CurrentEmblemHealthPolicy MG.MM.PH.CCS

Medical Policy: Metoclopramide and Ondansetron Infusion for Hyperemesis Gravidarum

Defines medical necessity criteria, limitations, applicable procedure and diagnosis codes, and documentation requirements for home infusion of metoclopramide or ondansetron to treat members with hyperemesis gravidarum.

Policy Summary

PayerEmblemHealth

PolicyMedical Policy: Metoclopramide and Ondansetron Infusion for Hyperemesis Gravidarum

Policy CodePolicy MG.MM.PH.CCS

Change TypeAnnual reviewhistorical revision (2017)

Effective DateMar 17, 2025

Next Review Date

Key ActionTreating physician must submit documentation that the member meets HG criteria (weight loss, dehydration/labs, nutritional deficiencies, difficulty with daily activities) to EmblemHealth for preauthorization or post-payment review.

SourceLink

POLICY UPDATE CHANGES

Annual Review: no criteria changes (03/17/2025).

Original policy moved ondansetron position in treatment paradigm and removed time-frame prerequisite prior to IV fluid replacement (04/21/2017).

2ICD-10 Codes Listed

6Therapeutic steps described

6Applicable procedure/drug codes listed

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Coverage Summary

Overview: This EmblemHealth policy (Policy Number MG.MM.PH.CCS, effective 2025-03-17, last reviewed 2025-03-17) addresses coverage for home infusion of metoclopramide or ondansetron to treat members diagnosed with hyperemesis gravidarum (HG). Coverage stance: covered with criteria; home infusion is authorized when the policy’s specified diagnostic features and medication trial requirements are met and documentation is submitted for review.

Surface thresholds and brief definitions

Weight loss criterionLoss of weight > 5% of pre-pregnancy body weight (usually > 10%)

Dehydration evidenceMay be evidenced by labs (urinalysis for ketones/specific gravity, serum electrolytes, liver enzymes/bilirubin, amylase/lipase, TSH/free thyroxine, urine culture, calcium, hematocrit)

Nutritional / functional impactNutritional deficiencies and/or difficulty with daily activities are part of HG definition

Definition (HG)A severe form of nausea and vomiting in pregnancy, unrelenting and excessive, preventing adequate food and fluid intake; usually starts before 9 weeks and may resolve by 22 weeks, though refractory cases can last until delivery

Medication safety thresholdDo not administer ondansetron IV in doses greater than 16 mg due to QT prolongation risk; monitor electrolytes and ECG for arrhythmia risk

Applicable codes (examples)J2405 (ondansetron per 1 mg), J2765 (metoclopramide up to 10 mg), 99601/99602 and S9351/S9379 for home infusion administration

Medical Necessity Criteria

Pharmacologic management sequence (recommended community practice)

Covered when ALL of the following are met:

ALL of the following

Member diagnosed with hyperemesis gravidarum (HG)
Documentation must support HG features listed below
HG diagnostic features (must support 1-4 above)
- Unrelenting and excessive nausea and vomiting in pregnancy (HG)
- Loss of weight > 5% of pre-pregnancy body weight (usually > 10%)>5%

Coding

Applicable procedure / administration codesmixedCovered

99601	Home infusion/specialty drug administration, per visit (up to 2 hours)
99602	Home infusion/specialty administration, per visit; each additional hour (List separately in addition to code for primary procedure)
S9351	Home infusion therapy, continuous or intermittent antiemetic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and visits coded separately) per diem
S9379	per diem

Drug J-codesHCPCSCovered

J2405	Injection, ondansetron HCl, per 1 mg
J2765	Injection, metoclopramide HCl, up to 10 mg

Applicable ICD-10 diagnoses for HGICD-10Covered

O21.0	Mild hyperemesis gravidarum
O21.1	Hyperemesis gravidarum with metabolic disturbance

Provider Actions

Prior Authorization

Prior authorization required

Requests for home infusion with metoclopramide or ondansetron require clinical submission to EmblemHealth for review; coverage is contingent on meeting the policy criteria. Submit the request for preauthorization or it may be subject to post-payment review. Coverage will be determined based on whether the member meets the policy’s HG medical necessity criteria.

99601
99602
S9351
S9379
J2405
J2765

Documentation Required

Submit clinical evidence supporting HG criteria

Treating physician must submit clinical documentation that the member meets the HG diagnostic criteria. Provide evidence of unrelenting/excessive nausea and vomiting in pregnancy, weight loss greater than 5% of pre-pregnancy body weight, dehydration with supporting laboratory studies (for example urinalysis for ketones/specific gravity, serum electrolytes, liver enzymes, amylase/lipase, TSH/free thyroxine, calcium, hematocrit), documentation of nutritional deficiencies, and information about difficulty with daily activities to support medical necessity.

Background and Evidence

Background and intent: Hyperemesis gravidarum (HG) is defined as a severe, unrelenting form of nausea and vomiting in pregnancy that prevents adequate food and fluid intake and is commonly associated with loss of weight > 5% of pre-pregnancy body weight (usually > 10%), dehydration, nutritional deficiencies, and difficulty with daily activities. The policy’s intent is to define medical necessity and documentation requirements so that members with HG who do not respond to outpatient medication trials may be eligible for home infusion therapy with metoclopramide or ondansetron; the guideline specifies that home infusion is considered when a trial of medications (either two oral agents or one oral plus one rectal agent) fails to relieve symptoms.

Reference	Source
ACOG Practice Bulletin No. 153 (2015)
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin number 153. Nausea and Vomiting of Pregnancy. 2015.
HER Foundation: Understanding Hyperemesis (2016)
HER Foundation: Understanding Hyperemesis. April 2016.
Micromedex (updated periodically)
Micromedex: Specialty-matched clinical peer review (updated periodically).

Clinical context and complications: The policy restates that HG can cause significant complications including >5% pre-pregnancy weight loss, dehydration (which may be evidenced by laboratory studies such as urinalysis for ketones and specific gravity, serum electrolytes, liver enzymes, and others), and nutritional deficiencies. These complications are part of the documentation required to support eligibility for home infusion when outpatient medication trials have failed.

Revision History

03/17/2025annual_reviewLatest

Annual Review: no criteria changes.

04/21/2017material_change

Original policy moved ondansetron position in treatment paradigm and removed time-frame prerequisite prior to IV fluid replacement; added administration protocol.

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