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    v1.0.30
    OpenPayerPolicy UpdatesHome Health & HospiceUnitedHealthcare Home Health Coverage | OpenPayer
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    ModifiedUnitedHealthcarePolicy CS137KS.04

    Home Health, Skilled, and Custodial Care Services (for Kansas Only)

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    This policy governs coverage of home health, skilled, and custodial care services under the UnitedHealthcare Community Plan in Kansas. Medical necessity criteria are directed to the Kansas Medical Assistance Program Home Health Agency Fee-For-Service Provider Manual.

    Policy Summary
    PayerUnitedHealthcare
    PolicyHome Health, Skilled, and Custodial Care Services (for Kansas Only)
    Policy CodePolicy CS137KS.04
    Change TypeModified
    Effective DateSeptember 1, 2026
    Next Review DateNot specified
    Key ActionEnsure the medical record fully supports the medical necessity of requested services and is available upon request.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    Medical-record documentation requirements were added for reviews of requested services.

    The policy clarified that benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

    The definition of Conductive Hearing Loss was updated.

    Fourteen CPT and HCPCS codes for fitting and testing of hearing aids were removed from the applicable codes.

    The Clinical Evidence, FDA, and References sections were updated and the prior policy version CS137KS.03 was archived.

    KansasGeographic application
    1External criteria source
    100+Codes listed for reference
    2Related policies
    14Codes removed
    InsufficientFDA approval limitation

    Medical Necessity and Coverage Criteria

    Medical necessity criteria

    For medical necessity clinical coverage criteria, refer to the Kansas Medical Assistance Program: Home Health Agency Fee-For-Service Provider Manual.

    External medical necessity criteria: Apply the medical necessity clinical coverage criteria in the Kansas Medical Assistance Program Home Health Agency Fee-For-Service Provider Manual.

    The criteria are not reproduced in this policy.

    FDA approval alone is not a basis for coverage. Home health care, including skilled care, is rendered by licensed health care professionals and is not subject to FDA regulation; therefore, FDA approval by itself does not establish coverage.

    Applicable Procedure and HCPCS Codes

    Applicable CPT CodesCPT
    99500Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring.
    99501Home visit for postnatal assessment and follow-up care.
    99502Home visit for newborn care and assessment.
    99503Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation).
    99504Home visit for mechanical ventilation care.
    99505Home visit for stoma care and maintenance including colostomy and cystostomy.
    99506Home visit for intramuscular injections.
    99507Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral).
    99511Home visit for fecal impaction management and enema administration.
    99601Home infusion/specialty drug administration, per visit (up to 2 hours).
    Applicable HCPCS CodesHCPCS
    G0068Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour.
    G0069Professional 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.
    G0070Professional 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.
    G0088Professional services, initial visit, for administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological, each 15 minutes.
    G0090Professional services, initial visit, for administration of intravenous chemotherapy or other highly complex infusion drug or biological, each 15 minutes.
    G0155Services of clinical social worker in home health or hospice settings, each 15 minutes.
    G0156Services of home health/hospice aide in home health or hospice settings, each 15 minutes.
    G0157Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes.
    G0158Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes.
    G0160Services performed by a qualified occupational therapist in the home health setting in establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes.
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    Applicable HCPCS CodesHCPCS
    G0320Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system.
    G0321Home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system.
    G0322Collection of physiologic data digitally stored or transmitted by the patient to the home health agency, including remote patient monitoring.
    G0493Skilled services of a registered nurse for observation and assessment of the patient's condition, each 15 minutes.
    G0494Skilled services of a licensed practical nurse for observation and assessment of the patient's condition, each 15 minutes.
    G0495Skilled services of a registered nurse in training or education of a patient or family member, each 15 minutes.
    G0496Skilled services of a licensed practical nurse in training or education of a patient or family member, each 15 minutes.
    G2168Services performed by a physical therapist assistant in the home health setting in delivery of a safe and effective physical therapy maintenance program, each 15 minutes.
    G2169Services performed by an occupational therapist assistant in the home health setting in delivery of a safe and effective occupational therapy maintenance program, each 15 minutes.
    H1004Prenatal care, at-risk enhanced service; follow-up home visit.
    1–10 of 15
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    Applicable HCPCS CodesHCPCS
    S5111Home care training, family; per session.
    S5115Home care training, nonfamily; per 15 minutes.
    S5116Home care training, nonfamily; per session.
    S5180Home health respiratory therapy, initial evaluation.
    S5181Home health respiratory therapy, NOS, per diem.
    S5497Home infusion therapy, catheter care/maintenance, not otherwise classified; includes administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment, per diem.
    S5498Home infusion therapy, catheter care/maintenance, simple single lumen, including administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment, per diem.
    S5501Home infusion therapy, catheter care/maintenance, complex more than one lumen, including administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment, per diem.
    S5517Home infusion therapy, all supplies necessary for restoration of catheter patency or declotting.
    S5518Home infusion therapy, all supplies necessary for catheter repair.
    1–10 of 17
    1/2
    Applicable HCPCS CodesHCPCS
    S9122Home health aide or certified nurse assistant, providing care in the home; per hour.
    S9123Nursing care in the home by registered nurse, per hour.
    S9124Nursing care in the home by licensed practical nurse, per hour.
    S9127Social work visit in the home, per diem.
    S9128Speech therapy in the home, per diem.
    S9129Occupational therapy in the home, per diem.
    S9131Physical therapy in the home, per diem.
    S9208Home management of preterm labor, including administrative services, professional pharmacy services, care coordination, and necessary supplies or equipment, per diem.
    S9209Home management of preterm premature rupture of membranes, including administrative services, professional pharmacy services, care coordination, and necessary supplies or equipment, per diem.
    S9211Home management of gestational hypertension, including administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment, per diem.
    1–10 of 13
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    Applicable HCPCS CodesHCPCS
    S9325Home infusion therapy, pain management infusion; administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment, per diem.
    S9326Home infusion therapy, continuous pain management infusion for 24 hours or more, per diem.
    S9327Home infusion therapy, intermittent pain management infusion for less than 24 hours, per diem.
    S9328Home infusion therapy, implanted pump pain management infusion, per diem.
    S9329Home infusion therapy, chemotherapy infusion, per diem.
    S9330Home infusion therapy service, professional pharmacy services, care coordination, and necessary supplies and equipment, per diem.
    S9331Home infusion therapy service, professional pharmacy services, care coordination, and necessary supplies and equipment, per diem.
    S9335Home infusion therapy service including care coordination and necessary supplies and equipment, per diem.
    S9336Home infusion therapy service including professional pharmacy services, care coordination, and necessary supplies and equipment, per diem.
    S9338Home infusion therapy service including care coordination and necessary supplies and equipment, per diem.
    1–10 of 20
    1/2
    Applicable HCPCS Codes—Home Infusion TherapyHCPCS
    S9345Home infusion therapy, antihemophilic agent infusion therapy (e.g., factor VIII); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
    S9346Home 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.
    S9347Home 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.
    S9348Home 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.
    S9351Home 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.
    S9353Home 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.
    Applicable HCPCS Codes—Home Therapy and Infusion ServicesHCPCS
    S9370Home 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.
    S9372Professional 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.
    S9373Home 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.
    S9374Home 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.
    S9375Home 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.
    S9474Enterostomal therapy by a registered nurse certified in enterostomal therapy, per diem.
    S9490Home 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.
    S9497-S9504Home infusion therapy, antibiotic, antiviral, or antifungal therapy, with hourly dosing schedules; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
    S9538Home 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.
    S9542Home 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.
    1–10 of 13
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    Applicable HCPCS Codes—Nursing and Home Health ServicesHCPCS
    S9590Home 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.
    T1001Nursing assessment/evaluation.
    T1002RN services, up to 15 minutes.
    T1003LPN/LVN services, up to 15 minutes.
    T1004Services of a qualified nursing aide, up to 15 minutes.
    T1021Home health aide or certified nurse assistant, per visit.
    T1022Contracted home health agency services, all services provided under contract, per day.
    T1028Assessment of home, physical and family environment, to determine suitability to meet patient's medical needs.
    T1030Nursing care, in the home, by registered nurse, per diem.
    T1502Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit.

    Documentation, Coverage, and Billing Guidance

    Documentation Required

    Medical-Record Documentation Required

    Ensure the patient's medical record fully supports the medical necessity of the requested services. Documentation should be legible, maintained in the medical record, and made available upon request; it may be required to assess clinical criteria but does not guarantee coverage.

    • Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
    Billing Rule

    Code Listing Does Not Guarantee Coverage

    Code listings are provided for reference only and may not be all inclusive. Listing a code does not establish that the service is covered or non-covered, create a right to reimbursement, or guarantee claim payment.

    Policy Scope and Service Context

    This policy addresses home-based skilled nursing, therapy, aide services, home infusion, respiratory care, wound care, telemedicine, remote physiologic monitoring, and related home health or hospice services, including skilled and custodial care under the UnitedHealthcare Community Plan in Kansas. Medical necessity criteria are incorporated by reference to the Kansas Medical Assistance Program Home Health Agency Fee-for-Service Provider Manual rather than reproduced in this policy.

    Policy Summary
    PayerUnitedHealthcare
    PolicyHome Health, Skilled, and Custodial Care Services (for Kansas Only)
    Policy CodePolicy CS137KS.04
    Change TypeModified
    Effective DateSeptember 1, 2026
    Next Review DateNot specified
    Key ActionEnsure the medical record fully supports the medical necessity of requested services and is available upon request.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaApplicable Procedure and HCPCS CodesDocumentation, Coverage, and Billing GuidancePolicy Scope and Service Context
    Note

    FDA Approval Does Not Establish Coverage

    FDA approval alone is not a basis for coverage. Home health care, including skilled care, is rendered by licensed health care professionals and is not subject to FDA regulation.

    Billing Rule

    Applicable Benefit Requirements Control

    Apply the federal, state, or contractual benefit requirements and applicable laws when determining coverage. If those requirements conflict with this policy, the applicable benefit requirements govern; verify them before using this policy.