Currentmeridian_health_plan_of_michiganPolicy CP.MP.71

Long Term Care Placement

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Defines medical necessity criteria, intensity of service, and discharge criteria for long term care placement across custodial, dementia, dialysis, respiratory, ventilator, and bariatric care settings for Meridian Health Plan of Michigan members.

Policy Summary

Payermeridian_health_plan_of_michigan

PolicyLong Term Care Placement

Policy CodePolicy CP.MP.71

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain authorization when placement is based on category-specific medical necessity criteria and provide documentation supporting diagnosis and placement criteria.

SourceLink

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Currentmeridian_health_plan_of_michiganPolicy CP.MP.71

Long Term Care Placement

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Policy Summary

Payermeridian_health_plan_of_michigan

PolicyLong Term Care Placement

Policy CodePolicy CP.MP.71

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain authorization when placement is based on category-specific medical necessity criteria and provide documentation supporting diagnosis and placement criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7distinct long term care indications

BMI ≥50bariatric BMI threshold

≥6 hrs/dayventilator threshold

3+ /dayrespiratory interventions

94004ventilation code referenced

Long Term Care Placement — Coverage Criteria

Custodial/Non-Skilled Care

Placement is appropriate when care does not meet skilled criteria and member requires assistance/supervision with ADLs.

Custodial placement decision: Care does not meet criteria for skilled nursing/rehabilitation or specialized services; member requires assistance or supervision with activities of daily living (bathing, dressing, toileting, transferring, eating) or supervision for safety/behavior management; decision is based on level of care and medical supervision required rather than diagnosis; select custodial level matching the individual's needs

Levels: Intermediate-Light (help with up to 2 ADLs), Intermediate-Moderate (3-4 ADLs), Intermediate-Heavy (all 5 ADLs or constant supervision)

Dementia/Wandering Care

Covered when ALL of the following are met

Admission: Diagnosis of dementia, Alzheimer disease, organic brain syndrome, or other cognitive disorder; failed to adequately improve with appropriate psychiatric evaluation and treatment attempts; documentation of problematic wandering behavior that endangers the member or others as characterized in policy (e.g., repeated exits, wandering into off-limit areas, unable to find way back) in a residential setting, or evidence of repeated wandering away from home or requiring locking by caregivers in an HCBS setting.

Examples of wandering behaviors referenced in policy

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

Dementia with Behaviors Care

Covered when ALL of the following are met

Admission: Diagnosis of dementia, Alzheimer disease, organic brain syndrome, or similar cognitive impairment; failed to adequately improve with appropriate psychiatric evaluation and treatment attempts; documentation of daily problematic behaviors that endanger the member or others and cannot be managed in a traditional facility or HCBS setting, characterized by behaviors listed in policy (e.g., repeated exit attempts, physical aggression, suicide or self-injury, continuous prolonged yelling, sexualized behaviors, medication/drug misuse, psychosis/depression); two documented failed attempts to step down may be required if specified.

Behavior examples listed in policy

Intensity of service: Separate secure living area distinct from other residents; staff able to directly observe and supervise the member at all times; psychiatric nursing care with ongoing observation and assessment; activities appropriate for dementia; and all services, medications, supplies and equipment necessary to manage the member's needs.

Dialysis Care

Covered when ALL of the following are met

Admission: Member requires dialysis and is unable to receive it in an outpatient setting due to medical conditions such as pericarditis, infection (eg, pneumonia), gastrointestinal bleeding, confusion/dementia, or hemodynamic instability; and member cannot sit for four hours at a time and 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; timely reporting of relevant diagnostic studies to the ordering physician; and all services, medications, supplies and equipment necessary to manage the member's needs.

Respiratory Care

Covered when ALL of the following are met

Admission: Member requires three or more specified respiratory interventions in a 24-hour period performed by facility licensed staff. Interventions include: tracheostomy care twice daily and as needed; tracheal suctioning every four hours and as needed; aerosol therapy with FIO2 ≥28%; chest physical therapies (percussion/postural drainage); continuous CPAP/BIPAP; CPAP or pressure support ventilation settings on a ventilator; or mechanical ventilation < six hours/day without weaning in progress.Three or more specified interventions in 24 hours

Intensity of service: Respiratory therapy as prescribed by the physician; ongoing evaluation and monitoring; timely reporting of relevant diagnostic studies to the ordering physician; and all services, medications, supplies and equipment necessary to manage the member's needs.

Ventilator Care

Covered when ANY of the following are met

Admission options: Member requires mechanical ventilation ≥ six hours per day (acceptable modes include Assist Control (AC) or SIMV) OR member requires < six hours per day with active weaning from the ventilator in progress.Mechanical ventilation ≥ six hours per day (or < six hours if weaning in progress)

Intensity of service: Mechanical ventilation needs as prescribed by the physician; ongoing evaluation and monitoring; timely reporting of relevant diagnostic studies to the ordering physician; and all services, medications, supplies and equipment necessary to manage the member's needs.

Bariatric Care

Covered when ALL of the following are met

Admission: Member has BMI ≥ 50 kg/m2 AND is unable to change position, ambulate, or transfer without hands-on assistance from three or more caregivers.BMI ≥ 50 kg/m2; assistance from ≥3 caregivers

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

Mechanical ventilation placement

Placement requiring mechanical ventilation

Intensity of service for ventilator-dependent member: Member must be provided with: (a) mechanical ventilation needs as prescribed by physician; (b) ongoing evaluation and monitoring of condition; (c) relevant diagnostic studies with timely reporting to ordering physician; and (d) all services, medications, supplies and equipment necessary to manage the member's needs.

From Intensity of Service for Ventilator Care

Bariatric placement

Bariatric care placement criteria

Bariatric placement requirements: Member must meet both: (a) BMI ≥ 50 kg/m2; and (b) inability to change position, ambulate, or transfer without hands-on assistance from three or more caregivers.BMI ≥ 50 kg/m2; 3+ caregivers

From Bariatric Care Placement Criteria

Discharge criteria

Discharge criteria for placement

Discharge triggers: Member no longer meets placement criteria AND either is able to be safely managed in a lower level of care, OR requires a higher level of care than the facility can provide.

Discharge Criteria section

Care that meets the criteria for skilled nursing, skilled rehabilitation, or the specialized skilled services described elsewhere in this policy must not be classified as custodial (non‑skilled) care. Custodial care is defined as care that does not meet skilled criteria and is focused on assistance or supervision with activities of daily living (ADLs) and safety/behavior management. Decisions about classifying care should be based on the level of care and medical supervision required rather than on diagnosis alone; if a member requires skilled services that need licensed clinical staff, the placement should be managed and billed as skilled care, not custodial.

The need for basic custodial care is determined by the member’s requirement for assistance or supervision with ADLs (bathing, dressing, toileting, transferring, eating) and not by medical diagnosis. Custodial services can be provided by non‑licensed caregivers when the member has reached maximal physical or mental function and requires hands‑on help or supervision for personal needs. Coverage and payment source may differ between custodial and skilled care (for example, Medicaid, long‑term care insurance, or out‑of‑pocket), so correctly distinguishing custodial versus skilled needs is important for authorization and billing.

Admission Criteria for Covered Settings

SNF | residential | HCBS

General admission rule: Member must meet the specific placement criteria for the relevant category (custodial level matching ADL needs; dementia with wandering or behaviors; inability to receive outpatient dialysis; respiratory or ventilator thresholds; bariatric BMI and caregiver assistance requirements).

Admission requires comprehensive assessment to develop treatment plan

SNF/long term care facility

General admission criteria: Admission requires a comprehensive geriatric assessment at the time of admission to develop a treatment plan determining required level of care; for bariatric care admission requires BMI ≥ 50 kg/m2 and need for hands-on assistance from three or more caregivers.

Share changes with Health Plan Case Manager

Criteria for Continued Stay

SNF | residential

Discharge/continued stay: Continued stay is appropriate while the member continues to meet placement criteria; discharge should be considered when the member no longer meets placement criteria and either can be safely managed at a lower level of care or requires a higher level of care than the facility can provide.

Continued stay follows placement-specific criteria

SNF/long term care facility

Continued stay requirements: Ongoing evaluation and monitoring, timely diagnostic reporting, necessary services/supplies/equipment, and multidisciplinary care for specialized needs (eg, bariatric therapy); share changes with Health Plan Case Manager.

From Continued Stay Criteria for SNF/long term care facility

Discharge Criteria and Settings

Discharge from any covered long‑term care setting is appropriate when the member no longer meets the placement criteria and either can be safely managed at a lower level of care or requires a higher level of care than the facility can provide. Examples of lower‑level transition criteria include the member being independent or needing only intermittent home caregiver assistance, a safe home environment, and the availability of required equipment and supports.

For SNF or long‑term care facility placements, discharge should be considered when the member no longer meets the facility’s placement criteria and either can be managed safely at a lower level of care or requires a higher level of care than the facility can provide. Ongoing facility responsibilities include providing required specialized services (for example, mechanical ventilation per physician orders), ongoing evaluation and monitoring, timely diagnostic reporting, and all necessary services, medications, supplies and equipment until discharge.

Referenced Codes and Thresholds

Referenced CPT Codes (ESRD)CPT

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 Codes (ventilation and ESRD)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, initiation of pressure or volume preset ventilators for assisted or controlled breathing, nursing facility, per day

Bariatric placement threshold

Associated caregiver requirementUnable to change position, ambulate, or transfer without hands-on assistance from three or more caregivers

Ventilator dependence threshold

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

Weaning exceptionRequires < six hours/day if active weaning from ventilator is in progress

Respiratory interventions threshold

Respiratory interventions thresholdRequires three or more specified respiratory interventions in a 24-hour period

Documentation, Coding, and Provider Requirements

Prior Authorization

Obtain authorization only when category-specific placement criteria are met

Long term care placement is medically necessary only when the member meets the specific placement criteria for the relevant category; facilities should obtain authorization when placement is based on these criteria and select the custodial level matching the member's ADL and supervision needs rather than basing placement solely on diagnosis.

Select the placement category that matches the member's clinical needs (custodial, dementia/wandering, dementia with behaviors, dialysis, respiratory, ventilator, bariatric).
Ensure level of custodial care corresponds to hands-on ADL assistance and supervision required (Intermediate-Light/Moderate/Heavy as applicable).

Billing Rule

Reference policy-listed CPT codes (informational) before claim submission

Key Definitions

Custodial / Non-Skilled Care (definition)

Definition (Custodial/Non-Skilled Care)Care focused on assistance and supervision with activities of daily living (bathing, dressing, toileting, transferring, eating) provided by non-licensed caregivers when maximum functional level reached

Primary purposeHands-on help and/or supervision for ADLs or safety/behavior management

Not based on diagnosisPlacement decision based on level of care and medical supervision required, not diagnosis

Custodial care (definition)

Definition (Custodial care)Provides services that assist a member/enrollee with ADLs such as walking, bathing, dressing, feeding, toileting, and supervision of medication that can normally be self-administered

Provider typeServices can be provided by someone who is not trained medical or paramedical personnel

Background

Long‑term care placement encompasses a spectrum from custodial (non‑skilled) care to specialized skilled residential services for complex medical needs. Custodial care addresses assistance and supervision with ADLs and safety/behavior management and may be provided by non‑licensed personnel once the member has reached maximal function. Specialized skilled residential services include care for dementia with wandering or behavioral needs, dialysis dependence, complex respiratory management including mechanical ventilation, and bariatric care — each of which requires licensed staff, ongoing physician oversight, and facility resources beyond custodial supports.

Policy Revision History

2024-02annual_reviewLatest

Annual review completed; edit to description for CPT 94004 with references reviewed and updated.

2023-04annual_review

Annual review completed; references reviewed and updated; edit to description for CPT 94004 and annual review noted.

2023-04annual_review

Policy Summary

Payermeridian_health_plan_of_michigan

PolicyLong Term Care Placement

Policy CodePolicy CP.MP.71

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain authorization when placement is based on category-specific medical necessity criteria and provide documentation supporting diagnosis and placement criteria.

SourceLink

On This Page

Performed byFacility licensed staff

Bariatric placement threshold (duplicate)

Hands-on assistance requirementRequires hands-on assistance from three or more caregivers for position, ambulation, or transfers

Codes listed in the policy are provided for informational purposes; providers should reference current professional coding guidance prior to claim submission and may need to follow plan-specific prior authorization processes when applicable.

Referenced CPT codes include 94004 (ventilation assist and management) and ESRD monthly codes 90960–90962 — use these as informational guidance only.
Confirm coding and prior authorization requirements with the Health Plan before submitting claims.

Step Therapy

Document failed psychiatric evaluation/treatment and step-down attempts for dementia placements

For dementia-related placements, documentation must show failed attempts at appropriate psychiatric evaluation and treatment; for dementia with behaviors, documentation must also include the required step-down attempts where specified.

Document psychiatric evaluations and specific treatments attempted and their outcomes.
For dementia with behaviors, include records of the two documented attempted step-downs and evidence they failed when that requirement applies.

Documentation Required

Include admission supporting documentation demonstrating diagnosis and specific placement criteria

Provider must submit all supporting documentation at admission that demonstrates the diagnosis and how the member meets the chosen placement criteria; for example, dementia placement must include evidence of wandering or behavioral examples as described in the policy.

Include diagnostic documentation (e.g., dementia diagnosis) and clinical notes describing specific behaviors or functional limitations (wandering episodes, aggression, inability to sit for dialysis, respiratory intervention frequency, ventilator dependence, BMI and transfer assistance needs).
Attach relevant specialist documentation (nephrologist dialysis orders, respiratory therapy plans, ventilator settings/weaning notes, nutrition/weight management plans).

Documentation Required

Complete comprehensive geriatric assessment at admission and maintain ongoing assessments

A comprehensive geriatric assessment must be completed at admission and ongoing assessments and treatment plans must be maintained; significant changes in status should be communicated to the Health Plan Case Manager.

Perform and document the OBRA-compliant comprehensive assessment at admission to develop the treatment plan.
Document ongoing reassessments, family meetings, and share changes in functional or medical status with the Health Plan Case Manager.

Documentation Required

Document level-of-care and medical supervision to justify placement

Placement decisions must be justified by documented level-of-care and medical supervision required rather than by diagnosis alone; failure to document the level-of-need may result in denial of long term care coverage.

Provide clear documentation of ADL assistance needs, supervision or continuous observation requirements, and any specialized skilled services needed.
If multiple custodial levels exist, document why the selected level matches the member's needs.

Denial Risk

Maintain documentation for continued stay; risk of discharge or denial if criteria are not met

Placement may be discontinued if the member no longer meets placement criteria or requires a different level of care; failure to demonstrate continued eligibility or appropriate intensity of service may lead to discharge or denial.

Continue to document that the member meets placement criteria for continued stay; if criteria are no longer met, prepare for transition to lower or higher level of care.
Notify the Health Plan of status changes that could affect continued coverage.

Documentation Required

Provide specific supporting documentation tied to the placement criteria at admission

Admission requires documentation supporting the diagnosis and the specific placement criteria (e.g., dementia diagnosis with evidence of wandering behavior); ensure records show the precise criteria from the policy that the member meets.

For dementia/wandering: include descriptions of wandering episodes or behaviors listed in the policy.
For dialysis: include nephrology orders and reasons outpatient dialysis is infeasible (pericarditis, infection, inability to sit 4 hours, Hoyer lift need).
For respiratory/ventilator/bariatric: include frequency of respiratory interventions, ventilator hour totals or weaning notes, BMI documentation and number of caregivers required for transfers.

Examples of ADLsWalking, bathing, dressing, feeding, toileting, medication supervision

Annual review; references reviewed and updated.

2022-04annual_review

Annual review completed; references reviewed and updated; definition edited for custodial care and background on state waivers added.

2021-04edit

Replaced all instances of 'member' with 'member/enrollee'; references reviewed and updated.

2020-04coding_update

Annual review completed; coding reviewed and updated including new ICD-10 additions and edits to codes.

2019-04coding_update

References reviewed and updated; codes updated and specialist reviewed.

2019-05code_deletion

Deleted certain codes (94660, E0470, E0471, E0472) as informational only.

2018-04minor_edit

Minor wording changes for clarity; references reviewed and updated.

2014-05approval

Policy developed and reviewed by specialist (approval recorded).