CurrentAnthemPolicy CG-MED-23

Home Health

Defines medical necessity criteria, coding, and coverage stance for intermittent skilled home health services (nursing, therapy, infusion, etc.) provided by or through a licensed home health agency to members in their place of residence. Affects providers requesting authorization or submitting claims for home health services.

Policy Summary

PayerAnthem

PolicyHome Health

Policy CodePolicy CG-MED-23

Change TypeReviewed - no material change

Effective DateJan 6, 2026

Next Review DateN/A

Key ActionObtain and maintain a physician‑prescribed written plan of care reviewed at least every 30 days and document homebound status when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All of A–DPrimary criteria

30 daysPhysician review

IV infusions, wound careSkilled services examples

CPT/HCPCS/S-codesCoding lists

Medical Necessity and Coverage Criteria

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A. 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; leaving home would require considerable and taxing effort; absences from the home are infrequent or brief or attributable to receiving health care (examples: outpatient dialysis, chemotherapy, adult day-care, funerals, brief trips). Absences for receiving health care do not disqualify homebound status.

B. Physician-prescribed plan of care: The service must be prescribed by the attending physician, a health care provider practicing within the scope of their license, or the primary care physician in coordination with the attending physician as part of a written plan of care.

C. Skilled complexity and qualified personnel: The service must be inherently complex such that it can be safely and effectively performed only by qualified technical or professional health personnel (e.g., registered nurses, licensed practical/vocational nurses, physical therapists, licensed social workers, speech pathologists, audiologists); services must be provided directly by or under the general supervision of these skilled personnel to assure safety and achieve the desired result.

D. Ongoing review: The primary care physician, attending physician, or other prescribing health care provider should review the treatment plan at least once every 30 days to assess continued need for skilled intervention.

Extended Home Infusion

Certain extended home infusion treatments are medically necessary even if the member is not homebound when they are more appropriately performed at home due to toxicity, monitoring needs, prior response, or the individual’s underlying condition.

Medically necessary home infusions examples: Examples include intravenous gamma globulin; intravenous hydration for a variety of conditions; infusions for pain control; and some chemotherapy regimens.

Intermittent IV Infusions

Other conditions for which intermittent intravenous infusions in the home are considered medically necessary include:

Conditions: Infections requiring a prolonged treatment course; coagulation disorders; enzyme deficiency states; and pain management.

This guideline does not address home health care for primary mental health conditions. In addition, the policy excludes services that do not meet the document’s clinical criteria — for example, procedure codes shown in the coding lists are considered not medically necessary when the specified clinical criteria are not satisfied or when the Clinical Indications section designates them as not medically necessary (see coding lists for details).

Home health services are not medically necessary when the treatment plan from the primary care or attending physician does not demonstrate continued need for a skilled intervention, or when the plan’s goals have been achieved. The policy also indicates that services tied to the listed procedure codes may be denied when the clinical criteria are not met.

Procedure, HCPCS, and Diagnosis Codes

Covered CPT Codes (selected excerpt)CPTCovered

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.
99601	Home infusion/specialty drug administration, per visit (up to 2 hours).

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Covered HCPCS/G-codes (selected excerpt)HCPCSCovered

G0068	Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual’s home, each 15 minutes.
G0069	Professional services for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0070	Professional services for the administration of intravenous chemotherapy or other intravenous highly complex drug or biological infusion for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0320	Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system.
G0321	Home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system.
G0322	The collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (i.e., remote patient monitoring).
G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
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 non-skilled care achieves its purpose in the home health or hospice setting).

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Covered S- and T-codes and other HCPCS (selected excerpt)HCPCSCovered

S5035	Home infusion, therapy, routine service of infusion device (e.g., pump maintenance).
S5036	Home infusion therapy, repair of infusion device (e.g., pump repair).
S5108	Home care training to home care client; per 15 minutes.
S9329	Home infusion therapy, chemotherapy infusion, per diem.
S9364	Home infusion therapy, total parenteral nutrition (TPN); per diem.
S9494	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; per diem.
S9538	Home transfusion of blood product(s); per diem.
T1001	Nursing assessment/evaluation.
T1002	RN services, up to 15 minutes.
T1003	LPN/LVN services, up to 15 minutes.

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Diagnosis codesICD-10

All diagnoses

ICD-10 Diagnosis: All diagnoses listed as applicable for home health when criteria met.

Physician plan review interval (inv-10)

RequirementPrimary care/attending physician must review the treatment plan to assess continued need for skilled intervention at least once every 30 days.

Responsible clinicianReview may be performed by the primary care physician, attending physician, or a health care provider practicing within scope of license in coordination with the attending physician.

DocumentationA written plan of care must document continued need for skilled intervention and be available for review at each 30-day interval.

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization May Be Required

Prior authorization for listed home health services may be required per the member's contract. Check the payer/product prior authorization rules before scheduling services.

Prior authorization requirement varies by contract and line of business.
Verify authorization for home infusion, skilled nursing visits, and other listed home health CPT/HCPCS codes prior to service.

Documentation Required

Required Plan of Care and Periodic Review

The attending physician or primary care physician must provide and periodically review the written plan of care. The plan of care must support the need for skilled services and be reviewed at least every 30 days to assess continued need.

Written plan of care must be prescribed by the attending physician or provider practicing within scope of license (or PCP in coordination with attending).
Document goals, skilled interventions required, and progress; review and update at least once every 30 days.

Documentation Required

Homebound Documentation

Document clinical evidence that the individual is homebound. Records must show that the member's condition makes leaving home a considerable and taxing effort and that absences are infrequent or for short duration (or for medical treatment). Examples of acceptable absences include outpatient dialysis, chemotherapy, or brief nonmedical activities (e.g., barber, religious service).

Describe specific functional limitations preventing safe travel to outpatient settings.
If the member leaves home, note the reason, frequency, and duration of absences and whether absences are for health care treatment.
Include clinician assessment and supporting objective findings in chart notes.
Examples of acceptable medical absences: outpatient dialysis, chemotherapy, adult day-care for treatment.

Denial Risk

Denial If Criteria Not Met

Services may be denied when medical necessity criteria are not met. Denial reasons include lack of documented homebound status, absence of a written plan of care signed/prescribed by the attending/PCP, failure to document continued need for skilled intervention, or when goals have been achieved.

If documentation does not support confinement to the home, services can be denied.
If the plan of care does not demonstrate need for skilled care or is not reviewed at required intervals, consider denial.
Goals achieved per plan of care is a basis for denial or discontinuation of services.

Denial Risk

Coding Denial Risk

Procedure codes may be denied or deemed not medically necessary when clinical criteria are not satisfied or when indications in the Clinical Indications section designate services as not medically necessary.

Coding denial risk applies to listed CPT, HCPCS, and revenue codes when supporting documentation is insufficient.
Examples: home infusion administration codes, home visit CPTs, and home health G-codes may be denied if clinical criteria (homebound status, skilled complexity, plan of care) are not met.
Verify that documentation supports billed units, frequency, and medical necessity for each code prior to claim submission.

Policy Background

Home health provides intermittent skilled services delivered in the member’s residence when equivalent facility-based skilled care can be safely and effectively provided at home. These services are intended for situations where the individual’s condition requires qualified personnel (for example, RNs, LPNs/LVNs, PTs, OTs, or speech-language pathologists) to perform inherently complex skilled care such as IV infusions, central line dressing changes, and sterile wound care. The attending or primary care physician must prescribe services as part of a written plan of care and review that plan at least once every 30 days to document ongoing need for skilled intervention.

Key Definitions

Homebound / Confined to the home (inv-18)

DefinitionConfined to the home (homebound): the individual’s physical/medical condition poses a serious and significant impediment to leaving home; leaving home would require considerable and taxing effort.

Medical absences allowedAbsences to receive health care (eg, outpatient dialysis, outpatient chemotherapy/radiation, participation in licensed adult day-care) do not disqualify homebound status.

Non-medical absences allowedInfrequent or short-duration non-medical absences (eg, attending a funeral, religious service, graduation, brief trips like barber or a short walk) are permissible and do not negate homebound status.

Other infrequent eventsOccasional unique events (for example, a family reunion) are acceptable if infrequent or brief and do not indicate capacity to obtain care outside the home.

Guidance sourceCriteria are based on DHHS and CMS recommendations; lack of transportation alone does not qualify an individual as homebound.