lieu Of remote patient monitoring program

Related outcomeReduced emergency department utilization and preventable hospitalizations for hypertension and diabetes-related complications

RPM must be ordered by a physician or other qualified health professional.
Auxiliary personnel, including contracted employees, may deliver RPM services under the supervision of the billing physician or qualified health professional.
Document equipment delivery, member education, monitoring, out-of-range follow-up, and engagement activities.

Documentation Required

Validate Devices and Train Members

Use a reliable and valid non-invasive RPM device that appropriately measures or detects the member’s physiological information and securely transmits it to the provider or monitoring entity. Confirm that the member is trained or sufficiently knowledgeable in proper device use and wearing to ensure accurate recording of medical information.

Devices may monitor parameters such as blood pressure, heart rate and rhythm, or blood glucose.
Confirm the member has smartphone or tablet access and connectivity for data reporting.
Document device reliability and validity and the member’s training or competency.

Documentation Required

Report Outcomes to ACLA and PCPs

Report aggregate and member-level monitoring outcome data to ACLA in a mutually agreed format and on a mutually agreed basis. Report monitoring activities to the member’s PCP on an ongoing basis.

Maintain the data needed for aggregate outcome reporting.
Provide member-level outcome data to ACLA as agreed.
Keep the PCP informed of monitoring activities on an ongoing basis.

Denial Risk

Confirm Eligibility and Technology Requirements

RPM is covered only for eligible members who meet the applicable clinical and technology requirements. Do not enroll or bill when the member lacks the required eligibility, smartphone or tablet access, or connectivity for data reporting.

Eligible populations include adults with hypertension or diabetes and a recent or anticipated potentially preventable admission, readmission, or ED visit; adults with poorly controlled hypertension (>140/90) or diabetes (HbA1c >9.0%) at risk for those events; and pregnant members with hypertensive disorders and/or insulin-dependent diabetes.
The member must have smartphone or tablet access and connectivity for data reporting.
A member who does not meet the applicable clinical eligibility or technology requirements is subject to denial or non-coverage.

Denial Risk

Do Not Bill Without Participation Authorization

Participation must be authorized by ACLA before the provider enrolls the member or submits RPM claims. ACLA identifies members or responds to PCP requests and authorizes participation by issuing a roster of eligible members to the RPM provider.

Verify roster inclusion before service delivery and billing.
Absent ACLA roster authorization, RPM participation is not authorized and claims may be denied.

Billing Rule

Avoid Duplicate Ongoing-Monitoring Billing

For ongoing monitoring, bill either CPT 99454 or CPT 99199 for the applicable 30-day period, but not both for the same member. Duplicate billing of these codes for the same member and period is not permitted.

CPT 99454 and CPT 99199 are ongoing-monitoring codes billable every 30 days.
Select one code for the member’s ongoing monitoring period; do not submit both codes.

Unsupported block type: billing_rule

Member choiceProvided to Enrollees at their option

State Plan statusApproved as a medically appropriate and cost-effective substitute under the Louisiana Medicaid State Plan

PPA/PPR/PPV

PPAPotentially preventable admission

PPRPotentially preventable readmission

PPVPotentially preventable emergency department visit