Home Health Services Policy - CAM 222

  • Description

Home Health Care
Home Health Care Services are for an essentially homebound member in a personal residence. Home health care must be provided by, or through, a community home health agency on a part-time visiting basis and according to a physician-prescribed course of treatment. Preauthorization of care is based on an established home health care treatment plan before being eligible for benefits. Please refer to the Schedule of Benefits to see what benefit limitations apply. Home health care includes: 

  1. Services by a registered nurse (RN) or licensed practical nurse (LPN);
  2. Physical, speech and occupational therapy (benefit period maximum applies)
  3. Services provided by a home health aide or medical social worker;
  4. Nutritional guidance;
  5. Diagnostic services;
  6. Administration of prescription drugs;
  7. Medical and surgical supplies;
  8. Oxygen and its use; and
  9. Durable medical equipment (a separate preauthorization isn’t needed when we approve the entire home health care plan).

Policy
Medically Necessary:
Home health services are considered MEDICALLY NECESSARY when all of the following criteria 1 through 4 are met:

  1. The individual is confined to the home:
  • Ongoing receipt of outpatient kidney dialysis; or
  • The individual’s overall physical/medical condition poses a serious and significant impediment to receiving intermittent or occasional, skilled, medically necessary services outside the home setting. This includes those who are bedridden and those who are non-bedridden but whose medical condition is such that they meet all other criteria for home health services. In general, the condition of these individuals should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort; and
  • If the individual does in fact leave the home, the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. The following are examples of acceptable medical and non-medical absences (these examples are not all-inclusive and are provided as a means to illustrate the kinds of infrequent or unique events an individual may attend):
    • Medical absences to receive health care treatment, including, but not limited to:
      • Receipt of outpatient chemotherapy or radiation therapy; or
      • Participation in psychosocial or medical treatment in an adult day-care program that is licensed or certified by a state, or accredited, to furnish adult day-care services; or
    • ​​​​​​​Non-medical absences:
      • To attend a funeral, religious service, or graduation; or
      • An occasional trip to the barber, a walk around the block; or
      • Other infrequent or unique event (for example, a family reunion or other such occurrence);

Note: Any absence of an individual from the home attributable to the need to receive health care treatment of the types described above shall not disqualify an individual from being considered to be confined to the home. Any other absence from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. It is expected that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment. However, occasional absences from the home for nonmedical purposes, as described above, would not necessitate a finding that one is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the individual has the capacity to obtain the health care provided outside rather than in the home.

  1. The service must be prescribed by the attending physician, health care provider practicing within the scope of license, or the primary care physician in coordination with the attending physician as part of a written plan of care; and
  2. The service(s) is so inherently complex that it can be safely and effectively performed only by:
    • Qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, licensed social-workers, licensed mental health professionals, and speech pathologists, or audiologists; and
    • The home health services are provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation and/or skilled licensed mental health professional personnel to assure safety and to achieve the desired result; and
  3. The primary care physician, health care provider practicing within the scope of license, or attending physician in coordination with the primary care physician should review the treatment plan at least once every 30 days to assess the continued need for skilled intervention.

Home Infusion (IVTX)
Certain extended home infusion treatments are considered MEDICALLY NECESSARY because they are more appropriately performed in the home setting, even if the member is not homebound. The optimal location for these treatments is dependent upon a number of factors, including the toxicity of the medication, the individual’s previous response to the treatment, the monitoring required for safe administration, and the individual’s underlying medical condition. Examples of infusion treatments sometimes performed in the home setting include, but are not limited to, the following:

  1. Intravenous gamma globulin; or
  2. Intravenous hydration for a variety of conditions; or
  3. Infusions for pain control; or
  4. Some chemotherapy regimens.

Other conditions for which intermittent intravenous infusions of medications provided in the home setting are considered MEDICALLY NECESSARY, either because of the complexity of the underlying condition, or the infusion itself include, but are not limited to, the following:

  1. Infections requiring a prolonged treatment course; or
  2. Coagulation disorders; or
  3. Enzyme deficiency states; or
  4. Pain management. 

Not Medically Necessary:
Home health services are considered NOT MEDICALLY NECESSARY when:

  1. The treatment plan provided by the primary care physician does not demonstrate the continued need for skilled intervention; or
  2. Goals have been achieved per plan of care. 

Termination of expanded services related to COVID-19 pandemic:

Effective May 1, 2021, all services addressed in this policy will require the member to meet the homebound criteria detailed in the policy.

TEMPORARY EXPANSION OF SERVICES DURING THE COVID-19 PANDEMIC 

In response to the recent coronavirus (COVID-19) outbreak, BlueCross BlueShield of South Carolina is waiving the homebound requirement for services addressed in this policy.  The expansion supports the diagnosis and treatment of COVID-19 as well as minimizes unnecessary exposure to individuals needing medical care for other conditions.  This expansion will be reviewed for extension on May 16, 2020. 

Effective May 12, 2020, the expansion of these services has been extended to 06/15/2020.

Effective June 10, 2020, the expansion of these services has been extended to 08/01/2020.

Effective July 16, 2020, the expansion of these services has been extended to 10/01/2020.

Effective Sept. 8, 2020, the expansion of these services has been extended to 12/31/2020.

Effective Jan. 1, 2021, the expansion of telehealth services will continue to be allowed until further notice. Ongoing coverage will be continually assessed during the COVID-19 pandemic. Telehealth delivered via non-HIPAA-compliant technologies will remain noncovered.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2019 Forward     

06/15/2022 Annual review, no change to policy intent. 

06/02/2021

Annual review, no change to policy intent. 

03/24/2021 

Interim review adding termination date for expanded services during COVID pandemic. No other changes made. 

12/11/2020 

Effective 01/01/2021, the expansion of telehealth services will continue to be allowed until further notice. Ongoing coverage will be continually assessed during the COVID-19 pandemic. Telehealth delivered via non-HIPAA-compliant technologies will remain noncovered. 

09/08/2020 

Interim review extending the expansion of services related to COVID 19 to 12/31/2020. 

07/16/2020 

Interim review, updating expanded services related to the COVID-19 pandemic to 10/01/2020. No other changes 

06/10/2020 

Interim review to update the date of expanded service coverage related to COVID-19 to 08/01/2020. No other changes made.

06/01/2020 

Annual review, no change to policy intent. 

05/12/2020 

Interim review extending expanded coverage related to COVID-19 to 06/15/2020. 

04/14/2020 

Interim review for the expansion of coverage during the COVID-19 pandemic. For the duration of the pandemic, the requirement for homebound status is waived. 

06/24/2019

New Policy

 

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