CurrentUnitedHealthcarePolicy CS137OH.E

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

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Policy governing medical necessity, coverage, and applicable billing codes for home health, skilled, and custodial care services for UnitedHealthcare Community Plan members in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyHome Health, Skilled, and Custodial Care Services (for Ohio Only)

Policy CodePolicy CS137OH.E

Change TypeReferences updatedprior version archived

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionVerify medical necessity using InterQual LOC: Home Care Q & A and comply with Ohio Administrative Code 5160-101 when requesting prior authorization.

SourceLink

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CurrentUnitedHealthcarePolicy CS137OH.E

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

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Policy governing medical necessity, coverage, and applicable billing codes for home health, skilled, and custodial care services for UnitedHealthcare Community Plan members in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyHome Health, Skilled, and Custodial Care Services (for Ohio Only)

Policy CodePolicy CS137OH.E

Change TypeReferences updatedprior version archived

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionVerify medical necessity using InterQual LOC: Home Care Q & A and comply with Ohio Administrative Code 5160-101 when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

Supporting information updated in References; previous policy version CS137OH.D archived.

Ohio-onlyState applicability

InterQual LOCClinical criteria source

100+CPT/HCPCS codes provided

04/21/2026Reference update

Coverage Criteria

Medical necessity (referenced InterQual criteria)

Covered when medical necessity is met per InterQual and Ohio Administrative Code

General coverage pathway: Home health and skilled care services are considered medically necessary when ALL medical necessity criteria in InterQual LOC: Home Care Q & A (Adult or Pediatric) are met and any Ohio-specific requirements (Ohio Administrative Code 5160-101) for services stated as unproven or with limits are satisfied.

InterQual LOC: Home Care Q & A is the primary clinical criteria source referenced by this policy; Ohio Administrative Code 5160-101 applies for unproven services or those with coverage/quantity limits.

General coverage criteria

Covered when services are prescribed and meet applicable medical necessity and state/contractual rules

General coverage conditions: Service is prescribed by an MD, DO, PA, or NP; delivered in the member's residence; intended to restore or maintain function or manage chronic conditions and prevent or shorten hospitalization; and meets applicable Ohio Administrative Code (e.g., Rule 5160-12-01) and InterQual criteria when applicable.

Documentation should support that skilled care is intermittent, ordered by an authorized prescriber, and meets InterQual/OAC medical necessity criteria.

The list of procedure and diagnosis codes included in this policy is provided for reference only. Listing of a code does not imply that the service described by the code is a covered health service. Benefit coverage and reimbursement are determined by applicable federal, state, or contractual requirements and laws; inclusion in this list is not a guarantee of payment.

For informational purposes only: home health and skilled care are services delivered by licensed health care professionals and are not regulated by the U.S. Food and Drug Administration (FDA). FDA approval or regulation does not determine coverage for these services under this policy.

Services described in this policy as unproven, or services that do not meet the medical necessity requirements of InterQual and Ohio Administrative Code 5160-101, may be considered not medically necessary and therefore not covered. Providers should note that code listing alone does not establish coverage; requests for such services will be evaluated against Ohio Administrative Code requirements and InterQual clinical criteria before a coverage determination is made.

Coding and Procedure Codes

Reference 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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Reference HCPCS / S codesHCPCS

G0151	Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological ... each 15 minutes.
G0152	Professional services for the administration of subcutaneous immunotherapy or other subcutaneous home, each 15 minutes.
G0153	Services performed by a qualified occupational therapist 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.
G0158	Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes.
G0159	Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes.
G0160	Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, 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.
G0162	Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential nonskilled care achieves its purpose in the home health or hospice setting).

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Home infusion and TPN HCPCSHCPCSCovered

S9366	Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous = Home infusion therapy, total parenteral nutrition (TPN); up to two liters per day, administrative services, professional pharmacy services, care coordination, and supplies, 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.
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

Miscellaneous home infusion, therapy, and nursing service codesHCPCSCovered

S9474	Enterostomal therapy by a registered nurse certified in enterostomal therapy, per diem
S9502	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9503	Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
S9504	Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
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.
T1002	Nursing assessment/evaluation. 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.
T1021	Home health aide or certified nurse assistant, per visit.
T1022	Contracted home health agency services, all services provided under contract, per day.

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TPN volume thresholds (S9365–S9368)

S9365TPN daily volume band: up to 1.0 liter per day (one liter); administrative services, pharmacy services, care coordination, and supplies, per diem.

S9366TPN daily volume band: more than 1.0 liter up to 2.0 liters per day; administrative services, pharmacy services, care coordination, and supplies, per diem.

S9367TPN daily volume band: more than 2.0 liters up to 3.0 liters per day; administrative services, pharmacy services, care coordination, and supplies, per diem.

S9368TPN daily volume band: more than 3.0 liters per day; administrative services, pharmacy services, care coordination, and supplies, per diem.

TPN and hydration volume thresholds — delineation by daily volume

Provider Actions and Prior Authorization

Prior Authorization

InterQual + Ohio rule-based prior authorization

Medical necessity for home health and skilled care in Ohio is determined using InterQual LOC: Home Care Q & A; services stated as unproven or with coverage/quantity limits will be evaluated under Ohio Administrative Code 5160-101 and may require prior authorization.

Use InterQual LOC: Home Care Q & A (Adult and Pediatric) to evaluate level-of-care and medical necessity.
Services described as unproven or with limits are evaluated per Ohio Administrative Code 5160-101 and may require authorization.

Prior Authorization

Verify code-level prior authorization requirements

Verify plan-specific prior authorization requirements at the code level before submitting claims for listed HCPCS/home infusion and nursing service codes; the policy provides numerous applicable HCPCS/T and S codes that may be subject to prior authorization.

Confirm prior authorization rules for HCPCS codes such as S9366–S9368, S9370, S9474, S9502–S9504, S9537 and nursing codes T1002–T1030 before billing.

Background

Home health and skilled care services provide nursing, therapy, infusion, and other supportive services in the member's residence for individuals who meet medical necessity criteria. These services are intended to restore or maintain function, manage chronic conditions, and help prevent or shorten hospitalizations. Medical necessity for home care is determined using the InterQual LOC: Home Care Q & A clinical criteria (adult and pediatric) and must also satisfy applicable Ohio Administrative Code requirements.

Definitions

InterQual LOC: Home Care Q & A — referenced clinical criteria set

Referenced clinical criteria setInterQual LOC: Home Care Q & A (Adult and Pediatric modules)

Use for medical necessityMedical necessity determinations for home health and skilled care reference InterQual LOC: Home Care Q & A as the primary clinical criteria source.

State rule interactionRequests for unproven services or those with limits are evaluated per Ohio Administrative Code 5160-101 in conjunction with InterQual criteria.

Skilled care services — definition and examples

DefinitionSkilled care services are medically necessary services provided in the member's residence by licensed health care professionals.

ExamplesMay include medical or psychological evaluation, wound care, medication teaching, pain management, disease education and management, and therapies (physical, speech, occupational).

Policy Summary

PayerUnitedHealthcare

PolicyHome Health, Skilled, and Custodial Care Services (for Ohio Only)

Policy CodePolicy CS137OH.E

Change TypeReferences updatedprior version archived

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionVerify medical necessity using InterQual LOC: Home Care Q & A and comply with Ohio Administrative Code 5160-101 when requesting prior authorization.

SourceLink

On This Page

TPN codes (volume-based)TPN HCPCS codes S9365–S9368 are delineated by daily total parenteral nutrition volume: up to 1 L; >1–2 L; >2–3 L; and >3 L per day (each billed per diem with associated administrative, pharmacy, coordination, and supply components).

Hydration therapy codes (volume-based)Hydration HCPCS codes use the same daily volume scale: 1 L; >1–2 L; >2–3 L; and >3 L per day, with drugs and nursing visits coded separately and per diem reimbursement for administrative/pharmacy/care coordination and supplies.

Do not combine codesHydration codes S9374–S9377 reference daily volume bands and should not be used concurrently with non-volume hydration codes for the same service/day (drugs and nursing visits are coded separately).

Listing of a code in the policy is reference only and does not guarantee coverage or authorization.

Note

Provider actions — summary reminder

Follow the documentation, prescribing, and medical necessity requirements described below to support coverage and authorization decisions.

Document services using the CPT/HCPCS codes listed in the policy when applicable.
Ensure clinical documentation supports the code-level service billed.

Step Therapy

InterQual-based clinical criteria and step requirements

InterQual is the primary medical/surgical criteria used to determine coverage and may define required steps of care prior to authorization or coverage decisions.

If InterQual criteria apply, use its step and level-of-care logic to establish medical necessity and any required prior steps of care.
If InterQual lacks applicable criteria, UnitedHealthcare may use approved Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines.

Documentation Required

Document services using listed CPT/HCPCS codes

Providers must document services using the CPT/HCPCS codes listed in the policy; inclusion of a code is for reference only and does not guarantee coverage—benefit coverage is determined by federal, state, or contractual requirements.

Use the policy’s code lists when assigning billing codes, but verify coverage and reimbursement eligibility against applicable benefit rules.
Do not assume listing implies reimbursement or authorization.

Documentation Required

Prescriber and medical necessity documentation requirements

Home health services must be prescribed by an MD, DO, PA, or NP and documented as intermittent skilled care delivered in the member’s residence; documentation should support medical necessity per Ohio Administrative Code and InterQual criteria.

Ensure the prescriber (MD, DO, PA, or NP) documents the order and clinical rationale that services are intermittent skilled care in the member’s residence.
Include documentation that satisfies InterQual LOC and Ohio Administrative Code 5160-101 where applicable.

Denial Risk

Denial risk for unproven or limited services

Requests for services described as unproven or for services that have coverage or quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-101 and may be denied if Ohio administrative medical necessity is not met.

When submitting requests for unproven services or services with limits, include documentation addressing Ohio Administrative Code 5160-101 criteria.
Failure to meet Ohio administrative medical necessity criteria may trigger denial.

Note

Follow federal, state (OAC), or contractual precedence

When this policy differs from federal, state (Ohio Administrative Code), or contractual requirements, the federal, state (OAC) or contractual requirements govern; verify and follow those requirements to avoid coverage denial.

Check applicable federal, OAC, or contractual plan terms before relying on this policy for coverage decisions.
If a conflict exists, follow the governing federal, state (OAC), or contractual requirement.

PurposeDelivered intermittently to restore or maintain function, manage chronic conditions, and help prevent or shorten hospitalization.

Custodial care services — definition and nonmedical nature

DefinitionCustodial care services are nonmedical services that provide assistance with personal care (activities of daily living), housekeeping, cooking, or laundry, or supervision of self-administered medication that can be provided by nonlicensed caregivers.

Nonmedical natureServices are custodial in nature and do not require licensed clinical professionals to perform; they focus on daily living support rather than clinical treatment.

ExamplesAssistance with ADLs, household tasks (housekeeping, cooking, laundry), and supervision of self-administered medication.