Harvard Pilgrim Health Care Medical Policy

Home Infusion Therapy Services

STRIDE^sm (HMO) MEDICARE ADVANTAGE

Subject: Home Infusion Therapy (HIT) Services

Background:

Home Infusion Therapy Services provide an essential service when the home setting provides

• A safe, effective, and less costly alternative to inpatient (e.g., in a hospital, LTAC, or SNF) or outpatient settings;
• Skilled infusion nurses (provided directly by the infusion pharmacy, or by an affiliated contracted home health agency) provide timely evaluation/assessment of the patient, appropriate patient education and training, and monitoring of the patient's clinical status and response to treatment;
• Requested services are medically necessary to achieve defined medical goals and expected to improve the patient's condition in a reasonable (and generally predictable) period of time.

Authorization:

Prior authorization from Harvard Pilgrim Stride^sm (HMO) Medicare Advantage is required for all HIT services.

Additional review is required to evaluate the medical necessity and clinical appropriateness of the following medical benefit drugs – please refer to the Stride Prior Authorization List for complete list:

• Antiemetics including Aloxi® (palonosetron HCI injection) and Emend® (fosaprepitant dimeglumine)
• Orencia® (abatacept)
• Remicade® (infliximab)
• Rituxan® (rituximab)
• Stelara™ (ustekinumab)
• Yervoy (ipilimumab)

Note: Criteria used to review/authorize drugs listed above can be accessed under Medical Management on Harvard Pilgrim's Provider site.

Policy and Coverage Criteria:

Harvard Pilgrim Stride^sm (HMO) Medicare Advantage considers Home Infusion Therapy (HIT) services (including associated pumps, equipment, supplies, and professional services) as medically necessary for members when ALL the following criteria are met:

• Covered HIT services must be:
• Reasonable and medically necessary based on the member's condition, complexity of requested service(s), and accepted standards of clinical practice;
• An essential part of active treatment of the member's medical condition, and ordered under a plan of care established and reviewed regularly by the attending physician caring for the member; and Furnished by provider(s) with appropriate state licensure, and accreditation/certification from an appropriate accrediting organization.
• Administration of the requested drug is:
• Ordered by the attending physician;
• Reasonable and medically necessary for the member's condition; and
• An essential part of the active treatment plan developed by the physician caring for the member.

Exclusions:

Harvard Pilgrim Stride^sm (HMO) Medicare Advantage considers home infusion therapy (HIT) services as not medically necessary for all other indications. In addition, Harvard Pilgrim Stride^sm (HMO) Medicare Advantage does not cover:

• Medical benefit drugs listed above when relevant drug-specific criteria are not met
• Private duty nursing or block nursing services

HPHC Medical Policy
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Home Infusion Therapy (HIT) Services
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Harvard Pilgrim Stride^sm (HMO) policies are based on medical science and relevant information including current Medicare coverage (including National and Local Coverage Determinations), Harvard Pilgrim medical policies, and Harvard Pilgrim Stride^sm (HMO) Medicare Advantage Plan materials. These policies are intended to provide benefit coverage information and guidelines specific to the Harvard Pilgrim Stride^sm (HMO) Medicare Advantage Plan. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.