Blue Cross Blue Shield MI Home Infusion Coverage Update

Coverage Criteria

General coverage criteria

Covered when ALL of the following are met:

Eligibility: Beneficiary must have Medicare Part B and be under the care of an applicable provider (physician, nurse practitioner, or physician assistant) with a physician-established plan of care that meets the requirements specified in 42 CFR

Reference Original Medicare eligibility criteria

Medical necessity: Physician certifies infusion therapy is medically necessary to manage an incurable or chronic condition or to treat an acute condition that can be safely managed at home

Must be appropriate for home use and documented in the plan of care

Therapy type: Therapy must be medical IV therapy, injectable therapy, or total parenteral nutrition (TPN) as prescribed and appropriate for home administration

Includes drugs/biologics administered intravenously or subcutaneously for an administration period of 15 minutes or more when applicable

Service setting: Therapy and associated services must be furnished in the patient's home by a qualified home infusion therapy supplier

Excludes institutional settings such as hospitals, critical access hospitals, and SNFs; beneficiary need not be homebound

Home infusion drugs that do not meet Original Medicare coverage criteria are not covered under the Medicare Plus Blue enhanced home infusion therapy benefit. Such drugs may instead be covered under the member's Part D prescription drug plan. Providers should confirm whether an infusion drug is covered by Original Medicare before billing under the enhanced benefit.

Providers must collect only the applicable Medicare Plus Blue member cost sharing (copayment, coinsurance, or deductible) at the time of service when possible. If a member elects to receive a noncovered service, the member is responsible for the full charge, but providers may not have members sign an Advance Beneficiary Notice of Noncoverage (ABN) to accept financial responsibility for items that are potentially noncovered. If there is any uncertainty about coverage, obtain a coverage determination from Medicare Plus Blue before providing the item. If a noncovered item is issued without a prior coverage determination, the member must be held harmless for all charges except any applicable cost share.

Claims that violate per diem frequency rules for S-codes or that exceed the time limits for CPT codes 99601/99602 may be denied. Specifically, per diem S-codes are allowable only once each calendar day, and professional infusion services billed with 99601/99602 must not exceed 4 hours for payment eligibility.

Coding and Billing

Covered CPT/HCPCS CodesHCPCS | CPTCovered

S5497	Home infusion therapy, catheter care / maintenance; per diem
S5498	Home infusion therapy, catheter care / maintenance, simple (single lumen); per diem
S5501	Home infusion therapy, catheter care / maintenance, complex (more than one lumen); per diem
S5502	Home infusion therapy, catheter care / maintenance, implanted access device; per diem
S5517	Home infusion therapy, supplies for restoration of catheter patency or declotting
S5518	Home infusion therapy, supplies necessary for catheter repair
S5520	Home infusion therapy, supplies for PICC line insertion
S5521	Home infusion therapy, supplies for midline catheter insertion
S5522	Home infusion therapy, insertion of PICC, nursing services only
S5523	Home infusion therapy, insertion of midline catheter, nursing services only

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Diagnosis CodesICD-10

ICD-10

Consistent with Original Medicare

Billing examples and changed codesmixed

99601	Home infusion administration (example mapping in billing examples)
99602	Home infusion administration (example mapping in billing examples)
S9542	Example paired with 99601 for self-injectable in home or suite
S9330	Example paired with 99601 for chemotherapy infusion in home without nurse
S9123	Removed code (effective 01/01/2026)

Per diem frequency

Per‑diem frequency rulePer diem (S‑codes) is allowable only once each calendar day

Applies toS‑codes listed for home infusion therapy per policy (e.g., S5497, S9340, S9494, etc.)

Billing consequenceClaims reporting more than one per‑diem S‑code service in the same calendar day may be denied

99601/99602 time limit

Time limit for 99601/99602Total time for 99601/99602 not to exceed 4 hours

Code descriptions99601: Home infusion/specialty drug administration, per visit (up to 2 hours); 99602: each additional hour

Provider Actions & Requirements

Prior Authorization

Prior Authorization / Coverage Determination

Prior authorization is required for services that are not clearly covered under Original Medicare or when documentation is needed to determine coverage under the Medicare Plus Blue enhanced home infusion therapy benefit. Obtain prior authorization before providing noncovered or enhanced services to avoid member financial liability.

Obtain prior authorization for services not covered by Original Medicare or when eligibility is unclear
Seek coverage determination from Medicare Plus Blue before providing noncovered items to avoid member billing
If a provider issues a noncovered item without prior determination, the member must be held harmless except for any applicable cost share

Billing Rule

Claims & Billing Requirements

Background

Home infusion therapy is the administration of drugs, nutrients, antibiotics or fluids in the patient's residence using devices such as infusion pumps and related supplies. The Medicare Plus Blue enhanced benefit recognizes both nursing-delivered and independently administered infusion care; bundled per diem services can include pharmacy support, 24/7 care coordination, patient education and infusion-related supplies. Coverage is available when a physician prescribes and certifies the therapy as medically necessary for management of a chronic/incurable condition or for an acute condition that can be safely managed at home, and when the therapy is appropriate for use in the patient's home.

Definitions

Definition of Home Infusion Therapy

DefinitionHome infusion therapy involves continuous, slow administration of a drug, nutrient, antibiotic or other fluid into a vein or other tissue at home, delivered IV or subcutaneous using equipment such as pumps and supplies like tubing and catheters

ComponentsIncludes the drug (e.g., antivirals, immune globulin), equipment (e.g., pump), and supplies (e.g., tubing, catheters)

Care processesNurses train patients/caregivers on self‑administration, monitor side effects, and perform periodic site assessments

Medical Necessity for DME

DME medical necessity — DME covered when associated with covered home infusion therapy meeting clinical criteria

DME is covered when associated with covered home infusion therapy meeting clinical criteria:

DME necessity: Equipment and supplies (e.g., infusion pumps, IV poles, catheters, tubing, needles, syringes, flushing supplies, and needleless connectors) are necessary for the safe administration of prescribed home infusion therapy and are identified in the physician-established plan of care

Includes items of DME that enable safe home administration and are documented in plan of care

Supplier enrollment: Supplier must be a qualified home infusion therapy supplier and meet Medicare enrollment requirements to bill for DME under this benefit

Supplier enrollment and Medicare supplier requirements apply for payment

Bundling and billing: DME rental and related equipment (including infusion pump and IV pole) and routine supplies are considered part of the per diem bundled services when the per diem applies and are not separately billed when included in an applicable per diem code

Rental and Purchase Rules

Item	Rule
Pump, IV pole
Equipment rental (including pump and IV pole) is included in the per diem and not separately billed; rental is bundled into per diem services.

Item	Details
Infusion pump, IV pole
Equipment rental for infusion pump and IV pole is included in the per diem; providers should not bill these items separately. Reimbursement follows the Medicare Plus Blue fee schedule on Availity (provider paid the lesser of allowed amount or charge minus member cost share).

Supplies and Equipment Included in Per Diem

Supplies and equipment included in the per diem

Included in per‑diem (explicit list)Pharmacy compounding fees; procurement/stocking of IV medication; delivery; clinical pharmacy services; patient care/coordination; on‑call availability and telephone consultation; training/education; lab blood drawing by nurse; waste disposal; postage/shipping; drug administration

Included supplies/equipmentEquipment rental (including pump and IV pole); medical supplies such as needles, syringes, tubing, flushing supplies, needleless connectors, peripheral IV start kits, IV start catheters, dressings

Associated servicesAll services including nursing and supplies associated with self‑injectable drug administration and monitoring/consultations by dietitian where applicable

Documentation & Submission Requirements

Documentation Required

Maintain physician-established plan of care and Medicare enrollment

Keep the physician‑established plan of care on file and ensure the supplier is enrolled as a Medicare home infusion therapy supplier to be eligible for payment under the benefit.

Plan of care must meet 42 CFR requirements and physician certification must document medical necessity and home suitability.
Eligible provider for payment is a Medicare‑enrolled home infusion therapy supplier.

Documentation Required

Submit supporting documentation upon request; follow provider manual for contracted providers

Submit supporting documentation when requested and follow the BCBSM/BCN provider manual for additional claim submission requirements if you are contracted; non‑contracted providers may be required to submit medical records to substantiate billed claims.

Review Availity Essentials and the provider manual for fee schedules and claim submission instructions.
Send claims to your local Blue Cross plan and include requested supporting records for non‑contracted provider claim reviews.

Not Covered / Exclusions

Home infusion drugs that do not meet Original Medicare coverage criteria are not covered under the Medicare Plus Blue enhanced home infusion therapy benefit. When a drug is not covered under Original Medicare, providers should submit the claim for that drug to the member's Part D prescription drug plan.

Certain services and charges are bundled into the per diem and are not separately billable. Examples include infusion-related supplies, equipment rental (such as pumps and IV poles) and daily pharmacist support provided as part of the per diem. Per diem billing is the primary frequency for S-codes and should be used in accordance with the policy payment rules.

Duplicate or related billing that conflicts with the per diem bundling may be denied. For example, claims that separately bill equipment rental (pump, IV pole), supplies, or services already included in the per diem may be rejected. Adhere to the policy that per diem S-codes are allowable only once each calendar day and that equipment and supplies included in the per diem should not be billed separately.

OpenPayer

Home Infusion Therapy — Medicare Plus Blue (Medicare Advantage)