CurrentAnthemPolicy CG-MED-23

Home Health

Defines medical necessity criteria for intermittent skilled home health services (nursing, PT/OT/SLP, social work, home infusion, etc.) provided by or through a licensed home health agency to individuals in their place of residence; includes CPT/HCPCS/S codes for informational purposes and exclusions.

Policy Summary

PayerAnthem

PolicyHome Health

Policy CodePolicy CG-MED-23

Change TypeRevisions & Reviews

Effective Date

Next Review Date

Key ActionDocument that the member is confined to the home with examples of acceptable medical/non-medical absences and that leaving home would require considerable and taxing effort; document if absences are for treatment.

SourceLink

POLICY UPDATE CHANGES

Revised Discussion/General Information and References sections during 11/06/2025 review.

11/14/2024: Revised criteria IA1 in MN statement, deleting sentence with the term 'bedridden'.

11/10/2022: Updated Description and References sections and added G0320, G0321, G0322 to Coding section (01/01/2023 HCPCS changes).

11/05/2020: Updated number hierarchy and formatting in MN clinical indications and added multiple HCPCS codes (G0068, G0069, G0070, G0088, G0089, G0090).

5Core MN criteria (A-D)

4Infusion/IV indications listed

150+Procedure/CPT/HCPCS/T/S/Q codes listed

Coverage Summary

Medical‑Necessity Criteria

Medically Necessary - General Home Health Services

Home health services are medically necessary when ALL of the following A through D are met:

ALL of the following

Homebound / confined to the home: The individual is confined to the home: the individual’s overall physical/medical condition poses a serious and significant impediment to receiving intermittent or occasional, skilled, medically necessary services outside the home setting; there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort
If the individual does leave home, absences are infrequent or of relatively short duration, or attributable to receiving health care treatment (examples provided). Lack of transportation alone does not qualify.
Acceptable absences: If the individual leaves home, absences are infrequent/short or for health care (acceptable medical absences include outpatient dialysis, outpatient chemotherapy/radiation, participation in licensed adult day-care; non-medical absences include funeral, religious service, occasional barber trip or a walk around the block; other infrequent events like family reunions).
Any absence for receiving health care does not disqualify homebound status.
Prescription by provider: The service must be prescribed by the attending physician, health care provider practicing within scope of license, or the primary care physician in coordination with the attending physician as part of a written plan of care
Home health services must be provided directly by or under general supervision of these personnel to assure safety and achieve desired result.
Complexity of services: The service(s) is so inherently complex that it can be safely and effectively performed only by qualified technical or professional health personnel (e.g., RNs, LPNs/LVNs, PT, OT, speech pathologists, audiologists)
30-day review: The primary care physician, health care provider practicing within scope of license, or attending physician in coordination with the primary care physician should review the treatment plan at least once every 30 days to assess continued need for skilled intervention

Medically Necessary - Extended Home Infusion Treatments (not requiring homebound status)

Certain extended home infusion treatments are considered medically necessary even if the member is not homebound when appropriate due to treatment toxicity, monitoring needs, prior response, or underlying condition. Examples include:

ANY of the following

IVIG: Intravenous gamma globulin
Hydration: Intravenous hydration for various conditions
Pain infusions: Infusions for pain control
Some chemotherapy regimens

Medically Necessary - Other intermittent IV infusion indications

Intermittent IV infusions in the home are medically necessary for conditions where complexity or infusion itself warrants home administration. Examples include:

ANY of the following

Infections requiring a prolonged treatment course
Coagulation disorders
Enzyme deficiency states
Pain management

Not Medically Necessary

Home health services are not medically necessary when ANY of the following apply:

ANY of the following

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

Provider Actions

Documentation Required

Homebound status documentation

Document that the member is confined to the home with examples of acceptable medical and non-medical absences and that leaving home would require considerable and taxing effort; document if absences are for treatment.

Examples of acceptable medical absences: outpatient dialysis, outpatient chemotherapy or radiation, participation in licensed/certified adult day-care programs
Examples of acceptable non-medical absences: attending a funeral or religious service, an occasional trip to the barber, a walk around the block, family reunions or other infrequent events
Any absence to receive health care treatment should be documented and does not disqualify homebound status

Documentation Required

Prescription and plan of care

Ensure services are prescribed by the attending/primary care provider and included in a written plan of care reviewed at least every 30 days by the primary/attending physician to support continued skilled need.

Plan of care must be reviewed at least once every 30 days

Billing Rule

Use listed CPT/HCPCS/T codes per service

Report appropriate CPT/HCPCS/T/S/Q codes for home health skilled services and infusions as applicable; codes in the document are informational and do not guarantee coverage—verify member contract benefits.

Codes listed (CPT/HCPCS/Q/S/T) are informational only
Verify member contract benefits to determine coverage

Coding

Informational — CPT codes listedCPT

99500	Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring
99503	Home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation)
99504	Home visit for mechanical ventilation care
99505	Home visit for stoma care and maintenance including colostomy and cystostomy
99506	Home visit for intramuscular injections
99507	Home visit for care and maintenance of catheter(s) (eg, urinary, drainage, and enteral)
99509	Home visit for assistance with activities of daily living and personal care
99511	Home visit for fecal impaction management and enema administration
99512	Home visit for hemodialysis
99600	Unlisted home visit service or procedure

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Informational — HCPCS / G codes listedHCPCS

G0068	Professional services for administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other IV infusion drug (excluding chemo/highly complex) - per 15 minutes, per infusion calendar day in home
G0069	Professional services for subcutaneous immunotherapy or subcutaneous infusion - per 15 minutes, per infusion calendar day in home
G0070	Professional services for IV chemotherapy or other highly complex infusion - per 15 minutes, per infusion calendar day in home
G0088	Professional services, initial visit, for administration of anti-infective/pain/other IV infusion (excluding chemo/highly complex) - per 15 minutes
G0089	Professional services, initial visit, for administration of subcutaneous immunotherapy - per 15 minutes
G0090	Professional services, initial visit, for administration of IV chemotherapy/highly complex infusion - per 15 minutes
G0151	Qualified physical therapist services in home health/hospice, each 15 minutes
G0152	Qualified occupational therapist services in home health/hospice, each 15 minutes
G0153	Qualified speech-language pathologist services in home health/hospice, each 15 minutes
G0155	Clinical social worker services in home health/hospice, each 15 minutes

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Informational — HCPCS Q, S, T codes and others listedHCPCS

Q5001	Hospice or home health care provided in patient's home/residence
Q5002	Hospice or home health care provided in assisted living facility
Q5009	Hospice or home health care provided in place NOS
S5035	Home infusion, therapy, routine service of infusion device (pump maintenance)
S5036	Home infusion therapy, repair of infusion device (pump repair)
S5108	Home care training to home care client; per 15 minutes
S5109	Home care training to home care client; per session
S5110	Home care training, family
S5111	Home care training, family (adjacent code pair)
S5115	Home care training, non-family

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Informational — Diagnosis codesICD-10

All diagnoses

Policy states 'All diagnoses' are included in the coding list; specific ICD-10 codes are not enumerated in the document.

Background

Home health care refers to intermittent skilled health care related services provided by or through a licensed home health agency to an individual in his or her place of residence, and includes skilled nursing and other skilled services such as physical, occupational, and speech therapies. Eligibility criteria for patients unable to leave home align with DHHS/CMS guidance identifying individuals for whom obtaining necessary care outside the home would impose substantial hardship. Lack of transportation alone does not qualify an individual as homebound.

Homebound / confined to the home: Condition where leaving home requires considerable and taxing effort due to the individual’s overall physical/medical condition; absences must be infrequent or of relatively short duration or attributable to receiving health care treatment to preserve homebound status.

Evidence: CMS Medicare Benefit Policy Manual Chapter 7, Rev. 258, Issue date 2023-12-21 supports the home health criteria and homebound definitions referenced in this policy.

NCD Number	Name	Effective Date
290.2	Home nurses' visits to patients requiring heparin injection
290.1	Home health visits to a blind diabetic	2006-10-01
240.7	Postural drainage procedures and pulmonary exercises	1988-09-01

OpenPayer

Home Health

Coverage Summary

Medical‑Necessity Criteria

Provider Actions

Coding

Background

Medicare Determinations

Revision History

Additional Notes