Long Term Care Placement (PDF)
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Defines medical necessity criteria for long term care (nursing home) placement across custodial/non-skilled care, dementia/wandering care, dementia with behaviors care, dialysis care, respiratory care, ventilator care, and bariatric care for members/enrollees of Centene-affiliated health plans.
Annual review completed. References reviewed and updated. Reviewed by external specialist.
Edit to description for 94004 and coding updates across years.
Coverage Summary
Defines medical necessity criteria for long term care (nursing home) placement across custodial/non-skilled care, dementia/wandering care, dementia with behaviors care, dialysis care, respiratory care, ventilator care, and bariatric care for members/enrollees of Centene-affiliated health plans. Status: CURRENT; Date of Last Review: 01/26 (annual reviews and minor updates documented). Coverage stance: covered_with_criteria. The policy identifies 7 covered indication categories: Custodial/Non-Skilled Care; Dementia/Wandering Care; Dementia with Behaviors Care; Dialysis Care; Respiratory Care; Ventilator Care; Bariatric Care.
Medical-Necessity Criteria (Placement and Discharge)
Overview - Medical Necessity Statement
Long term care placement is medically necessary for the following indications:
ANY of the following
- Custodial/Non-Skilled Care (see section A)
- Dementia/Wandering Care (see section B)
- Dementia with Behaviors Care (see section C)
- Dialysis Care (see section D)
- Respiratory Care (see section E)
- Ventilator Care (see section F)
- Bariatric Care (see section G)
A. Custodial/Non-Skilled Care - Placement Criteria
Placement considered when care does not meet skilled criteria and member/enrollee requires assistance or supervision with ADLs or behavior/safety management. Decision is based on level of care/medical supervision required, not diagnosis.
ALL of the following
- Care does not meet criteria for skilled nursing or skilled rehabilitation or specialized care services.
- Member/enrollee needs assistance and/or supervision with activities of daily living (ADLs): bathing, dressing, toileting, transferring, eating.
- Consider ability to communicate, cognitive status, behavior, ability to self-administer medications.
Level examples
- Intermediate-Light Care: needs help with or dependent for up to two ADLs; intermittent supervision and/or occasional behavior management.
- Intermediate-Moderate Care: needs help with or dependent for three or four ADLs; frequent supervision and/or behavior management.
- Intermediate-Heavy Care: needs help with or dependent for all five ADLs; constant supervision and/or behavior management.
A. Custodial/Non-Skilled Care - Discharge Criteria
ALL of the following
- Member/enrollee is independent or requires only limited assistance with ADLs which could be provided by a home caregiver on an intermittent basis.
AND patient/caregiver able and willing to meet care needs including
- Managing medication regimen
- Transfers and ambulation
- Home exercise program and/or prescribed therapy program
- Home environment is safe and accessible
- Appropriate equipment/devices are prearranged
B. Dementia/Wandering Care - Placement Criteria
Admission requires diagnosis and failed treatment plus evidence of problematic wandering.
ALL of the following
- Diagnosis of dementia (including Alzheimer's), organic brain syndrome, or other diagnoses affecting cognitive ability (e.g., traumatic brain injury).
- Failed to adequately improve with appropriate psychiatric evaluation and treatment attempts.
Either residential or HCBS wandering behaviors
- Residential setting: Documentation that member/enrollee exhibits problematic wandering behavior which endangers self or others, characterized by one or more of: Repeatedly exits through outside doors; Frequently wanders into off-limit areas without responding to redirection; Is unable to find way back to own room after wandering episode.
- Home and Community Based Services (HCBS) setting: Documentation that member/enrollee exhibits problematic wandering behavior characterized by one or more of: Repeatedly wanders away from home requiring police or others to return them; Requires family/caregiver to lock member/enrollee in the house when leaving unattended to prevent them from getting out and lost; Unsafe driving despite actions taken by family, caregiver, or authorities.
B. Dementia/Wandering Care - Intensity of Service
ALL of the following
- Secure living area indoors and outdoors via locks and/or electronically controlled access
- Activities appropriate for persons with dementia
- All services, medications, supplies and equipment necessary to manage needs of the member/enrollee
B. Dementia/Wandering Care - Discharge Criteria
ALL of the following
- Member/enrollee no longer meets placement criteria
ANY of the following
- Member/enrollee is able to be safely managed in a lower level of care
- Member/enrollee requires higher level of care than what is able to be provided
C. Dementia with Behaviors Care - Placement Criteria
Admission requires all listed criteria.
ALL of the following
- Diagnosis of dementia (including Alzheimer's), organic brain syndrome, or other diagnoses affecting cognitive ability (e.g., traumatic brain injury).
- Failed to adequately improve with appropriate psychiatric evaluation and treatment attempts.
ALL of the following
- Examples of behaviors: Repeated attempts to exit through outside door, repeatedly banging on locked door (unable to redirect); Physical aggression toward other residents; Suicide attempts or other self-injurious behaviors; Throwing things in an uncontrolled manner and unable to redirect; Yelling continuously for several hours despite treatments and non-pharmacological interventions; Repeatedly throwing self out of wheelchair/bed or to floor requiring increased staffing; Displaying sexualized behaviors, attempts to inappropriately touch other residents; Misuse/abuse of medications, alcohol, and/or drugs; Mental disorders such as psychosis or depression not manageable at a lower level of care; Two documented attempts to step member/enrollee down from dementia/wandering unit have been attempted and failed causing exacerbation of symptoms and increased behaviors.
C. Dementia with Behaviors Care - Intensity of Service
ALL of the following
- Secure living area indoors and outdoors separate from areas of other facility residents
- Staff ability to directly observe and supervise member/enrollee at all times
- Psychiatric nursing care services with observation and assessment of changing condition
- Activities appropriate for persons with dementia
- All services, medications, supplies and equipment necessary to manage needs
C. Dementia with Behaviors Care - Discharge Criteria
ALL of the following
- Member/enrollee no longer meets placement criteria
ANY of the following
- Member/enrollee is able to be safely managed in a lower level of care
- Member/enrollee requires higher level of care than what is able to be provided
D. Dialysis Care - Placement Criteria
ALL of the following
- Member/enrollee requires dialysis and is unable to receive it in an outpatient setting due to a medical condition (e.g., pericarditis, pneumonia or other infection, gastrointestinal bleeding, confusion or dementia, or hemodynamic instability).
ANY of the following
- Member/enrollee is unable to sit up for four hours at a time AND has a wound that prohibits outpatient dialysis
- Member/enrollee is unable to sit up for four hours at a time AND has to use a Hoyer lift for transfers
D. Dialysis Care - Intensity of Service
ALL of the following
- Dialysis treatment as prescribed by a nephrologist
- Evaluation and monitoring of condition on an ongoing basis
- Relevant diagnostic studies and reporting of results to ordering physician on a timely basis
- All services, medications, supplies and equipment necessary to manage needs
D. Dialysis Care - Discharge Criteria
ALL of the following
- Member/enrollee no longer meets placement criteria
ANY of the following
- Member/enrollee is able to be safely managed in a lower level of care
- Member/enrollee requires higher level of care than what is able to be provided
E. Respiratory Care - Placement Criteria
Admission requires member/enrollee to require three or more of the listed respiratory services in a 24-hour period performed by licensed facility staff.
ALL of the following
- Member/enrollee requires three or more of the following in a 24-hour period performed by facility licensed staff:
ANY of the following
- Tracheostomy care twice a day and as needed
- Tracheal suctioning every four hours and as needed
- Aerosol therapy, cool mist, FIO2 28% or greater
- Chest physical therapies (percussion and postural drainage)
- Continuous positive airway pressure CPAP/BiPAP continuous or during sleep
- CPAP or pressure support ventilation (PSV) setting on a ventilator
- Mechanical ventilation < six hours in a calendar day, without weaning in progress
E. Respiratory Care - Intensity of Service
ALL of the following
- Respiratory therapy needs as prescribed by physician
- Evaluation and monitoring of condition on an ongoing basis
- Relevant diagnostic studies and reporting of results to ordering physician on a timely basis
- All services, medications, supplies and equipment necessary to manage needs
E. Respiratory Care - Discharge Criteria
ALL of the following
- Member/enrollee no longer meets placement criteria
ANY of the following
- Member/enrollee is able to be safely managed in a lower level of care
- Member/enrollee requires higher level of care than what is able to be provided
F. Ventilator Care - Placement Criteria
ANY of the following
ALL of the following
- Acceptable setting modes include Assist Control (AC)
- Acceptable setting modes include Spontaneous Intermittent Mandatory Ventilation (SIMV)
- Member/enrollee requires < six hours of mechanical ventilation and weaning from the ventilator is in progress.< 6 hours/day
F. Ventilator Care - Intensity of Service
ALL of the following
- Mechanical ventilation needs as prescribed by physician
- Evaluation and monitoring of condition on an ongoing basis
- Relevant diagnostic studies and reporting of results to ordering physician on a timely basis
- All services, medications, supplies and equipment necessary to manage needs
F. Ventilator Care - Discharge Criteria
ALL of the following
- Member/enrollee no longer meets placement criteria
ANY of the following
- Member/enrollee is able to be safely managed in a lower level of care
- Member/enrollee requires higher level of care than what is able to be provided
G. Bariatric Care - Placement Criteria
ALL of the following
- Body mass index (BMI) ≥ 50 kg/m2.>= 50 kg/m2
- Member/enrollee is unable to change position, ambulate, or transfer without hands-on assistance from three or more caregivers.3 or more caregivers
G. Bariatric Care - Intensity of Service
ALL of the following
- Nutritional counseling to assist with appropriate caloric needs
- Physical, occupational or restorative therapies tailored to the member/enrollee
- An ongoing, multidisciplinary approach to weight loss
- All services, medications, supplies and bariatric equipment necessary to manage needs
G. Bariatric Care - Discharge Criteria
ALL of the following
- Member/enrollee no longer meets placement criteria
ANY of the following
- Member/enrollee is able to be safely managed in a lower level of care
- Member/enrollee requires higher level of care than what is able to be provided
Provider Actions & Documentation Requirements
Document diagnosis and failed treatments for dementia-related placements
Providers must document diagnosis of dementia or related disorder and documentation of failed appropriate psychiatric evaluation and treatment attempts for dementia/wandering and dementia with behaviors placements.
Document specific behaviors or functional limitations
Providers must document specific wandering behaviors, problematic behaviors (examples listed), or functional limitations (ADL dependencies, inability to sit for dialysis, need for Hoyer lift, ventilator hours, BMI and caregiver assistance) that meet the listed placement criteria.
Document intensity of services required
Providers must document required intensity of services (e.g., secure environment, psychiatric nursing, dialysis prescribed by nephrologist, respiratory therapies) and that the facility can provide those services.
Coding (Informational)
| 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 |
Background and Context
Provides rationale and context for long term care placement criteria, distinguishing between custodial (non-skilled) care and skilled services that require licensed clinical personnel. Nursing home care includes long-term residential care and short-term post-acute/rehabilitative care; skilled services are those needing the skills of professionals such as RNs, PTs, OTs, and others.
Explains that custodial care addresses assistance with activities of daily living (ADLs) and supervision for safety or behavior management and is not based solely on medical diagnosis. Room and board costs for long-term residents are generally paid by Medicaid, long term care insurance, or out-of-pocket, whereas short-stay post-acute rehabilitation is generally paid through the SNF skilled benefit, most often under Medicare.
Notes federal and regulatory context: the Omnibus Budget Reconciliation Act (OBRA) requires a comprehensive assessment at admission (a comprehensive geriatric assessment evaluating functional, physical, cognitive, emotional, and psychosocial status) to develop a treatment plan and determine level of care. Ongoing reassessment is required to ensure the appropriate level of care is maintained and to communicate status changes with facility staff, family, and the Health Plan Case Manager.
Coding and administrative guidance are included for informational purposes only: referenced CPT/HCPCS codes (e.g., 90960–90962, 94004) are informational; inclusion or exclusion does not guarantee coverage and providers should reference current professional coding guidance prior to claims submission. The policy has undergone multiple annual reviews and minor coding/description edits over time.
Revision History
Policy developed and reviewed by specialist; Approval Date 05/14.
Minor wording changes for clarity; References reviewed and updated; Approval Date 04/18.
References reviewed and updated; Codes updated; Specialist reviewed; Approval Date 04/19.
Deleted listed codes as informational only (94660, E0470, E0471, E0472); Revision Date 05/19.
Annual review completed; Coding reviewed and updated; New ICD-10 codes added; G30.1 changed to G30.0; Revision and Approval Date 04/20.
Replaced 'member' with 'member/enrollee'; References reviewed and updated; Revision and Approval Date 04/21.
Annual review; ICD-10 codes deleted; Definition edited for custodial care; Background info on state waivers added; Reviewed by specialist; Revision and Approval Date 04/22.
Annual review; References reviewed and updated; Approval Date 04/23.
Annual review; Edit to description for 94004; References reviewed and updated; Reviewed by external specialist; Revision and Approval Date 02/24.
Annual review; References reviewed and updated; Reviewed by external specialist; Revision and Approval Date 01/25.
Annual review completed; References reviewed and updated; Reviewed by external specialist; Revision Date and Approval Date 01/26 (last review).
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