CurrentCentenePolicy CP.MP.71

Long Term Care Placement

Defines medical necessity criteria, intensity of service, and discharge criteria for long term care (LTC) placement in nursing homes across levels from custodial care to specialized services (dementia, dialysis, respiratory, ventilator, bariatric). Affects members/enrollees and providers arranging or delivering LTC placement.

Policy Summary

PayerCentene

PolicyLong Term Care Placement

Policy CodePolicy CP.MP.71

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDocument comprehensive geriatric assessment at admission and perform ongoing assessments to determine and maintain the appropriate level of care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7LTC categories described

BMI ≥ 50Bariatric BMI threshold

≥6 hrs/dayVentilator dependence threshold

≥3Respiratory interventions/day

90960–90962,94004Example referenced codes

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Custodial/Non-Skilled Care

Custodial/Non-Skilled Care — Covered when criteria below are met

Custodial definition: Care that does not meet criteria for skilled nursing, skilled rehabilitation, or specialized care; assistance with ADLs and supervision for safety or behavior management

Decision not based on diagnosis, type of condition, degree of functional limitation, or rehabilitation potential

Level examples: Intermediate-Light: needs help with up to two ADLs; Intermediate-Moderate: needs help with three or four ADLs; Intermediate-Heavy: needs help with all five ADLs

Used to determine appropriate custodial level when multiple levels are available

Dementia/Wandering Care

Dementia/Wandering Care — Covered when ALL of the following are met

Admission requirements: Diagnosis of dementia or related cognitive disorder (including Alzheimer disease or organic brain syndrome); failed to adequately improve with appropriate psychiatric evaluation and treatment; documentation of problematic wandering behavior in the residential or HCBS setting as characterized in policy (repeated exits, wandering into off-limit areas, unable to find way back to room, repeated wandering away from home requiring return by police, need to lock home to prevent exit, unsafe driving)

Wandering behaviors include repeated exits, getting lost, and unsafe driving despite interventions

Intensity of service: Secure living area (locks/electronically controlled access), activities appropriate for persons with dementia, and all services/medications/supplies/equipment necessary to manage the member's needs

Dementia with Behaviors Care

Dementia with Behaviors Care — Covered when ALL of the following are met

Admission requirements: Diagnosis of dementia or related disorder; failed to adequately improve with appropriate psychiatric evaluation and treatment; documentation of daily problematic behaviors that endanger the member or others and cannot be managed in a traditional facility or HCBS (examples: repeated exit attempts, physical aggression, suicide or self-injury, uncontrolled throwing, continuous prolonged yelling, repeated self‑injury from falls, sexualized behaviors, misuse/abuse of medications/alcohol/drugs, psychosis or depression not manageable at lower level) and two documented failed attempts to step down from a dementia/wandering unit

Behaviors and two failed step‑down attempts required

Intensity of service: Separate secure living area with continuous direct observation/supervision, psychiatric nursing care with ongoing assessment, activities appropriate for persons with dementia, and all services/medications/supplies/equipment necessary to manage the member's needs

Staff must be able to directly observe and supervise the member at all times

Dialysis Care

Dialysis Care — Covered when ALL of the following are met

Admission requirements: Requires dialysis and is unable to receive it in an outpatient setting due to medical conditions (e.g., pericarditis, pneumonia or other infection, gastrointestinal bleeding, confusion/dementia, hemodynamic instability); and unable to sit up for 4 hours at a time plus either has a wound that prohibits outpatient dialysis or requires a Hoyer lift for transfers

Intensity of service: Dialysis treatment as prescribed by a nephrologist; ongoing evaluation and monitoring; relevant diagnostic studies with timely reporting to ordering physician; and all services/medications/supplies/equipment necessary

Respiratory Care

Respiratory Care — Covered when ALL of the following are met

Admission criteria: Requires three or more specified respiratory interventions in a 24‑hour period performed by facility licensed staff (examples: tracheostomy care twice daily and prn; tracheal suctioning every 4 hours and prn; aerosol therapy with FIO2 ≥28%; chest physical therapies; continuous CPAP/BIPAP; CPAP or PSV setting on a ventilator; mechanical ventilation < six hours/day without weaning in progress)three or more interventions per 24 hours

Intensity of service: Respiratory therapy as prescribed; ongoing evaluation and monitoring; relevant diagnostic studies with timely reporting to ordering physician; and all services/medications/supplies/equipment necessary

Ventilator Care

Ventilator Care — Covered when ONE of the following is met

Primary ventilator dependence: Requires mechanical ventilation for ≥ six hours per day to sustain life; acceptable modes include Assist Control (AC) or SIMV≥ six hours/day

Weaning in progress: Requires < six hours of mechanical ventilation and weaning from the ventilator is in progress< six hours/day with weaning in progress

Intensity of service: Mechanical ventilation needs as prescribed; ongoing evaluation and monitoring; relevant diagnostic studies with timely reporting to ordering physician; and all services/medications/supplies/equipment necessary

Bariatric Care

Bariatric Care — Covered when ALL of the following are met

Admission criteria: BMI ≥ 50 kg/m2; and unable to change position, ambulate, or transfer without hands‑on assistance from three or more caregiversBMI ≥ 50 kg/m2; assistance from ≥3 caregivers

Intensity of service: Nutritional counseling, tailored physical/occupational/restorative therapies, an ongoing multidisciplinary approach to weight loss, and all services/medications/supplies/bariatric equipment necessary to manage the member's needs

This policy distinguishes custodial (non‑skilled) care from skilled nursing and specialized facility services. Custodial care is care that does not meet criteria for skilled nursing, skilled rehabilitation, or the specialized care services described elsewhere in this policy and may be provided by family members, health aides, or other unlicensed individuals when the member has reached maximum physical or mental function. Custodial services primarily address assistance with activities of daily living (ADLs) — bathing, dressing, toileting, transferring, and eating — and supervision for safety or behavior management rather than treatment of a specific medical condition. Determination of need for custodial placement should consider ADL assistance requirements, communication and cognitive status, behavior, and the member’s ability to self‑administer medications, and is not based solely on diagnosis, functional limitation degree, or rehabilitation potential.

Coverage determinations made under this clinical policy are intended to guide medical necessity decisions but do not replace the member's contract of coverage. All coverage decisions remain subject to the specific terms, conditions, exclusions, and limitations of the member’s coverage documents (for example, evidence of coverage, certificate of coverage, policy or contract). Where applicable, state Medicaid provisions and other legal or regulatory requirements take precedence over this policy. Providers should consult the member’s benefit plan and applicable state rules when arranging placement or services.

Coding References and Thresholds

Referenced CPT/HCPCS CodesCPT

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

Referenced CPT/HCPCS CodesCPT

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, assist of pressure or volume preset ventilators for assisted or controlled breathing, nursing facility, per day

Informational CPT CodesCPT

90960

Informational CPT Codes (continued)CPT

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, assist of pressure or volume preset ventilators for assisted or controlled breathing, nursing facility, per day

Bariatric Care threshold

Bariatric BMI thresholdBMI ≥ 50 kg/m2

Associated admission requirementMember unable to change position, ambulate, or transfer without hands-on assistance from three or more caregivers

Intensity of service noteRequires nutritional counseling, tailored therapies, multidisciplinary weight-loss approach, and bariatric equipment as needed

Ventilator Care threshold

Ventilator dependence thresholdMechanical ventilation ≥ six hours/day

Alternate qualifying conditionRequires < six hours/day when weaning from ventilator is in progress

Acceptable ventilator modesAssist control (AC) or Spontaneous Intermittent Mandatory Ventilation (SIMV)

Provider Requirements, Documentation, and Billing Notes

Note

Coding references (informational)

This policy references CPT® and other coding systems for informational purposes only. CPT codes and descriptions are copyrighted by the American Medical Association and are not all‑inclusive. Inclusion or omission of any code in this policy does not guarantee coverage. Providers should reference the most up‑to‑date professional coding guidance and payer billing instructions prior to claims submission.

CPT® and HCPCS codes are informational only; check current manuals and payer guidance before billing.
Inclusion or exclusion of codes in this policy does not imply coverage.

Denial Risk

General denial risk

Placement and coverage decisions must meet the clinical and documentation criteria outlined in this policy. Failure to demonstrate that placement criteria and required documentation are met may result in claim denials or retrospective adverse determinations.

Placement must meet the stated admission and clinical criteria (e.g., dementia with behaviors requirements).
Insufficient documentation of clinical need, failed treatment attempts, or unsafe behaviors may lead to denial.

Prior Authorization

General coverage and denial risk note

Coverage decisions are subject to the terms, conditions, exclusions, and limitations of members' benefit documents and applicable state and federal requirements. This clinical policy is a guidance document and does not guarantee payment; the Health Plan's coverage documents and administrative policies govern benefits.

Refer to the member's evidence of coverage, certificate, or contract for specific benefit limits and exclusions.
State Medicaid provisions take precedence over this policy where conflicts exist.

OpenPayer

Long Term Care Placement

Long Term Care Placement Coverage Criteria

Admission Criteria for SNF / Residential Placement

Continued Stay Criteria for SNF / Residential Placement

Discharge and HCBS Considerations

Coding References and Thresholds

Provider Requirements, Documentation, and Billing Notes

Key Definitions

Background and Scope