Sierra Health and Life Home Health Coverage

Coverage Criteria

Medical necessity per InterQual

Covered when ALL of the following are met per InterQual LOC: Home Care

InterQual criteria: Patient meets InterQual LOC: Home Care criteria for home health or skilled care (adult or pediatric) as referenced in policy.

Providers must reference InterQual for specific clinical elements.

Home health skilled care coverage criteria

Covered when ALL of the following are met

Core coverage requirements: 1) Services are ordered and directed by a treating practitioner (M.D., D.O., P.A., or N.P.); 2) Care is delivered or supervised by a licensed professional to obtain a specified medical outcome; 3) Services are not custodial care; 4) Services are not for comfort/convenience; 5) Services are provided in the home in lieu of skilled care in another setting; 6) Services are clinically appropriate and not more costly than an alternative; 7) Services are intermittent and part-time (typically <4 hours/day), with finite predictable exceptions allowed.

See related definitions for skilled vs custodial care.

The list of procedure and/or diagnosis codes provided in this policy is for reference only and does not imply coverage. Benefit coverage for a specific service is determined by the member's specific benefit plan document and applicable law. Inclusion of a code in this policy is not a guarantee of reimbursement or payment and other policies or guidelines may apply.

Major exclusions to the home health benefit include custodial care, domiciliary care, private duty nursing, respite care, rest cures, and homemaker services (for example, home meal delivery or transportation). Additional exclusions include independent nurses hired directly by the family/member, services by unlicensed caregivers or personal care attendants, and services beyond stated benefit limits.

Services that do not meet the InterQual LOC: Home Care medical necessity criteria may be considered not medically necessary and therefore not covered. Providers should reference InterQual when requesting authorization to demonstrate that the InterQual home care criteria are satisfied.

A service will not be determined to be skilled solely because no caregiver is available. Services that are custodial in nature (non‑medical assistance with activities of daily living, supervision, housekeeping, etc.) are excluded from the home health benefit and will not meet the requirement for skilled care.

Coding and Billing Codes

Listed CPT CodesCPT

99500	Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring.
99501	Home visit for postnatal assessment and follow-up care.
99502	Home visit for newborn care and assessment.
99503	Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation).
99504	Home visit for mechanical ventilation care.
99505	Home visit for stoma care and maintenance including colostomy and cystostomy.
99506	Home visit for intramuscular injections.
99507	Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral).
99511	Home visit for fecal impaction management and enema administration.
99601	Home infusion/specialty drug administration, per visit (up to 2 hours).

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Listed HCPCS/S CodesHCPCS

G0068	Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0069	Professional services for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0070	Professional services for the administration of intravenous chemotherapy or other intravenous highly complex drug or biological infusion for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0088	Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0089	Professional services, initial visit, for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0090	Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes.
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
G0155	Services of clinical social worker in home health or hospice settings, each 15 minutes.
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes.
G0157	Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes.

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Home infusion per-diem S-codes (partial list)HCPCSCovered

S9346	Home infusion therapy, alpha-1-proteinase inhibitor (e.g., Prolastin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9347	Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous infusion therapy (e.g., epoprostenol); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9348	Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., Dobutamine); administrative services, professional pharmacy services, care coordination, all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
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.
S9353	Home infusion therapy, continuous insulin infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9355	Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9357	Home infusion therapy, enzyme replacement intravenous therapy; (e.g., Imiglucerase); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9359	Home infusion therapy, antitumor necrosis factor intravenous therapy; (e.g., Infliximab); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.

TPN S-codes and additional infusion codesHCPCSCovered

S9361	Home infusion therapy, diuretic intravenous therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9363	Home infusion therapy, antispasmotic therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9364	Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem (do not use with home infusion codes S9365-S9368 using daily volume scales).
S9365	Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem.
S9366	Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem.
S9367	Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem.
S9368	Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem.

Additional home infusion and therapy S-codesHCPCSCovered

S9370	Home therapy, intermittent antiemetic injection therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9372	Home therapy; intermittent anticoagulant injection therapy (e.g., Heparin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code for flushing of infusion devices with Heparin to maintain patency).
S9373	Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use with hydration therapy codes S9374-S9377 using daily volume scales).
S9374	Home infusion therapy, hydration therapy; 1 liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9375	Home infusion therapy, hydration therapy; more than 1 liter but no more than 2 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9376	Home infusion therapy, hydration therapy; more than 2 liters but no more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9377	Home infusion therapy, hydration therapy; more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies (drugs and nursing visits coded separately), per diem.
S9379	Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9474	Enterostomal therapy by a registered nurse certified in enterostomal therapy, per diem.
S9490	Home infusion therapy, corticosteroid infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.

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Home injectable, transfusion, and other therapy S-codesHCPCSCovered

S9537	Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, G-CSF, GM-CSF); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9538	Home transfusion of blood product(s); administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (blood products, drugs, and nursing visits coded separately), per diem.
S9542	Home injectable therapy, not otherwise classified, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9559	Home injectable therapy, interferon, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9560	Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9562	Home injectable therapy, palivizumab or other monoclonal antibody for RSV, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9590	Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.

Home health T-codesHCPCSCovered

T1001	Nursing assessment/evaluation.
T1002	RN services, up to 15 minutes.
T1003	LPN/LVN services, up to 15 minutes.
T1004	Services of a qualified nursing aide, up to 15 minutes.
T1005	Respite care services, up to 15 minutes.
T1021	Home health aide or certified nurse assistant, per visit.
T1022	Contracted home health agency services, all services provided under contract, per day.
T1028	Assessment of home, physical and family environment, to determine suitability to meet patient's medical needs.
T1030	Nursing care, in the home, by registered nurse, per diem.
T1502	Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit.

Time threshold — 99601/99602 per visit (up to 2 hours) and each additional hour

Per-visit base timeCPT 99601 — Home infusion/specialty drug administration, per visit (up to 2 hours)

Additional hourCPT 99602 — Home infusion/specialty drug administration; each additional hour (list separately in addition to primary procedure)

Coding note99601 is reported per visit covering up to 2 hours; 99602 reports each additional hour beyond the 2-hour visit

Intermittent care typical duration — Typically provided for less than four hours per day

Typical duration

Provider Actions and Prior Authorization

Prior Authorization

InterQual requirement — Medical necessity

For medical necessity clinical coverage criteria, refer to the InterQual® LOC: Home Care (Home Care Services, Adult; Home Care Services, Pediatric). Services that do not meet InterQual LOC: Home Care criteria may be considered not medically necessary and may be denied.

InterQual LOC: Home Care — Home Care Services, Adult; Home Care Services, Pediatric

Note

Benefit document and definitions

Refer to the member specific benefit plan document for definitions that may differ by plan, including Place of Residence and Respite Care.

Place of Residence: Wherever the member makes his/her home (may include dwelling, apartment, relative's home, or facility-based long-term care residence).
Respite Care: Short-term relief for primary caregivers; may be provided at the Place of Residence, in a facility, or at an adult day care center.

Definitions

Place of Residence — Definition of place of residence including dwelling, assisted living, nursing home, continuing care retirement community

DefinitionPlace of Residence — Wherever the member makes his/her home; may include a dwelling, apartment, relative's home, board and care home, assisted living facility, nursing home, or continuing care retirement community

Plan varianceDefinitions may not apply to all plans; refer to the member-specific benefit plan document for applicability

ExamplesIncludes facility-based long-term care residences such as assisted living and nursing homes

Respite Care — Short-term relief for primary caregivers provided at the member's residence, facility, or adult day care

DefinitionRespite Care — Short-term relief for primary caregivers provided at the member's Place of Residence, in a healthcare facility, or at an adult day care center

Background

Home health and skilled care provide medically necessary services delivered in the member's place of residence when clinical and administrative criteria are met. Medical necessity is determined using InterQual LOC: Home Care for adult and pediatric care; services must be ordered and directed by a treating practitioner and delivered or supervised by licensed professionals. Typical home health services are intermittent and part‑time (typically <4 hours/day) unless specific clinical circumstances justify otherwise.

Revision History

2026-01-01template_updateLatest

Created shared policy version to support application to Oxford plan membership and archived previous policy versions MP.022.26 and HOME 002.45.

OpenPayer

Home Health, Skilled, and Custodial Care Services