UnitedHealthcare Home Health Coverage Update

Coverage and Medical Necessity Criteria

Medical necessity (InterQual referenced)

Covered when ALL of the following are met

InterQual-based medical necessity: Home health and skilled care services are considered medically necessary in certain circumstances per InterQual LOC: Home Care; providers must refer to InterQual criteria for the specific clinical requirements.

This policy references InterQual LOC: Home Care for detailed clinical criteria; the InterQual rules determine medical necessity.

Initial Home Health Coverage Criteria

Covered when ALL of the following are met:

Home health general medical necessity: Care is ordered and directed by a treating practitioner or specialist and delivered or supervised by a licensed professional; services are intermittent and part-time (typically <4 hrs/day); services are clinically appropriate and not more costly than alternatives; provided in the home in lieu of skilled care in another setting; not custodial or for comfort/convenience.< 4 hours/day

Intermittent care exceptions may be made when need for more care is finite and predictable.

Skilled services included: Skilled care includes skilled rehabilitation (physical, occupational, and speech therapy), skilled nursing, and skilled teaching.

Therapies provided by independent therapists in the home may be covered under outpatient rehabilitation rather than the home health benefit.

Skilled Therapy Coverage

Covered therapy conditions:

Skilled rehabilitation or therapy: Physical, occupational, and speech therapy delivered in the home must require clinical training to be delivered safely and effectively to be covered under the home health benefit; if received from an independent therapist, coverage may fall under the outpatient rehabilitation benefit.

Therapy provided in the home by a home health agency is covered under the home health benefit; care from an independent therapist is billed to outpatient rehabilitation benefit per member plan.

The inclusion of a procedure or diagnosis code in this policy is for reference only and does not imply that the service described by the code is covered. Benefit coverage for any service is determined by the member-specific benefit plan document and applicable laws, which may require coverage for a particular service. The listing of a code is not a guarantee of reimbursement or claim payment; other policies and guidelines may apply.

The home health benefit does not include services that are domiciliary in nature or otherwise excluded by the member's benefit plan. Examples of services excluded from home health benefits include domiciliary care, respite care, private duty nursing, rest cures, Dial-a-Ride, services provided by unlicensed caregivers or personal care attendants, and independent nurses hired directly by the family or member. Coverage for pharmaceuticals, drugs, and durable medical equipment supplied in connection with home health may be governed under separate benefit categories in the member-specific plan.

Services that are primarily custodial in nature or that do not meet the requirement for skilled, physician-directed medical management are not considered medically necessary under the home health benefit and will be denied. Custodial care—assistance with activities of daily living, supervision, or nonmedical personal care that can be provided by non-licensed caregivers—is excluded from home health coverage. UnitedHealthcare will assess whether a service meets the skilled care standard and requires physician-directed medical management when determining benefit eligibility.

Applicable Codes and Coding Guidance

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 Codes (selected examples)HCPCS

G0068	Professional services for the administration of anti-infective, 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 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.
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes.
G0161	Services performed by a qualified speech-language pathologist in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program; each 15 minutes.
G0320	Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system.
S5497	Home infusion therapy, catheter care/maintenance, not otherwise classified; includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S5501	Home infusion therapy, catheter care/maintenance, complex (more than one lumen), includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S5520	Home infusion therapy, all supplies necessary for restoration of catheter patency or declotting.
S9340	Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula 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, per diem.

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Applicable HCPCS-like home infusion and therapy codesHCPCS

S9368	Home infusion therapy; total parenteral nutrition (TPN); more than three liters per administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula, per diem.
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; liter per 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 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 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 administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9379	Home infusion therapy; 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.

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Home health/visit and nursing CPT-like codesHCPCS

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.
T1031	Nursing care, in the home, by licensed practical nurse, per diem.

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TPN volume categories

S9365TPN — 1 liter per day

S9366TPN — more than 1 L but no more than 2 L per day

S9367TPN — more than 2 L but no more than 3 L per day

S9368TPN — more than 3 L per day

Typical daily service intensity

Service intensityIntermittent and part-time — typically provided for less than four hours per day

Provider Requirements, Prior Authorization, and Billing Guidance

Prior Authorization

Prior Authorization/Clinical Criteria

Prior authorization may be required for home health and home care services per the member-specific benefit plan and InterQual criteria. Refer to the member's benefit document to confirm prior authorization requirements and applicable InterQual LOC references.

When prior authorization is required, submit clinical documentation demonstrating medical necessity consistent with InterQual (Home Care) or equivalent criteria.

Billing Rule

Applicable Codes — Use Appropriately

The following codes are provided for reference only. Listing of a code in this policy does not imply the service is covered. Use codes only as appropriate to the service rendered and the member-specific benefit plan.

Ensure coding reflects the actual services rendered and the level of clinical complexity.

Key Definitions

Respite Care definition

DefinitionShort-term relief for primary caregivers that can be provided at the member's place of residence, in a healthcare facility, or at an adult care center; relief period can range from an afternoon up to several weeks

Benefit applicabilityRespite care is listed as not included in home health benefits and may be excluded from coverage depending on the member-specific plan

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

Skilled care definition

DefinitionMedically necessary services provided in the member's residence by licensed health care professionals that require clinical training (e.g., skilled nursing, skilled rehabilitation, skilled teaching)

Examples

Background and Scope

This policy relies on the InterQual Level of Care (LOC): Home Care criteria when determining the medical necessity of home health and skilled care services. Per the InterQual guidance, home health and skilled care services may be considered medically necessary in certain circumstances; providers must refer to the InterQual LOC: Home Care for the specific clinical requirements that must be met to support coverage.

OpenPayer

Home Health, Skilled Care, Respite and Home Infusion Services

Coverage and Medical Necessity Criteria

Applicable Codes and Coding Guidance

Provider Requirements, Prior Authorization, and Billing Guidance

Key Definitions

Background and Scope