Care Management Services Clinical Guideline

Guideline Skilled Home Health & Home Effective Date 1/1/2008 Name Guideline MN -131 Version 1.7 Number Manual Medical Necessity Criteria Guidelines Department(s) Medical Section Management

Committee & Revision Tracking

Status Document Effective Description Revision Date Baseline 1.0 01/2008 Medical Technology Assessment Committee (MTAC) Review Baseline 1.0 01/2008 Regional Medical Director (RMD) Committee Approval Revision 1.1 01/2010 Medical Technology Assessment Committee (MTAC) Review Revision 1.2 04/16/2015 Medical Technology Assessment Committee (MTAC) Review Update 1.3 2/18/2016 Medical Technology Assessment Committee (MTAC) Review Update 1.3 2/25/2016 Medical Technology Assessment Committee (MTAC) Approval Update 1.4 4/17/17 Medical Technology Assessment Committee (MTAC) Review Update 1.5 7/18/2017 Medical Technology Assessment Committee (MTAC) Review Update 1.5 8/3/2017 Medical Technology Assessment Committee (MTAC) Approval Update 1.6 8/21/2018 Medical Technology Assessment Committee (MTAC) Review Update 1.6 8/23/18 Medical Technology Assessment Committee (MTAC) Approval Update 1.7 8/13/19 Medical Technology Assessment Committee (MTAC) Review Update 1.7 8/22/2019 Medical Technology Assessment Committee (MTAC) Approval Update 1.7 2/ 1/2021 Medical Policy Management Workgroup - Approved 12/17 /2020

Policy: Note: Many Commercial and Self-Funded policies have a benefit limit on number of visits. Please refer to the member’s Evidence of Coverage.

Note: For Medicaid and Medicare members FirstCare does not handle authorization for hospice. They need to contact DADS.

Use MCG CG-PCC Inpatient Palliative Care Criteria for inpatient hospice.

Skilled Home Health/Home Hospice

Home healthcare/Hospice is needed for appropriate care of the patient, as indicated by 1 or more of the following: o Request is for skilled home health for a Medicare member who is a Blind Diabetic and may be indicated for ALL of the following: . The member is confined to the home, as indicated by 1 or more of the following:

• Member has an illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence, as indicated by ALL of the following: o There must exist a normal inability to leave home o Leaving the home must require a considerable and taxing effort • Member has a condition such that leaving his or her home is medically contraindicated, as indicated by ALL of the following: o There must exist a normal inability to leave home o Leaving the home must require a considerable and taxing effort . The member is under the care of a physician . The member requires skilled services on an intermittent basis *Prefilling syringes is not considered a skilled service o Request is for skilled home health for a Medicare member who requires Heparin injections and may be indicated by ALL of the following: . The member is confined to the home, as indicated by 1 or more of the following: • Member has an illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence, as indicated by ALL of the following: o There must exist a normal inability to leave home o Leaving the home must require a considerable and taxing effort • Member has a condition such that leaving his or her home is medically contraindicated, as indicated by ALL of the following: o There must exist a normal inability to leave home o Leaving the home must require a considerable and taxing effort . The member is under the care of a physician . The member has a diagnosis requiring Heparin injections, as indicated by 1 or more of the following: • The member is pregnant and requires anticoagulant therapy • The member requires treatment for deep venous thrombosis or pulmonary emboli or for another condition requiring anticoagulation and documentation justifies that the patient cannot tolerate warfarin . Skilled care required, as indicated by 1 or more of the following: • Nurse to teach the member or caregiver to give subcutaneous injections • Nurse to administer subcutaneous injections daily due to member or caregiver unable to give injections and 1 or more of the following: o Request is for the first 6 months of treatment o Request is for subsequent injections after the first 6 months of treatment and 1 or more of the following: . The member is pregnant and needs additional injections through the end of pregnancy . The prescribing physician has provided documentation of the need for such an extended course of treatment o Request is for skilled home health for a Medicaid member who requires Synagis ® (Palivizumab) injections and may be indicated by ALL of the following: . Prior authorization for Synagis ® has been completed and approved. . Member is already receiving nursing services at home. . A physician’s order must be present either on the plan of care form or as a supplemental order for the administration of Synagis ® injections during the RSV season.

NOTE: If a physician, other than the physician ordering home health nursing or services, prescribes Synagis ® injections, it is the home health agency's responsibility to ensure that the additional order for the administration of Synagis ® injections is in place. o Request is for skilled home health for all other services/policies and may be indicated for ALL of the following : . Select here to document homebound status , may be indicated by 1 or more of the following: • The member has a FirstCare Medicaid, CHIP, HMO, or PPO policy • The member has a FirstCare Medicare policy and 1 or more of the following: o The member is confined to the home, as indicated by 1 or more of the following: . Member has an illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence, as indicated by ALL of the following: • There must exist a normal inability to leave home • Leaving the home must require a considerable and taxing effort . Member has a condition such that leaving his or her home is medically contraindicated, as indicated by ALL of the following: • There must exist a normal inability to leave home • Leaving the home must require a considerable and taxing effort . The member's needs can be safely met with intermittent home care . The member requires Skilled care at home, as indicated by 1 or more of the following: • Home safety assessment • Medication management, adherence instruction, and side effects assessment • required (respiratory status, cardiovascular status, skin integrity,neurologic status, genitourinary status, neurovascular status) • Nutrition and hydration management • Ongoing condition management education required • Pain management • Psychosocial assessment, management, and referrals • Rehabilitation therapy or equipment coordination • Significant chronic condition exacerbation with need for clinical intervention and monitoring • Wound or dressing management • A clinician assessment after emergency department or observation care without hospitaladmission • Infusion (IV) therapy management • Electrolyte management • Coordination of care with care transition program • Oxygen or respiratory equipment management • Developmental status assessment . The member is expected to require Skilled care for a reasonable amount of time, as indicated by 1 or more of the following: • The member requires a high frequency (3+ visits per week) of visits, as indicated by ALL of the following: o The member has potential for rapid decline or loss of function if skilled care is notadministered o The member’s plan of care demonstrates frequent skilled care is needed o The member requires a high frequency of intervention for a limited duration (usually 60days or fewer) to recover from recent surgery, illness, or trauma

• The member requires a moderate frequency (2 visits per week) of visits, as indicated by 1 or more of the following: o The member is in a critical period to restore function (such as the post-acute periodafter hospitalization) o The member’s plan of care demonstrates skilled care is needed at least 2 times perweek o The member has complex medical needs requiring ongoing education • The member requires a low frequency (1 visit or less per week) of visits, as indicated by 1 or more of the following: o The member requires disease management education o The member’s plan of care demonstrates skilled care is needed 1 time a week or less o Request is for home hospice and may be indicated by ALL of the following: . The individual is terminally ill and expected to live six months or less . Potentially curative treatment for the terminal illness is not part of the prescribed plan of care . The individual or appointed designee has formally consented to hospice care (i.e., care which is directed mostly toward palliative care and symptom management) . The hospice services are provided by a certified/accredited hospice agency with care available 24 hours per day, seven days per week

Documentation Required for Review:

Medical History, Diagnosis, Home bound status

Coding References:

CPT codes covered if selection criteria are met : 99509 Home visit for assistance with activities of daily living and personal care Other CPT codes related to the CPB : 92507 Treatment of speech, language, voice communication, and/or auditory processing disorder; individual 97001 - 97799 Physical Medicine and Rehabilitation 99500 - 99507, Home Health Procedures/Services 99510 - 99600 99601 - 99602 Home Infusion Procedures/Services HCPCS codes covered if selection criteria are met : G0156 Services of home health aide in home health or hospice setting, each 15 minutes S9122 Home health aide or certified nurse assistant, providing care in the home; per hour T1004 Services of a qualified nursing aide, up to 15 minutes T1021 Home health aid or certified nurse assistant, per visit Other HCPCS codes related to the CPB : G0151 - G0155 Services of physical therapist, occupational therapist, speech and language

pathologist, skilled nurse, or clinical social worker in home health or hospice setting, each 15 minutes S9123 - S9124 Nursing care in the home; by , or , per hour S9128 - S9131 Speech therapy, occupational therapy, or physical therapy, in the home, per diem S9208 - S9214 Home management S9325 - S9379 Home or home infusion therapy S9490 - S9810 Home infusion therapy, routine venipuncture for collection of specimen(s), home therapy, home transfusion of blood products, home injectable therapy T1030, T1031 Nursing care, in the home, by registered nurse or licensed practical nurse, per diem HCPCS codes covered if selection criteria are met : G0162 Skilled services by a registered nurse (RN) in the delivery of management & evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential non-skilled care achieve its purpose in the home health or hospice setting) G0163 Skilled services of a licensed nurse (LPN or RN) in the delivery of observation & assessment of the patient's condition, each 15 minutes (when the likelihood of change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possib le modification of treatment in the home health or hospice setting) G0164 Skilled services of a licensed nurse, in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes S9474 Enterostomal therapy by a registered nurse certified in enterostomal therapy, per diem T1000 Private duty/independent nursing service(s) - licensed, up to 15 minutes T1001 Nursing assessment/evaluation T1002 RN Services, up to 15 minutes T1003 LPN/LVN services, up to 15 minutes S5108 Home care training to home care client; per 15 minutes S5109 Home care training to home care client; per session S5110 Home care training, family; per 15 minutes S5111 Home care training, family; per session S5115 Home care training, nonfamily; per 15 minutes S5116 Home care training, nonfamily; per session S9098 Home visit, phototherapy services (e.g., Bili-lite) including equipment rental, nursing services, blood draw, supplies, and other services, per diem G0151 Services performed by a qualified physical therapist in the home health or hospice

setting, each 15 minutes G0152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes G0154 Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes G0155 Services of clinical soci al 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 G0162 Skilled services by a registered nurse (RN in the delivery of 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 non-skilled care achieve its purpose in the home health or hospice setting) G0163 Skilled services of a licensed nurse (LPN or RN) in the delivery of the observation and assessment of the patient's condition, each 15 minutes ( when the likelihood of change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible mod ification of treatment in the home health or hospice setting) G0164 Skilled services of a licensed nurse, in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes G0337 Hospice evaluation and counseling services, preelection Q5001 Hospice or home provided in patient's home/residence Q5002 Hospice or home health care provided in facility Q5003 Hospice care provided in nursing long-term care facility (LTC) or nonskilled nursing facility (NF) Q5004 Hospice care provided in skilled nursing facility (SNF) Q5005 Hospice care provided in inpatient hospital Q5006 Hospice care provided in inpatient hospice facility Q5007 Hospice care provided in long-term care facility (LTC) Q5008 Hospice care provided in inpatient psychiatric facility Q5009 Hospice or home health care provided in place not otherwise specified (NOS) Q5010 Hospice home care provided in a hospice facility S0255 Hospice referral visit (advising patient and family of care options) performed by nurse, social worker, or other designated staff S9126 Hospice care, in the home, per diem

Description:

Home Health: Skilled nursing care is health care given when a person needs skilled nursing staff (registered nurse (RN) or licensed practical nurse (LPN)) to manage, observe, and evaluate care. Skilled nursing care requires the involvement of skilled nursing staff in order to be given safely and effectively. Care that can be given by non-professional staff is not considered skilled nursing care. The goal of skilled nursing care is to help improve the patient's condition or to maintain the patient's condition and prevent it from getting worse. Custodial care is care that helps persons with usual daily activities like walking, eating, or bathing. It may also include care that most people do themselves, like using eye drops, oxygen, and taking care of colostomy or bladder catheters. A home health aide is a provider who assists a member with non-skilled care to meet activities of daily living, thereby maintaining the individual in his or her home environment. The services of a home health aide are rendered in conjunction with intermittent skilled home health care services provided by a registered or licensed practical nurse, physical therapist, occupational therapist, or speech therapist. Hospice: Hospice services are considered as a philosophy or concept of care; it is not a specific place of care or an evidence-based standard. A hospice program is defined as a program of palliative and supportive care services providing physical, psychological, social, and spiritual care for dying persons, their families, and other loved ones. The focus of treatment is palliative, not curative, and is based on a biopsychosocial model rather than a disease model of care (Fine and Davis, 2006). Palliative care may be defined as treatment for the relief of pain and other uncomfortable symptoms through the appropriate coordination of all aspects of care to maximize personal comfort and relieve distress (Centers for Medicare and Medicaid Services [CMS], Federal Register, 2005). Hospice care is comprehensive and coordinated palliative care that is provided in the final stages of life and allows the patient to remain at home for as long as possible by providing support to the patient and family, and keeping the patient as comfortable as possible while maintaining the patient’s dignity and quality of life. Hospice programs consider both the patient and the family as the unit of care. Services that are provided generally include nursing care, physicians' services, services, medical social services and other supportive services. Most hospice care services are provided in the home or in inpatient settings (e.g., hospital, freestanding hospice facility, ) and are provided to patients in all age groups. Inpatient care is generally short-term, and is provided for control of pain and management of acute symptoms (e.g., intractable nausea, vomiting, seizures), or to provide respite care for relief of the patient’s primary caregivers. Short- term inpatient hospice care may also be provided in order to prepare the patient and family for home-care services.

Coverage for Repeated Procedures: Coverage for a second or additional procedure will be allowed when there is evidence of medically necessity. This procedure limitation is in place whether or not the previous procedure was covered under the current benefit plan. Patient Selection Criteria: N/A Auth Requirement/RMD Review:

The first visit for newly ordered home care skilled services requires an authorization, but will not require a prior authorization. FirstCare will retrospectively approve the initial nursing evaluation visit when the written plan of care is received within four business days. Additional services rendered during the four business days will be retrospectively reviewed. Services may include home health aide, occupational

therapy, pediatric therapy services, physical therapy, private duty nursing (PDN), skilled nursing, speech therapy, and social work.

Home Hospice does not require authorization unless the supplier classification is home health and the place of service is home.

Exceptions:

None.

Regulatory / Literary References:

Home Health:

1. MCG - Home Care Guidelines for Skilled nursing visits. 2. TMHP - 3 Home Health Skilled Nursing and Home Health Aide Services Unless otherwise noted in this handbook, certain DME/supplies may be obtained without prior authorization although providers must retain a Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form that has been reviewed, signed, and dated ;by the treating physician for these clients. The Alberto N Agreement (Section 8.1) states that all DME policies, guidelines, or provider manuals will prominently display the following statement when describing the scope of DME available to beneficiaries: Medicaid beneficiaries under the age of 21 years are entitled to all medically necessary DME. DME is medical necessary when it is required to correct or ameliorate disabilities or physical or mental illnesses or condition. Any numerical limit on the amount of a particular item of DME can be exceeded for Medicaid beneficiaries under the age of 21 years if medically necessary. Likewise time period for replacement of DME will not apply to Medicaid beneficiaries under the age of 21 years if the replacement is medically necessary. When prior authorization is required, the information submitted with the request must be sufficient to document the reasons why the requested DME item or quantity is medical necessary. 3. Policy Reporter: a. Aetna b. Oxford- Home health c. Humana- Home health 4. CMS- 30 - Conditions Patient Must Meet to Qualify for Coverage of Home Health Services 5. NCD- 290.2 and 290.1 Hospice: 1. MCG -

CG -PCC Inpatient Palliative Care Criter ia 2. Hayes - Nothing found 3. TMHP - 4.4.3 Hospice Program. The Alberto N Agreement (Section 8.1) states that all DME policies, guidelines, or provider manuals will prominently display the following statement when describing the scope of DME available to beneficiaries: Medicaid beneficiaries under the age of 21 years are entitled to all medically necessary DME. DME is medical necessary when it is required to correct or ameliorate disabilities or physical or mental illnesses or condition. Any numerical limit on the amount of a particular item of DME can be exceeded for Medicaid beneficiaries under the age of 21 years if medically necessary. Likewise time period for replacement of DME will not apply to Medicaid beneficiaries under the age of 21 years if the replacement is medically necessary. When prior authorization is required, the information

submitted with the request must be sufficient to document the reasons why the requested DME item or quantity is medical necessary. 4. Policy Reporter: a. Cigna 5.

Disclaimer:

Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, take precedence over guidelines. Contract language, state and federal law must be considered first in determining eligibility for coverage. Coverage may also differ for Medicare and/or Medicaid members based on any applicable Centers for Medicare & Medicaid Services (CMS) coverage statements and/or Texas Medicaid Provider Procedures Manual. The member's health plan benefits, in effect on the date services are rendered, must be used. Guidelines are not intended to preempt the judgment of the reviewing Medical Director or dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in rendering the most appropriate care.