Centene Obstetrical Home Care Coverage Update

Coverage Criteria

COVERAGE CRITERIA

Covered when ALL of the following are met for each program-specific group:

General: An obstetrical nurse assessment is medically necessary when provided with any of the specified services (infusion, hydration, diabetes program, hypertensive disorder program, dietary analysis).

Metoclopramide/Ondansetron Infusion Therapy: Home visits for medication infusion therapy are medically necessary when: 1) home visits occur during the same period as the ordered infusion; 2) the member has tried and failed conservative treatment including medications by mouth and/or per rectum and/or other non-pharmacological treatments (see ACOG tiered approach); 3) for re-authorization, the ordering provider has reassessed the member since the prior authorization and documented the continued need for infusion therapy.

Hydration Therapy: Hydration therapy (one to four liters) is medically necessary for close surveillance when dehydration risk exists (examples: hyperemesis gravidarum, malabsorption, or illnesses impairing oral intake). A course of up to seven days is considered medically necessary; additional days may be granted if clinically indicated.1-4 liters; up to 7 days

Diabetes in Pregnancy Clinical Management Programs: Program is medically necessary when it includes diabetic nutrition education and one of the following: a) one visit for non–insulin-dependent diabetes managed by oral medications or diet; b) an initial course of visits for up to seven days for insulin-dependent diabetes requiring insulin administration; c) additional course(s) of visits up to seven days until self-management of blood sugar and insulin administration is achieved.up to 7 days

Program must include diabetic nutrition education

Hypertensive Disorders in Pregnancy and Postpartum (non-severe): Home visits are medically necessary when meeting one of the following: 1) one visit for gestational or chronic hypertension when either (a) elevated blood pressure without proteinuria is present or (b) the member could benefit from education and surveillance (examples include prior hypertensive disorder, multiple gestation, or diabetes); postpartum requests must be <14 days postpartum; OR 2) an initial home visit with remote blood pressure monitoring and additional phone/virtual follow-up for preeclampsia without severe features when either (a) blood pressure ≥140/90 mm Hg on two occasions at least four hours apart after 20 weeks gestation in a previously normotensive member or (b) proteinuria is demonstrated by ≥300 mg/24-hour collection or protein/creatinine ratio ≥0.3 or dipstick ≥2+; postpartum requests must be <14 days postpartum.BP ≥140/90 mm Hg on two occasions ≥4 hours apart after 20 weeks; proteinuria definitions as stated

Preeclampsia with severe features requires inpatient management

Dietary Analysis: Dietary analysis is medically necessary for members with obesity, malnutrition, or prior bowel/bariatric surgery affecting nutrient absorption.

Selected medical necessity statements

Selected medical necessity statements and program requirements present in this document excerpt:

Infusion therapy medical necessity: Medication infusion therapy is considered medically necessary when the member/enrollee has tried and failed conservative treatment including medications by mouth and/or per rectum and/or other non-pharmacological treatments; re-authorization requires reassessment and documentation by the ordering provider.

From revision history and criteria updates

Preterm labor management decision: Decision for inpatient versus outpatient management after preterm labor should be individualized based on cervical dilation, vaginal bleeding, fetal status, and travel time to an appropriate facility.

Clinical guidance added in revision history

The following services are considered not medically necessary when provided by a home health vendor: betamethasone therapy via multiple repeat courses or intermittent injections; management of multiple gestation (see individual program rules); continuous heparin infusion therapy; member-administered nonstress test (NST) or fetal heart rate monitoring; preterm prelabor rupture of membranes (PPROM) management; preterm labor management; and 17-hydroxyprogesterone caproate (Makena) injections.

Section I.H. (previously referencing nursing visits for administration of hydroxyprogesterone caproate/Makena) has been removed. Criteria for nursing visits to administer Makena were deleted to reflect the withdrawal/not-recommendation noted in the revision history.

When state Medicaid coverage provisions conflict with this clinical policy, state Medicaid coverage provisions take precedence; providers should follow the applicable state Medicaid requirements for coverage determinations.

Examples of services specifically identified as not medically necessary for home health vendors include: repeat or intermittent courses of betamethasone (ACOG recommends a single course with limited exceptions for a single repeat/rescue course); continuous heparin infusion therapy; and member-administered nonstress tests (NSTs) or fetal heart rate monitoring. The policy also cites that PPROM and preterm labor management are generally managed in-hospital rather than at home because available evidence is insufficient to support home management in most cases.

Use of 17-OHPC (hydroxyprogesterone caproate) to prevent preterm labor is no longer recommended following the FDA withdrawal of approval. The policy removed criteria and nursing visit language for administration of Makena consistent with that change.

Coding and Billing

Home nursing and management HCPCSHCPCS

G0162	Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes
G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes
S9123	Nursing care, in the home; by registered nurse, per hour
S9140	Diabetic management program, follow up-visit to non-MD provider
S9145	Insulin pump initiation, instruction in initial use of pump (pump not included)
S9211	Home management of gestational hypertension, per diem
S9213	Home management of preeclampsia, per diem
S9214	Home management of gestational diabetes, per diem

Home infusion and ancillary HCPCSHCPCS

S9351	Home infusion therapy, continuous or intermittent antiemetic infusion therapy; per diem
S9353	Home infusion therapy, continuous insulin infusion therapy; per diem
S9374	Home infusion therapy, hydration therapy; one liter per day; per diem
S9375	Home infusion therapy, hydration therapy; >1L to ≤2L per day; per diem
S9376	Home infusion therapy, hydration therapy; >2L to ≤3L per day; per diem
S9377	Home infusion therapy, hydration therapy; >3L per day; per diem
S9379	Home infusion therapy, infusion therapy, not otherwise classified; per diem
S9470	Nutritional counseling, dietitian visit
S9560	Home injectable therapy; hormonal therapy, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; per diem

Home infusion CPT/other procedure codesCPT

99601	Home infusion/specialty drug administration, per visit (up to 2 hours)
99602	Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour

Coding guidance notemixed

No codes listed

Hydration volume & BP thresholds

Hydration volumeOne to four liters per course (home hydration for dehydration risk such as hyperemesis gravidarum, malabsorption, or illness)

Hydration course lengthA course of up to seven days at a time; additional days may be granted if clinically indicated

Hypertension threshold (antepartum/post-20 weeks)Blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic on two occasions at least four hours apart after 20 weeks gestation

Provider Actions, Authorizations & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization may be required for home visits to administer metoclopramide or ondansetron infusion therapy. Verify with the member's health plan before scheduling services; documentation submitted with the authorization request should demonstrate that the infusion is ordered for the specified administration period and aligns with policy criteria.

Home visits must occur during the same period the infusion is ordered to be administered
Prior authorization should reference the ordering provider and planned infusion dates

Documentation Required

Infusion Therapy Requirements & Re-authorization

Infusion therapy for metoclopramide or ondansetron is authorized only when conservative therapies have been tried and failed and when the ordering provider documents the need for infusion. Re-authorization requests require documentation that the provider has reassessed the member and continues to need infusion therapy.

Background

Obstetrical homecare programs provide risk assessment, education, case management and home-based services to support high-risk pregnancies. Typical program components include an obstetrical nurse assessment tied to specified services (infusion, hydration, diabetes and hypertensive disorder programs, dietary analysis); hydration therapy in the home (commonly 1–4 liters, typically authorized for a course up to 7 days when at risk for dehydration); diabetes-in-pregnancy clinical management with nutrition education and insulin support as needed; and home blood pressure surveillance and follow-up for non-severe hypertensive disorders, with inpatient care recommended for preeclampsia with severe features.

Definitions

Obstetrical Nurse Assessment

DefinitionObstetrical Nurse Assessment: a nursing assessment that is considered medically necessary when provided in conjunction with services such as infusion therapy, hydration therapy, diabetes clinical management, hypertensive disorder management, or dietary analysis.

Context of useRequired as part of home obstetrical services listed in sections B–F of the policy (e.g., during infusion or hydration visits)

PurposeProvides evaluation, education, and surveillance to support medically necessary home care interventions for pregnant members/enrollees

Hydration Therapy

DefinitionHydration Therapy: home-administered intravenous hydration of one to four liters to provide close surveillance for onset of dehydration (e.g., from hyperemesis gravidarum, malabsorption, or illnesses impairing oral intake)

Authorized volume

OpenPayer

Obstetrical Home Care Programs

Coverage Criteria

Coding and Billing

Provider Actions, Authorizations & Documentation

Background

Definitions