This document addresses home health care and the conditions under which it would be considered medically necessary. Home health care refers to intermittent skilled health care related services provided by or through a licensed home health agency to an individual in his or her place of residence. Home health care includes skilled nursing care, as well as other skilled care services including, but not limited to, physical, occupational, and speech therapies.

Note: Please see the following related documents for additional information:

• CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia
• CG-DME-21 External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings
• CG-MED-19 Custodial Care
• CG-MED-71 Chronic Wound Care in the Home or Outpatient Setting
• CG-MED-89 Home Parenteral Nutrition
• CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 Private Duty Nursing in the Home Setting
• CG-REHAB-12 Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology

Note: This document does not address home health care for mental health conditions.

Clinical Indications

Medically Necessary:

1. Home health services are considered medically necessary when all of the following criteria A through D are met:
   1. The individual is confined to the home:
      1. 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
      2. 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):
         1. Medical absences to receive health care treatment, including but not limited to:
            1. Ongoing receipt of outpatient kidney dialysis; or
            2. Receipt of outpatient chemotherapy or radiation therapy; or
            3. 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
         2. Non-medical absences:
            1. To attend a funeral, religious service, or graduation; or
            2. An occasional trip to the barber, a walk around the block; or
            3. 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.
               and
   2. 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
   3. The service(s) is so inherently complex that it can be safely and effectively performed only by:
      1. Qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, licensed social-workers, speech pathologists, or audiologists; and
      2. The home health services are provided directly by or under the general supervision of these skilled nursing, skilled rehabilitation, or professional personnel to assure safety and to achieve the desired result; and
   4. 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.
2. 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.
3. 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.

Duration

Duration: Dependent upon the individual needs of the person receiving home health services.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

CPT

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

Discussion/General Information

Home health services are generally considered when the skilled services currently being provided by a facility (on an in-patient basis) can be provided in the home setting. Home health services are frequently provided by the following professionally trained practitioners:

• Physical therapists;
• Occupational therapists;
• Speech-language therapists;
• Licensed social workers; and
• Registered Nurses and Licensed Practical Nurses. Examples of skilled nursing services may include, but are not limited to, the following:
  • IV infusions;
  • Central line dressing changes; and
  • Sterile dressing changes for wounds with the application of a prescribed medication.

It is not unusual for a skilled nurse or other medical professional to educate the person receiving care, family member, or caregiver with regard to how to manage the treatment regimen and to provide skills for overcoming or adapting to functional loss. While services may be received from several skilled providers, it is important that the services provided during the home health visits are not duplicative. The determination of how long an individual requires home health care and what type of skilled practitioners will provide care is determined by the clinical response to treatment.

The homebound criteria set forth in this document are largely based on the recommendations made by the Department of Health and Human Services and the Centers for Medicaid and Medicare Services. The criteria are intended to be used as a tool to aid in the identification of individuals who will experience a significant hardship in obtaining the medical care needed for the treatment of an illness or recovery from an injury if medical services are not provided in the home setting. The lack of transportation does not automatically qualify an individual to be considered homebound.

References

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 7. Home Health Services. Rev. 258, Issue date 03-22-19. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed on September 26, 2023.
2. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination. Home nurses' visits to patients requiring heparin injection. NCD #290.2. Effective date not posted. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=210&ncdver=‌1&DocID=290.2&bc=gAAAAAgAAAAA&. Accessed on September 26, 2023.
3. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination. Home health visits to a blind diabetic. NCD #290.1. Version #2. Effective October 1, 2006. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=209&ncdver=2&‌CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=home+health+visits&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&. Accessed on September 26, 2023.
4. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination. Postural drainage procedures and pulmonary exercises. NCD #240.7. Effective September 1, 1988. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=17&ncdver=‌1&DocID=240.7&bc=gAAAAAgAAAAA&. Accessed on September 26, 2023.

Index

Home Health

History

Status