CurrentUniversity of Utah Health PlansPolicy PHARM-M026

Place of Service for Pharmaceutical Infusions

Customize your policy alerts

Sign up for universityofutahhealthplans Policy PHARM-M026 alerts

Get alerted when Policy PHARM-M026 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs the medically appropriate and preferred site of care for intravenous pharmaceutical infusion therapy. It applies to University of Utah Health Plans commercial and MHC lines of business and directs infusions to the lowest safe, cost-effective setting unless hospital-based care is medically necessary.

Policy Summary

PayerUniversity of Utah Health Plans

PolicyPlace of Service for Pharmaceutical Infusions

Policy CodePolicy PHARM-M026

Change TypeNo material change

Effective DateMay 1, 2025

Last ReviewApr 9, 2025

Next Review DateApril 9, 2026

Key ActionObtain prior authorization before providing services that require it.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

OutpatientPreferred infusion setting

9Hospital-based exception criteria

≤13 yearsAge criterion

50 milesOutpatient access distance

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.

CurrentUniversity of Utah Health PlansPolicy PHARM-M026

Place of Service for Pharmaceutical Infusions

Customize your policy alerts

Sign up for universityofutahhealthplans Policy PHARM-M026 alerts

Get alerted when Policy PHARM-M026 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerUniversity of Utah Health Plans

PolicyPlace of Service for Pharmaceutical Infusions

Policy CodePolicy PHARM-M026

Change TypeNo material change

Effective DateMay 1, 2025

Last ReviewApr 9, 2025

Next Review DateApril 9, 2026

Key ActionObtain prior authorization before providing services that require it.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

OutpatientPreferred infusion setting

9Hospital-based exception criteria

≤13 yearsAge criterion

50 milesOutpatient access distance

Interval since last infusion

Not medically necessaryUnqualifying hospital infusion

Pharmaceutical Infusion Coverage Criteria

General Pharmaceutical Infusion Coverage

Pharmaceutical infusion coverage is provided when medically necessary based on Health Plan Criteria. Certain intravenous (IV) infusion therapies must be administered through a preferred vendor and at a preferred site of care.

ALL of the following

Pharmaceutical infusion is determined to be medically necessary based on Health Plan Criteria.
When required by the University of Utah Health Plans, intravenous (IV) infusion therapy is administered at a preferred vendor and preferred site of care.
The infusion is delivered in an outpatient setting, such as home infusion, an ambulatory infusion center, or a provider office, unless a hospital-based setting (inpatient or outpatient) is medically necessary.

Hospital-Based Site-of-Care Exception

Medical necessity for a hospital-based setting may be established when the member meets ONE of the following criteria:

ONE of the following

Member is 13 years of age or younger.≤ 13 years
Member is medically unstable per clinical documentation.
Medication has a high risk of immediate life-threatening toxicities, including anaphylaxis, seizure, thromboembolism, myocardial infarction, or renal failure.
Member has a history of mild adverse events that have not been successfully managed with pre-medications such as antihistamines, corticosteroids, or intravenous fluids.
Member has co-morbidities that place the member at increased risk for severe adverse events, including unstable renal function, cardiopulmonary conditions, or unstable vascular access.

Inpatient and hospital outpatient infusion, in the absence of the clinical indications listed above, is not considered medically necessary.

An inpatient admission for the sole purpose of IV infusion is not medically necessary.

Hospital infusion without the specified clinical indications or applicable access limitations is not covered.

An inpatient admission solely to administer an IV infusion is not medically necessary.

Operational Thresholds

Outpatient infusion center distance

Distance thresholdWithin 50 miles of the member's home

Outpatient accessAn outpatient infusion center must not be available within this distance

Additional access conditionNo contracted home infusion agency will travel to the member's home

Interval since last infusion

Qualifying interval> 6 months since the last infusion

Therapy riskThe therapy must have moderate to high potential for an adverse event

Coverage relevance

Provider Requirements and Denial Risks

Prior Authorization

Obtain prior authorization before treatment

When the service requires prior authorization, obtain authorization before providing the service. Failure to obtain prior authorization may result in noncoverage.

Documentation Required

Support hospital-based medical necessity

For a requested hospital-based site of care, submit clinical documentation supporting medical necessity, such as medical instability, high risk of immediate life-threatening toxicity, inadequately managed adverse events, high-risk comorbidities, first infusion or prolonged interval since infusion, limited outpatient access, or the hospital being the only site offering the drug.

Documentation Required

Document the site-of-care rationale

Policy Background

This policy addresses site-of-care management for intravenous pharmaceutical infusion therapy. Infusions may be administered in a hospital inpatient or outpatient department, community provider office, ambulatory infusion suite, or home-based setting. Outpatient and home-based settings are generally preferred because they can provide safe care at lower member and plan cost; hospital-based care is reserved for specified clinical or access-related circumstances in which it is medically necessary.

Site-of-Care Definitions

Site of care

Hospital inpatientA hospital inpatient setting where pharmaceutical infusion therapy is administered

Hospital outpatientA hospital outpatient setting; appropriate only when a qualifying clinical or access circumstance establishes medical necessity

Community officeA provider or community office where infusion therapy may be administered

Ambulatory infusion suiteAn ambulatory infusion suite or center where infusion therapy may be administered

Home-based settingA home infusion setting where infusion therapy may be administered

Outpatient setting

Preferred and Exception Settings

Note

Prefer home infusion when appropriate

Use home infusion as a preferred place of service for medical infusions when a hospital-based setting is not medically necessary.

Note

Prefer the provider office when appropriate

Use a provider office as a preferred outpatient place of service for medical infusions unless a hospital-based setting is medically necessary.

Note

Prefer an ambulatory infusion center when appropriate

Use an ambulatory infusion center or suite as a preferred outpatient place of service for medical infusions unless a hospital-based setting is medically necessary.

Policy Summary

PayerUniversity of Utah Health Plans

PolicyPlace of Service for Pharmaceutical Infusions

Policy CodePolicy PHARM-M026

Change TypeNo material change

Effective DateMay 1, 2025

Last ReviewApr 9, 2025

Next Review DateApril 9, 2026

Key ActionObtain prior authorization before providing services that require it.

SourceLink

On This Page

This is the first infusion of therapy with moderate to high potential for an adverse event.

The infusion has moderate to high potential for an adverse event and it has been more than 6 months since the last infusion.> 6 months

There is no outpatient infusion center within 50 miles of the member's home and there is no contracted home infusion agency that will travel to the member's home.> 50 miles

A hospital is the only place that offers infusion of this drug.

This interval may support a hospital-based setting when the therapy meets the stated adverse-event risk condition

Age criterion

Age threshold13 years of age or younger

Qualifying settingHospital-based infusion may be medically necessary when this criterion is met

Exception standardAge is one of the criteria that may establish medical necessity for hospital-based care

Document the requested infusion setting, the member’s clinical condition, the therapy’s adverse-event risk, relevant prior infusion history, and why a preferred outpatient or home setting is not safe or available.

Denial Risk

Hospital infusion requires a qualifying indication

Hospital inpatient or hospital outpatient infusion may be denied as not medically necessary when none of the specified hospital-based clinical or access indications is present.

Denial Risk

Missing prior authorization may result in noncoverage

Services requiring prior authorization may not be covered if prior authorization is not obtained.

A provider or community office used to administer medical infusion therapy outside a hospital

Ambulatory infusion centerAn ambulatory infusion center or suite used to administer medical infusion therapy outside a hospital

Home infusionA home infusion setting used to administer medical infusion therapy outside a hospital

Hospital outpatient infusion requires medical necessity

Use a hospital outpatient setting only when at least one listed clinical or access criterion establishes medical necessity, such as medical instability, high toxicity risk, a first infusion, limited outpatient access, or the hospital being the only site offering the drug.

Denial Risk

Do not admit solely for IV infusion

Hospital inpatient infusion is appropriate only when at least one listed clinical or access criterion establishes medical necessity. An inpatient admission solely to administer IV infusion is not medically necessary.