Clinical Policy: Obstetrical Home Care Programs Form

# Clinical Policy: Obstetrical Home Care Programs
Reference Number: CP.MP.91  
Date of Last Review: 02/24  

**Revision Log**  
**Coding Implications**  

See [Important Reminder](at the end of this policy for important regulatory and legal information.  

## Description  
Medical necessity criteria for obstetrical home health programs offered by vendors.  

## Policy/Criteria  
I. It is the policy of health plans affiliated with Centene Corporation® that obstetrical home health services are **medically necessary** for members/enrollees meeting the following criteria:  
A. Obstetrical Nurse Assessment ........................................................................................................................................................................ 1  
B. Metoclopramide or Ondansetron Infusion Therapy .......................................................................................................................................... 1  
C. Hydration Therapy – one to four liters ........................................................................................................................................................... 2  
D. Diabetes in Pregnancy Clinical Management Programs ................................................................................................................................ 3  
E. Hypertensive Disorders of Pregnancy Program ............................................................................................................................................... 3  
F. Dietary Analysis ............................................................................................................................................................................................. 4  

### A. Obstetrical Nurse Assessment  
An obstetrical nurse assessment is considered **medically necessary** when provided with any of the services listed in B to F.  

### B. Metoclopramide or Ondansetron Infusion Therapy  
Home visits are considered **medically necessary** for the same period as the infusion therapy is administered, generally up to seven days of therapy based on clinical information. Medication infusion therapy is considered **medically necessary** when meeting the following criteria:  
1. Member/enrollee has tried and failed conservative treatment including medications by mouth and/or per rectum and/or other non-pharmacological treatments. See Table 1 below for recommendations from ACOG;  
2. If re-authorization is requested, the ordering provider has reassessed the member since the previous authorization and documented the need for continuation of infusion therapy.  

**Table 1: ACOG Tiered Approach to Hyperemesis Gravidarum Management**  
| First Line Therapy: Nonpharmacologic options | |
|--------------------------------------------|---|
| Convert prenatal vitamin to folic acid supplement only | |
| Ginger capsules 250 mg four times daily | |
| Consider P6 acupressure with wrist bands | *if symptoms persist* |

# Clinical Policy  
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**Table 1: ACOG Tiered Approach to Hyperemesis Gravidarum Management**  
| Vitamin B6 (pyridoxine) 10 mg/Doxylamine 10 mg combination product, two tablets orally at bedtime initially, up to four tablets per day (one tablet in the morning, one tablet in midafternoon, and two tablets at bedtime) OR | |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---|
| Vitamin B6 (pyridoxine) 20 mg/Doxylamine 20 mg combination product, one tablet orally at bedtime initially, up to two tablets per day (one tablet in the morning and one tablet at bedtime) | |
| *if symptoms persist* | |
| Add the following: (presented in alphabetical order) | |
| Dimenhydrinate 25-50 mg every four to six hours, orally as needed (not to exceed 200 mg per day if patient is also taking doxylamine) OR | |
| Diphenhydramine 25-50 mg orally every four to six hours OR | |
| Prochlorperazine 25 mg every 12 hours rectally OR | |
| Promethazine 12.5-25 mg every four to six hours, orally or rectally | |
| *if symptoms persist and no dehydration exists* | *if symptoms persist AND dehydration exists* |
| Add any of the following: (presented in alphabetical order) | Add any of the following: (presented in alphabetical order) |
| Metoclopramide 5-10 mg every six to eight hours, orally or intramuscularly OR | Dimenhydrinate 50 mg (in 50mL saline, over 20 min) every four to six hours, IV OR |
| Promethazine 12.5-25 mg every four to six hours, orally, rectally or intramuscularly OR | Metoclopramide 5-10 mg every 12 hours, IV OR |
| Trimethobenzamide 200 mg every six to eight hours, intramuscularly | Ondansetron 8 mg over 15 minutes, every 12 hours, IV OR |
| | Promethazine 12.5-25 mg every four to six hours, IV |
| | *if symptoms persist AND dehydration exists* |
| | Add the following: (presented in alphabetical order) |
| | Chlorpromazine 25-50 mg IV or intramuscularly every four to six hours or 10-25 mg orally every four to six hours OR |
| | Methylprednisolone 16 mg every eight hours, orally or IV for three days. Taper over two weeks to lowest effective dose. If beneficial, limit total duration of use to six weeks. |

### C. Hydration Therapy – one to four liters  
Hydration therapy is **medically necessary** for members/enrollees who could benefit from close surveillance for the onset of dehydration. Examples of diagnoses include:  
1. Hyperemesis gravidarum;  
2. Malabsorption;  
3. Diagnosis, such as flu or GI virus, which impairs the member/enrollee’s ability to maintain fluid and/or food in the system.  

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A course of up to seven days at a time is considered medically necessary. Additional days may be granted as clinically indicated.  

### D. Diabetes of Pregnancy Clinical Management Programs  
Diabetes of pregnancy clinical management (for gestational diabetes and those with pre-existing type I and type II diabetes) is **medically necessary** when meeting one of the following:  
1. Program includes diabetic nutrition education and one of the following:  
   a. One visit, for pregnant members/enrollees with a diagnosis of type II non-insulin dependent diabetes in pregnancy, or non-insulin dependent gestational diabetes;  
   b. An initial course of visits for up to seven days for pregnant members/enrollees with a diagnosis of insulin-dependent diabetes requiring insulin administration by any means;  
   c. An additional course(s) of visits for up to seven days for pregnant members/enrollees with a diagnosis of insulin-dependent diabetes requiring insulin administration by any means until the member/enrollee is able to self-manage blood sugar and insulin administration.  

### E. Hypertensive Disorders in Pregnancy Management  
Home visits for management of hypertensive disorders of pregnancy including chronic hypertension, gestational hypertension and management of preeclampsia without severe features are **medically necessary** when meeting one of the following:  
1. One visit for member/enrollees diagnosed with gestational or chronic hypertension and both of the following:  
   a. Elevated or unstable blood pressure without proteinuria;  
   b. Member/enrollee who could benefit from education and surveillance for the potential onset of hypertension. Categories of such members/enrollees could include but are not limited to:  
      i. Hypertensive disorder affecting previous pregnancy or postpartum;  
      ii. Multiple gestations;  
      iii. Diabetes;  
2. An initial home visit, with additional phone or virtual follow up as needed and including remote blood pressure monitoring, for members/enrollees diagnosed with preeclampsia without severe features meeting one of the following:  
   a. Blood pressure ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on two occasions at least four hours apart after 20 weeks gestation in a member/enrollee with a previously normal blood pressure;  
   b. Proteinuria demonstrated by one or more of the following:  
      i. ≥ 300 mg per 24-hour urine collection (or this amount extrapolated from a timed collection);  
      ii. Protein/creatinine ratio ≥ 0.3 mg;  
      iii. Dipstick reading of ≥ 2+ (30 mg/dL) (used only if other quantitative methods not available).  

**Note:** Preeclampsia with severe features should be managed through inpatient care.  

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### F. Dietary Analysis  
A dietary analysis is **medically necessary** for members/enrollees with a diagnosis of obesity, malnutrition, or prior bowel or bariatric surgery affecting nutrient absorption.  

II. It is the policy of health plans affiliated with Centene Corporation that the following services provided by a home health vendor are considered **not medically necessary**:  
A. Betamethasone therapy via multiple repeat courses or intermittent injections;  
B. Multiple gestation management (refer to individual program for identified risk factor);  
C. Continuous heparin infusion therapy;  
D. Member/enrollee-administered nonstress test or fetal heart rate monitoring;  
E. Gestational diabetes clinical management program for oral medications;  
F. Preterm prelabor rupture of membranes (PPROM) management;  
G. Preterm labor management;  
H. 17-hydroxyprogesterone caproate (Makena) injections.  

### Background  
Obstetrical homecare programs include risk assessment and education for identifying pregnant individuals at risk for complications, case management and homecare services for high-risk pregnancies. Obstetrical homecare services include providers, diagnostics, treatments, devices, and timely and actionable information that help member/enrollees and providers make informed healthcare decisions.  

#### Medically Necessary Services:  
Metoclopramide or Ondansetron Infusion Therapy  
The American College of Obstetricians and Gynecologists (ACOG) recommends a tiered approach to treatment of hyperemesis gravidarum. Treatment of nausea and vomiting of e-in pregnancy begins with prevention. Two studies found that individuals who were taking a multivitamin at the time of fertilization were less likely to need medical attention for vomiting. Although the biological basis of this observation is unclear, the authors speculate that this may have been because of a generalized optimization of nutritional status or because increasing levels of vitamin B6 (pyridoxine) may reduce vomiting in some individuals. Therefore, the standard recommendation to take prenatal vitamins for one month before pregnancy may reduce the incidence and severity of nausea and vomiting in pregnancy. Early treatment of nausea and vomiting in pregnancy is recommended to prevent progression to hyperemesis gravidarum. Those with a history of severe nausea and vomiting in pregnancy in their previous gestation, the initiation of antiemetic therapy before the onset of nausea and vomiting symptoms was associated with a reduction in the severity of nausea and vomiting of pregnancy compared with initiation of a combination of doxylamine and vitamin B6 (pyridoxine) after the onset of symptoms.  

Treatment of nausea and vomiting of pregnancy with vitamin B6 (pyridoxine) alone or vitamin B6 (pyridoxine) plus doxylamine in combination is safe and effective, as demonstrated in randomized controlled trials and should be considered first-line pharmacotherapy.  

When those with nausea and vomiting of pregnancy are unable to tolerate oral medications, other administration modalities may be beneficial. Some of the phenothiazine products (promethazine  

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and prochlorperazine) are available as rectal suppositories. The serotonin 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists are available as an oral dissolvable tablet (ondansetron) or a transdermal patch (granisetron) formulation.  

There is limited evidence regarding the clinical efficacy of the use of continuous subcutaneous microinfusion pumps to administer metoclopramide or ondansetron for the treatment of nausea and vomiting of pregnancy. Moreover, adverse effects with the use of continuous subcutaneous pumps were seen in 11–31% of selected patients.  

Although no single approach has been proven to be more effective than the other, ACOG has established a hierarchy of therapeutic interventions that balances safety and efficacy. As with all medications, the potential risks, benefits, adverse effects and costs should be weighed in each case. Care should be exercised if multiple antiemetic medications are used simultaneously. For individuals requiring the use of subcutaneous or intravenous therapy, the home environment should be clean to reduce the risk of infection and the individual should have a firm understanding of the risks of infection while undergoing such therapy.  

Parallel use of a dopamine antagonist (such as metoclopramide) and various phenothiazine medications (e.g., promethazine, prochlorperazine, or chlorpromazine) may result in an increased risk of extrapyramidal effects (e.g., tardive dyskinesia) or rarely, neuroleptic malignant syndrome (a life-threatening reaction, including high fever, confusion, rigid muscles, and symptoms of autonomic nervous system instability). The serotonin 5-HT3 inhibitor (e.g., ondansetron) when used with phenothiazine medications (such as chlorpromazine) may result in a potential cardiac risk of QT interval prolongation.³⁰  

#### Diabetes in Pregnancy Clinical Management  
Gestational diabetes mellitus (GDM) is a condition that can develop in pregnancy related to carbohydrate intolerance. Individuals who develop GDM are at a greater risk for developing preeclampsia, having to undergo a cesarean section, and developing diabetes later in life. Additionally, the offspring of those with GDM are at increased risk of macrosomia, neonatal hypoglycemia, hyperbilirubinemia, shoulder dystocia, and birth trauma.  

Treatment of GDM is paramount and associated with reduced risk of complications in the neonate as well as reduction in the risk of progression to preeclampsia.  

In the United States, the two-step test is the most widely used approach for identifying pregnant people with gestational diabetes mellitus (GDM). The test is endorsed by America College of Obstetricians and Gynecologists (ACOG) and the American Diabetes Association (ADA) considers it an acceptable option.¹⁰  

The first step of the test is a one-hour 50-gram oral GTT administered without regard to time of day/previous meals. This step has a practical advantage since fasting is not necessary and only one blood sample is required. After step one, screen-positive individuals, except for those with very high glucose values, go on to the second step of the test which consists of a three-hour 100-gram oral GTT performed after an overnight fast.¹⁰  

#### Gestational Hypertension Management  

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The ACOG Task Force on Hypertension in Pregnancy recommends that patients with gestational hypertension or preeclampsia without severe features monitor blood pressure twice weekly, self-monitor fetal movement daily, and have platelet counts and liver enzymes assessed weekly.² Few studies have evaluated whether outpatient care is a viable option for preeclamptic patients, although two small studies found positive results.¹⁸ In addition, a systematic review of three studies found no difference in clinical outcomes for mothers or babies receiving care in antenatal day units versus inpatient care.¹² ACOG recommends ambulatory management at home as an option for those with gestational hypertension or preeclampsia without severe features requiring frequent fetal and maternal evaluation. Hospitalization is recommended for individuals with severe features and for individuals in whom adherence to frequent evaluation may be a concern.²²  

Postpartum hypertension and preeclampsia are either persistent or exacerbated hypertension in women with previous hypertensive disorders of pregnancy or a new-onset condition. It is important to increase the awareness among health care providers and to empower patients to seek medical advice if symptoms that precede eclampsia, hypertensive encephalopathy, pulmonary edema, or stroke are noted in the postpartum period. Most women who present with eclampsia and stroke in the postpartum period have these symptoms for hours or days before presentation.²²  

#### Not Medically Necessary Services:  
Betamethasone therapy via intermittent injections  
ACOG recommends a single course of corticosteroids for individuals with preterm premature rupture of membranes (PPROM) between 22 and 34 weeks, as it reduces the risk of neonatal mortality, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. However, ACOG does not recommend multiple repeated injections as weekly administration is associated with lower birthweight and head circumference. Exceptions to this recommendation do exist under certain circumstances warranting a single repeat course. These circumstances include <34+0 weeks gestation, at high risk of preterm birth within the next seven days and the prior course of ACS was administered more than 14 days prior. However a rescue ACS may be provided as early as seven days from the previous dose, if clinically indicated. A Cochrane meta-review of repeat doses of antenatal corticosteroids states that there was lower incidence of respiratory distress and serious infant health problems in the first few weeks after birth, but no evidence of harm or benefit in early childhood. Furthermore, ACOG noted, repeat doses of corticosteroids were associated with lower birthweight and head circumference, even though these reductions were small. Crowther and colleagues conclude by recommending further research on the long-term benefits and risks of repeat doses of antenatal corticosteroids for the infant into adulthood.¹¹,¹⁵  

#### Preterm Prelabor Rupture of Membranes Management  
A Cochrane systematic review of two small studies concludes that the majority of patients should be managed in the hospital after PPROM. Although the two studies suggest that outcomes are similar between individuals and babies managed at home or inpatient, the evidence is not sufficient to make a recommendation regarding the safety of home care for PPROM.¹ An additional small study of 187 patients with PPROM indicated conventional hospitalization as the treatment of choice when compared to home management especially in the presence of PPROM before 26 weeks, non-cephalic fetal presentation and oligoamnios.²⁷ ACOG reviews the Cochrane review and also notes that the evidence is insufficient, adding that the increased risk of sudden  

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infection, placental abruption and umbilical cord compression with PPROM make hospital surveillance the appropriate management choice.⁴  

#### Preterm Labor Management  
There is little research on the management of patients after an episode of preterm labor. One underpowered study found no benefit to hospital care versus discharge home in the proportion of deliveries ≥36 weeks. It is thus recommended that the decision to manage an individual with preterm labor as an inpatient or outpatient should be made on a case-by-case basis, in conjunction with factors such as cervical dilation, vaginal bleeding, fetal status and travel time to the appropriate level of care facility.⁷ Furthermore, previous use of 17-OHPC/Makena and its generics to prevent preterm labor is no longer recommended as the FDA withdrew its approval of the product.  

#### Coding Implications  
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2023, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.  

| HCPCS*Codes | Description |
|-------------|-------------|
| 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) |
| G0299 | Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes |
| S9123 | Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used) |
| S9140 | Diabetic management program, follow up-visit to non-MD provider |
| S9145 | Insulin pump initiation, instruction in initial use of pump (pump not included) |
| S9211 | Home management of gestational hypertension, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code) |
| S9213 | Home management of preeclampsia, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code) |

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| HCPCS*Codes | Description |
|-------------|-------------|
| S9214 | Home management of gestational diabetes, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any home infusion per diem code) |
| S9351 | Home 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 |
| S9353 | Home 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 |
| S9374 | Home infusion therapy, hydration therapy; one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem |
| S9375 | Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
| S9376 | Home infusion therapy, hydration therapy; 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 (drugs and nursing visits coded separately), per diem |
| S9377 | Home infusion therapy, hydration therapy; more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
| S9379 | Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
| S9470 | Nutritional counseling, dietitian visit |
| S9560 | Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |

\*Not all codes in the table above are considered medically necessary.  

| CPT® Codes | Description |
|------------|-------------|
| 99601 | Home infusion/specialty drug administration, per visit (up to 2 hours); |

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| CPT® Codes | Description |
|------------|-------------|
| 99602 | Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary procedure) |

| Reviews, Revisions, and Approvals | Revision Date | Approval Date |
|----------------------------------|--------------|---------------|
| Policy Created. Reviewed by Specialist. | 01/14 | 01/14 |
| Specified that only preeclampsia without severe features is appropriate for home management and removed diagnostic criteria which included severe features. Changed “Alert” to “Optum” | 01/19 | 01/19 |
| Updated description to include OptionCare. Noted in D. Diabetes Clinical Management program that the case rate is with Optum. Pre-eclampsia program: I.H changed dipstick reading from 1+ to 2+. Updated background with ACOG’s statement on administration of Hydroxyprogesterone Caproate. Specialist review. | 12/19 | 12/19 |
| Removed reference to OptionCare in description. In C. Hydration therapy, changed initial course and additional course of up to 14 visits to up 7 visits at a time. In D. Diabetes in pregnancy, removed the word “program” from the title and criteria; deleted all criteria except the requirement for diagnosis of type 2 DM, or gestational diabetes, and specified that both are non-insulin dependent; deleted reference to case rate, and added that 1 visit is medically necessary. Combined criteria in E. for insulin injections and F. for insulin pump into E; removed criteria except for being pregnant and requiring insulin administration; changed number of medically necessary visits from 14 to up to 7 days for the initial and additional courses. For hypertensive disorders in pregnancy, replaced “program” in the title with “management;” changed number of medically necessary visits from up to 14 days with an additional 7 if needed for preeclampsia in pregnancy, replaced “program” with “visits for management;” changed the number of initial and additional medically necessary visits from up to 7 to an additional home visit with phone follow up as needed. For preterm labor management, changed number of medically necessary visits from 3 in one week to 1 home visit in a week, with additional phone follow up as needed. Replaced all instances of “member” with “member/enrollee.” Reviewed by specialist. References reviewed and updated. | 11/20 | 12/20 |
| Annual review. Updated table of contents. Corrected A. to state that it is medically necessary with services in A-J, not A-K. References reviewed and updated. Specialist review. Changed “Last Review Date” in the header to “Date of Last Review” and “Date” in revision log to “Revision Date”. Added info in Background regarding ACOG’s Statement on FDA Proposal to Withdraw 17 Hydroxyprogesterone Caproate. Note added to HCPCS S9123 regarding CPT usage. | 12/21 | 12/21 |

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| Reviews, Revisions, and Approvals | Revision Date | Approval Date |
|----------------------------------|--------------|---------------|
| Annual review completed. Added “without proteinuria” to I. F.1.Changed “woman” to “member/enrollee” in I.G.1. Added “demonstrated by one or more of the following” to I.G.2. for clarity. Added “≥” to I.G.2.c. Minor rewording with no clinical significance. Background updated. References reviewed and updated. | 12/22 | 12/22 |
| Removed references to CP.MP.34 Hyperemesis Gravidarum Treatment in I.B. and modified statement to reflect that home visits are medically necessary for the ondansetron/metoclopramide infusion administration period. Removed criteria J. for hydroxyprogesterone caproate (Makena) administration nursing visits. | 04/23 | 04/23 |
| Annual review. Updated Background with no impact to criteria. Updated version for inclusion. References reviewed and updated. | 11/23 | 11/23 |
| Updated A. to note that the assessment is applicable to sections B to F. Added criteria I.B.1.o include medication infusion therapy is considered medically necessary when meeting all of the following criteria: member/enrollee has tried and failed conservative treatment including medications by mouth and/or per rectum and/or other non-pharmacological treatments. In I.B.2, added: “If re-authorization is requested, the ordering provider has reassessed the member since the previous authorization and documented the need for continuation of infusion therapy.” Combined sections I.E. and I.D. along with sections I.F. and I.G. with no impact to criteria. Removed mention of the case rate in section D. Minor rewording of I.D. and I.E. for clarity. In I.D., specified that the program is for those with gestational hypertension as well as pre-existing type I and II diabetes. In I.D.1., added requirement that the program includes diabetic nutrition education. In I.E., clarified that the program also applies to chronic hypertension and added a note stating that preeclampsia with severe features is managed inpatient. In I.E.b.1., added the option for a previous episode of postpartum hypertension. Added to I.E.2. that virtual follow up would include remote blood pressure monitoring. Removed section I.H. including related content and criteria. Added II.G. Preterm labor management and II.H 17-hydroxyprogesterone caproate. Background updated with no impact to criteria. References reviewed and updated. Reviewed by internal specialist. Added HCPCS codes G0162, G0299, S9145, S9351, S9353, and S9379. Added CPT codes 99601 and 99602. | 02/24 | 02/24 |

  
30. ACOG Practice Bulletin 189: Nausea and Vomiting of Pregnancy. The American College of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/01/nausea-and-vomiting-of-pregnancy. Published January 2018. Accessed February 20, 2024.  

**Important reminder**  
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health  

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plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.  

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.  

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.  

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.  

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.  

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein is strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.  

**Note:** For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.  

**Note:** For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.  

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©2014 Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene® and Centene Corporation® are registered trademarks exclusively owned by Centene Corporation.  

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