CurrentUnitedHealthcarePolicy CS137KY.10

Home Health Care Services (for Kentucky Only)

Defines coverage and medical necessity criteria, applicable codes, and instructions for home health care services (including skilled nursing, home infusion, home therapy, and home visits) specific to Kentucky, referencing Kentucky Administrative Regulations and InterQual LOC for detailed criteria and hours determination.

Policy Summary

PayerUnitedHealthcare

PolicyHome Health Care Services (for Kentucky Only)

Policy CodePolicy CS137KY.10

Change TypeRevisions (KAR clarificationInterQual hourscode removal)

Effective DateAug 1, 2025

Next Review Date

Key ActionProviders must reference KAR Title 907, Chapter 001, Regulation 030 for regulatory requirements, medical necessity criteria, limitations, and exclusions when determining eligibility for home health agency services in Kentucky.

SourceLink

POLICY UPDATE CHANGES

Related Policies Added reference link to the Medical Policy titled Chelation Therapy (for Kentucky Only).

Replaced instruction to 'refer to KAR ... for regulatory requirements, limitations, and exclusions' with 'refer to KAR ... for regulatory requirements, medical necessity criteria, limitations, and exclusions'.

Added instruction to refer to InterQual LOC: Home Care Q & A for determination of hours once medical necessity has been determined for PT/OT/SLP.

Removed CPT code 99512 from Applicable Codes.

Archived previous policy version CS137KY.09.

1State-Specific Policy (Kentucky Only)

100+Listed Procedure/Service Codes

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Coverage Summary

This policy applies only to the state of Kentucky and defines coverage and medical necessity criteria, applicable procedure and supply codes, and instructions for Home Health Care Services (including skilled nursing, home infusion, home therapy, and home visits). Providers must reference KAR Title 907, Chapter 001, Regulation 030 for regulatory requirements, medical necessity criteria, limitations, and exclusions for home health agency services in Kentucky. Once medical necessity has been determined for physical therapy, occupational therapy, speech therapy, or skilled nursing, providers must use InterQual LOC: Home Care Q & A (Home Care Services, Adult or Pediatric) to determine the number of authorized hours.

Home Health Care Services are short-term, prescribed services delivered in a member’s residence to aid recovery after illness, injury, hospitalization, or to manage chronic conditions and to prevent or delay hospitalization. The policy lists applicable CPT/HCPCS/S/T/G codes for reference and instructs how state regulations and InterQual criteria are used together for coverage and hours determination.

Policy Metadata

Policy NumberCS137KY.10

Effective Date2025-08-01

Last Reviewed2025-08-01

Next Review

StateKentucky

Medical-Necessity Criteria

Application

This Medical Policy only applies to the state of Kentucky:

State restriction: Policy applies only to Kentucky state members

Home Physical Therapy, Occupational Therapy, Speech Therapy

Coverage governed by state regulations and InterQual for hours:

Home PT/OT/SLP criteria and hours

State medical necessity: Refer to Kentucky Administrative Regulations (KAR) Title 907, Chapter 001, Regulation 030 for regulatory requirements, medical necessity criteria, limitations, and exclusions for home health agency services
KAR reference per policy

Applicable Codes

CPT / HCPCS / S / T / G codes listed for referencemixed

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 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) (eg, 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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Provider Actions & Requirements

Documentation Required

Use Kentucky Regulations for medical necessity

Providers must reference KAR Title 907, Chapter 001, Regulation 030 for regulatory requirements, medical necessity criteria, limitations, and exclusions when determining eligibility for home health agency services in Kentucky.

KAR Title 907, Chapter 001, Regulation 030

Documentation Required

Use InterQual LOC to determine hours

Once medical necessity is met for PT/OT/SLP or skilled nursing, providers must use the InterQual LOC: Home Care Q & A (Home Care Services, Adult or Pediatric) to determine the number of hours authorized.

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

Background

Home health care services are short-term services prescribed by a treating practitioner and delivered in a member’s residence to help a member recover after an illness, injury, hospital stay, or surgery, or to manage a chronic condition with the goal of preventing an unplanned hospitalization or prolonging a current hospitalization. These services are provided intermittently to restore or maintain a member’s maximal level of function and health in lieu of receiving services in an outpatient, acute, or sub-acute setting.

Services include, but are not limited to, skilled nursing, home infusion, home therapy (physical, occupational, speech), home health aide services, and specified home visit procedures. Coverage and hours are determined by Kentucky Administrative Regulations and the InterQual LOC: Home Care Q & A once medical necessity has been established.

Home Health Care Services: Short-term services prescribed by a treating practitioner and delivered within a member’s residence to help recover after illness, injury, hospital stay, or surgery, or to manage chronic conditions; provided intermittently to restore or maintain maximal function.

Revision History

08/01/2025revisedLatest

Related Policies: Added reference link to the Medical Policy titled Chelation Therapy (for Kentucky Only).

08/01/2025revisedLatest

Replaced instruction to 'refer to the Kentucky Administrative Regulations (KAR) Title 907, Chapter 001, Regulation 030 for regulatory requirements, limitations, and exclusions for home health agency services' with 'refer to KAR Title 907, Chapter 001, Regulation 030 for regulatory requirements, medical necessity criteria, limitations, and exclusions for home health agency services'. (is_material: true)