CurrentMass General Brigham Health PlanPolicy 090

Medical Necessity Guidelines — Adult Day Health

Guidelines governing medical necessity and coverage criteria for adult day health services offered by Mass General Brigham Health Plan, specifying applicability by product (One Care and SCO) and exclusions.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines — Adult Day Health

Policy CodePolicy 090

Change TypeReformat and criteria updates

Effective Date2026-01-01 or as written

Next Review Date

Key ActionObtain prior authorization for One Care and SCO members before providing Adult Day Health services.

SourceLink

POLICY UPDATE CHANGES

Reformatted policy and updated criteria, related policies, and references.

One Care & SCOCovered products

MA, ACO, Commercial, QHPNot covered

Prior requiredAuthorization

2+ conditions + program needEligibility elements

2 HCPCSInformational codes

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Coverage Criteria for Adult Day Health (ADH)

Coverage Criteria

Covered for One Care and SCO members 18+ when ALL of the following are met:

Eligibility: 1) A recommendation for ADH is documented in the integrated care plan; and 2) The member has one or more chronic or post-acute medical, cognitive, or mental health condition(s) identified by the member's PCP that require active monitoring, treatment, or intervention and ongoing observation and assessment by a nurse, without which the member's condition will likely deteriorate; and 3) The member requires the ADH program to provide one or both of the following: a) at least one skilled service as defined in the policy; or b) assistance with one or more qualifying ADLs in which the member requires hands-on physical assistance or requires cueing and supervision throughout the task, needed at least daily or on a regular basis at the ADH.

Applies only to One Care and SCO products; prior authorization required.

Coverage is not allowed for any portion of a day when the member is receiving services that are duplicative of care provided by the Adult Day Health (ADH) program. Coverage is also excluded when the member is a resident or inpatient of a hospital, nursing facility, or intermediate care facility for the intellectually disabled, except for services on admission and discharge dates. Additionally, days will be denied if the provider has not obtained prior authorization, for canceled program days or missed time periods, or for any day portion when the member is absent from the ADH site unless the program documents that program staff provided services to the member in the community that day.

ADH services are not covered for the following products: Medicare Advantage, Mass General Brigham ACO, Commercial, and Qualified Health Plans. Coverage and authorization rules in this policy apply only to One Care and Senior Care Options (SCO) members.

Coding and Procedure Codes

Informational HCPCS CodesHCPCS

S5101	Day care services, adult; per half day.
S5102	Day care services, adult; per diem

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for One Care and SCO members. Providers must obtain prior authorization before providing ADH services to eligible One Care and SCO members age 18+.

Applies to One Care and SCO members only
Members must be 18 years or older

Step Therapy

No Step Therapy Specified

No step therapy applies to ADH services under this policy. Providers should not apply step edits when seeking authorization or billing for covered ADH services.

Documentation Required

Key Definitions

Activities of Daily Living (ADLs) — qualifying descriptions

BathingFull‑body bath or shower or sponge (partial) bath including washing and drying of face, chest, axillae, arms, hands, abdomen, back and peri‑area; may include personal hygiene (hair care, oral/denture care, shaving); mere hand/face washing or hygiene alone does not qualify.

ToiletingMember is incontinent of bladder and/or bowel or requires scheduled assistance or routine catheter or colostomy/urostomy care.

TransferringMember needs assistance or must be lifted to move from one position to another (e.g., wheelchair to commode).

Mobility (ambulation)Member must be physically steadied, assisted, or guided during ambulation, or unable to self‑propel a wheelchair appropriately without assistance.

EatingMember requires constant supervision and cueing during the entire meal or needs physical assistance (fed) for all or part of a meal; must be needed at least daily or regularly at ADH; limited diet alone does not qualify.

Background on Adult Day Health Programs

Adult Day Health (ADH) programs provide nursing observation and assessment, delivery of skilled clinical services, and assistance with Activities of Daily Living (ADLs) for adults with chronic or post‑acute medical, cognitive, or behavioral health conditions whose status requires ongoing monitoring and intervention to prevent deterioration. Skilled services include nursing procedures such as injections, tube feedings, airway suctioning, wound care requiring registered nurse skills, oxygen administration that requires skilled observation, catheter-related care in selected residents, medication management by nursing staff, behavior management oversight, intake/output measurement, and therapy services when part of a planned program. ADH also provides hands‑on assistance or cueing and supervision for qualifying ADLs (bathing, toileting, transferring, mobility, and eating) when these needs occur at least daily or regularly in the program and are documented in the integrated care plan.

Policy Revision History

June 2026annual_reviewLatest

Annual review: policy reformatted; coverage criteria, related policies, and references updated; formatting of skilled services list fixed.

January 2026effective_date

Policy effective date established.

Examples of Skilled Services

Injections & IV feedingIntravenous, intramuscular, or subcutaneous injections or intravenous feeding requiring skilled nursing.

Tube feedings & aspiration/tracheostomy careNasogastric, gastrostomy, or jejunostomy feedings; nasopharyngeal aspiration and tracheostomy care (long‑term tracheotomy care alone does not indicate skilled services).

Wound care & sterile proceduresTreatment, wound care and dressing application for ulcers, burns, open surgical sites, fistulas, tube sites, tumor erosions when RN skills are required, including physician‑prescribed irrigation and sterile dressings; insertion/sterile irrigation/replacement of catheters and suprapubic catheter care in select situations.

Oxygen & skilled observationAdministration of oxygen on a regular and continuing basis when the member's condition warrants skilled observation (e.g., COPD or pulmonary edema).

Nursing management & medication oversightSkilled‑nursing observation, evaluation, assessment, treatment and management to prevent exacerbation of chronic/behavioral conditions, and administration/oversight/management of medication by a licensed nurse including monitoring dose, response, and adverse reactions.

Therapies & gait trainingPhysical, speech, occupational therapy as part of a planned program; gait evaluation and training by a PT; certain ROM and modalities may be skilled when part of an active treatment plan and documented goals/timeframe.