Home Health, Skilled, and Custodial Care Services (for Commercial

Home Health, Skilled, and Custodial Care Services (for Commercial Only)

Page 1 of 11

UnitedHealthcare Commercial Medical Policy

Effective 05/01/2024

UnitedHealthcare

Commercial

Medical Policy

Home Health, Skilled, and Custodial Care Services

(for Commercial Only)

Policy Number: MP.022.23

Effective Date: May 1, 2024

 Instructions for Use

Table of Contents Page

Application ..................................................................................... 1

Coverage Rationale ....................................................................... 1

Definitions ...................................................................................... 1

Applicable Codes .......................................................................... 2

Description of Services ................................................................. 9

Benefit Considerations .................................................................. 9

U.S. Food and Drug Administration ........................................... 10

References ................................................................................... 10

Policy History/Revision Information ........................................... 10

Instructions for Use ..................................................................... 11

Application

This Medical Policy applies to all UnitedHealthcare Commercial benefit plans.

Coverage Rationale

 See Benefit Considerations

Home health and skilled care services are considered medically necessary in certain circumstances. For medical

necessity clinical coverage criteria, refer to the InterQual

LOC: Home Care Q & A:

Home Care Services, Adult

Home Care Services, Pediatric

Click here to view the InterQual

criteria.

Definitions

The following definitions may not apply to all plans. Refer to the member specific benefit plan document for applicable

definitions.

Place of Residence: Wherever the member makes his/her home. This may include a dwelling, an apartment, a relative's home,

or a facility-based long-term care residence, such as a board and care home, an assisted living facility, a nursing home, and a

continuing care retirement community (National Institute on Aging, 2017a).

Related Commercial Policies

• Home Hemodialysis

•

Private Duty Nursing Services

Community Plan Policy

• Home Health, Skilled, and Custodial Care Services

Medicare Advantage Coverage Summary

• Home Health Services, Home Health Visits, Respite

Care, and Hospice Care

Home Health, Skilled, and Custodial Care Services (for Commercial Only)

Page 2 of 11

UnitedHealthcare Commercial Medical Policy

Effective 05/01/2024

Respite Care: Short-term relief for primary caregivers that can be provided at the member’s Place of Residence, in a healthcare

facility or at an adult day center. The relief period can be arranged for just an afternoon or for several days or weeks (National

Institute on Aging, 2017b).

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive.

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service.

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may

require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim

payment. Other Policies and Guidelines may apply.

CPT Code

Description

99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine

monitoring, and gestational diabetes monitoring

99501 Home visit for postnatal assessment and follow-up care

99502 Home visit for newborn care and assessment

99503 Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment,

apnea evaluation)

99504 Home visit for mechanical ventilation care

99505 Home visit for stoma care and maintenance including colostomy and cystostomy

99506 Home visit for intramuscular injections

99507 Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral)

99511 Home visit for fecal impaction management and enema administration

99512 Home visit for hemodialysis

99601 Home infusion/specialty drug administration, per visit (up to 2 hours);

99602 Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List

separately in addition to code for primary procedure)

CPT

is a registered trademark of the American Medical Association

HCPCS Code

Description

G0068 Professional services for the administration of anti-infective, pain management, chelation, pulmonary

hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or

other highly complex drug or biological) for each infusion drug administration calendar day in the

individual's home, each 15 minutes

G0069 Professional services for the administration of subcutaneous immunotherapy or other subcutaneous

infusion drug or biological for each infusion drug administration calendar day in the individual's home,

each 15 minutes

G0070 Professional services for the administration of intravenous chemotherapy or other intravenous highly

complex drug or biological infusion for each infusion drug administration calendar day in the individual's

home, each 15 minutes

G0088

Professional services, initial visit, for the administration of anti-infective, pain management, chelation,

pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding

chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar

day in the individual's home, each 15 minutes

G0089 Professional services, initial visit, for the administration of subcutaneous immunotherapy or other

subcutaneous infusion drug or biological for each infusion drug administration calendar day in the

individual's home, each 15 minutes

Home Health, Skilled, and Custodial Care Services (for Commercial Only)

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UnitedHealthcare Commercial Medical Policy

Effective 05/01/2024

HCPCS Code

Description

G0090 Professional services, initial visit, for the administration of intravenous chemotherapy or other highly

complex infusion drug or biological for each infusion drug administration calendar day in the individual's

home, each 15 minutes

G0153

Services performed by a qualified speech-language pathologist in the home health or hospice setting,

each 15 minutes

G0155 Services of clinical social 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

G0157

Services performed by a qualified physical therapist assistant in the home health or hospice setting,

each 15 minutes

G0158 Services performed by a qualified occupational therapist assistant in the home health or hospice setting,

each 15 minutes

G0159

Services performed by a qualified physical therapist, in the home health setting, in the establishment or

delivery of a safe and effective physical therapy maintenance program, each 15 minutes

G0160 Services performed by a qualified occupational therapist, in the home health setting, in the

establishment or delivery of a safe and effective occupational therapy maintenance program, each 15

minutes

G0161 Services performed by a qualified speech-language pathologist, in the home health setting, in the

establishment or delivery of a safe and effective speech-language pathology maintenance program, each

15 minutes

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

G0300

Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting,

each 15 minutes

G0320 Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio

and video telecommunications system

G0321

Home health services furnished using synchronous telemedicine rendered via telephone or other real-

time interactive audio-only telecommunications system

G0322 The collection of physiologic data digitally stored and/or transmitted by the patient to the home health

agency (i.e., remote patient monitoring)

G0490

Face-to-face home health nursing visit by a rural health clinic (RHC) or federally qualified health center

(FQHC) in an area with a shortage of home health agencies; (services limited to RN or LPN only)

G0493 Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition,

each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and

evaluate the patient's need for possible modification of treatment in the home health or hospice setting)

G0494 Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's

condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to

identify and evaluate the patient's need for possible modification of treatment in the home health or

hospice setting)

G0495

Skilled services of a registered nurse (RN), in the training and/or education of a patient or family

member, in the home health or hospice setting, each 15 minutes

G0496 Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family

member, in the home health or hospice setting, each 15 minutes

G2168

Services performed by a physical therapist assistant in the home health setting in the delivery of a safe

and effective physical therapy maintenance program, each 15 minutes

Home Health, Skilled, and Custodial Care Services (for Commercial Only)

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UnitedHealthcare Commercial Medical Policy

Effective 05/01/2024

HCPCS Code

Description

G2169 Services performed by an occupational therapist assistant in the home health setting in the delivery of a

safe and effective occupational therapy maintenance program, each 15 minutes

H1004 Prenatal care, at-risk enhanced service; follow-up home visit

S5035 Home infusion therapy, routine service of infusion device (e.g., pump maintenance)

S5036 Home infusion therapy, repair of infusion device (e.g., pump repair)

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

S5180 Home health respiratory therapy, initial evaluation

S5181 Home health respiratory therapy, NOS, per diem

S5497 Home infusion therapy, catheter care/maintenance, not otherwise classified; includes administrative

services, professional pharmacy services, care coordination, and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S5498

Home infusion therapy, catheter care/maintenance, simple (single lumen), includes administrative

services, professional pharmacy services, care coordination and all necessary supplies and equipment,

(drugs and nursing visits coded separately), per diem

S5501 Home infusion therapy, catheter care/maintenance, complex (more than one lumen), includes

administrative services, professional pharmacy services, care coordination, and all necessary supplies

and equipment (drugs and nursing visits coded separately), per diem

S5502 Home infusion therapy, catheter care/maintenance, implanted access device, includes administrative

services, professional pharmacy services, care coordination and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem (Use this code for interim maintenance of vascular

access not currently in use)

S5517 Home infusion therapy, all supplies necessary for restoration of catheter patency or declotting

S5518 Home infusion therapy, all supplies necessary for catheter repair

S5520

Home infusion therapy, all supplies (including catheter) necessary for a peripherally inserted central

venous catheter (PICC) line insertion

S5521 Home infusion therapy, all supplies (including catheter) necessary for a midline catheter insertion

S5522 Home infusion therapy, insertion of peripherally inserted central venous catheter (PICC), nursing

services only (no supplies or catheter included)

S5523 Home infusion therapy, insertion of midline venous catheter, nursing services only (no supplies or

catheter included)

S9061 Home administration of aerosolized drug therapy (e.g., Pentamidine); administrative services,

professional pharmacy services, care coordination, all necessary supplies and equipment (drugs and

nursing visits coded separately), per diem

S9097 Home visit for wound care

S9098 Home visit, phototherapy services (e.g., Bili-lite), including equipment rental, nursing services, blood

draw, supplies, and other services, per diem

S9122 Home health aide or certified nurse assistant, providing care in the home; per hour

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)

S9124 Nursing care, in the home; by licensed practical nurse, per hour

S9127 Social work visit, in the home, per diem

Home Health, Skilled, and Custodial Care Services (for Commercial Only)

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UnitedHealthcare Commercial Medical Policy

Effective 05/01/2024

HCPCS Code

Description

S9208 Home management of preterm labor, including administrative services, professional pharmacy services,

care coordination, and all necessary supplies or equipment (drugs and nursing visits coded separately),

per diem (do not use this code with any home infusion per diem code)

S9209

Home management of preterm premature rupture of membranes (PPROM), including administrative

services, professional pharmacy services, care coordination, and all necessary supplies or equipment

(drugs and nursing visits coded separately), per diem (do not use this code with any home infusion per

diem code)

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)

S9212 Home management of postpartum 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 services coded

separately); per diem (do not use this code with any home infusion per diem code)

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)

S9325 Home infusion therapy, pain management infusion; 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 S9326, S9327 or S9328)

S9326

Home infusion therapy, continuous (24 hours or more) pain management infusion; administrative

services, professional pharmacy services, care coordination and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S9327 Home infusion therapy, intermittent (less than 24 hours) pain management infusion; administrative

services, professional pharmacy services, care coordination, and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S9328 Home infusion therapy, implanted pump pain management infusion; administrative services,

professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs

and nursing visits coded separately), per diem

S9329

Home infusion therapy, chemotherapy infusion; 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 S9330 or S9331)

S9330 Home infusion therapy, continuous (24 hours or more) chemotherapy infusion; administrative services,

professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs

and nursing visits coded separately), per diem

S9331 Home infusion therapy, intermittent (less than 24 hours) chemotherapy infusion; administrative services,

professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs

and nursing visits coded separately), per diem

S9335

Home therapy, hemodialysis; administrative services, professional pharmacy services, care coordination,

and all necessary supplies and equipment (drugs and nursing services coded separately), per diem

S9336 Home infusion therapy, continuous anticoagulant infusion therapy (e.g., Heparin), administrative

services, professional pharmacy services, care coordination and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S9338 Home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care

coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per

diem

Home Health, Skilled, and Custodial Care Services (for Commercial Only)

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UnitedHealthcare Commercial Medical Policy

Effective 05/01/2024

HCPCS Code

Description

S9339 Home therapy; peritoneal dialysis, administrative services, professional pharmacy services, care

coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per

diem

S9340

Home therapy; enteral nutrition; administrative services, professional pharmacy services, care

coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded

separately), per diem

S9341 Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy services, care

coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded

separately), per diem

S9342 Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care

coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded

separately), per diem

S9343

Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care

coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded

separately), per diem

S9345 Home infusion therapy, antihemophilic agent infusion therapy (e.g., factor VIII); administrative services,

professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs

and nursing visits coded separately), per diem

S9346 Home infusion therapy, alpha-1-proteinase inhibitor (e.g., Prolastin); administrative services, professional

pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing

visits coded separately), per diem

S9347

Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous infusion

therapy (e.g., epoprostenol); administrative services, professional pharmacy services, care coordination,

and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

S9348 Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., Dobutamine);

administrative services, professional pharmacy services, care coordination, all necessary supplies and

equipment (drugs and nursing visits coded separately), per diem

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

S9355 Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care

coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per

diem

S9357 Home infusion therapy, enzyme replacement intravenous therapy; (e.g., Imiglucerase); administrative

services, professional pharmacy services, care coordination, and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S9359

Home infusion therapy, antitumor necrosis factor intravenous therapy; (e.g., Infliximab); administrative

services, professional pharmacy services, care coordination, and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S9361 Home infusion therapy, diuretic intravenous therapy; administrative services, professional pharmacy

services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded

separately), per diem

S9363 Home infusion therapy, antispasmotic therapy; administrative services, professional pharmacy services,

care coordination, and all necessary supplies and equipment (drugs and nursing visits coded

separately), per diem

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UnitedHealthcare Commercial Medical Policy

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HCPCS Code

Description

S9364 Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy

services, care coordination, and all necessary supplies and equipment including standard TPN formula

(lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded

separately), per diem (do not use with home infusion codes S9365-S9368 using daily volume scales)

S9365

Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative services,

professional pharmacy services, care coordination, and all necessary supplies and equipment including

standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and

nursing visits coded separately), per diem

S9366

Home infusion therapy, total parenteral nutrition (TPN); 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 including standard TPN formula (lipids, specialty amino acid formulas, drugs

other than in standard formula and nursing visits coded separately), per diem

S9367 Home infusion therapy, total parenteral nutrition (TPN); 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 including standard TPN formula (lipids, specialty amino acid formulas, drugs

other than in standard formula and nursing visits coded separately), per diem

S9368 Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative

services, professional pharmacy services, care coordination, and all necessary supplies and equipment

including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard

formula and nursing visits coded separately), per diem

S9370 Home therapy, intermittent antiemetic injection therapy; administrative services, professional pharmacy

services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded

separately), per diem

S9372

Home therapy; intermittent anticoagulant injection therapy (e.g., Heparin); 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 for flushing of infusion devices with

Heparin to maintain patency)

S9373

Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care

coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per

diem (do not use with hydration therapy codes S9374-S9377 using daily volume scales)

S9374 Home infusion therapy, hydration therapy; 1 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 1 liter but no more than 2 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 2 liters but no more than 3 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 3 liters per day, administrative services,

professional pharmacy services, care coordination, and all necessary supplies (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

S9474 Enterostomal therapy by a registered nurse certified in enterostomal therapy, per diem

S9490 Home infusion therapy, corticosteroid infusion; administrative services, professional pharmacy services,

care coordination, and all necessary supplies and equipment (drugs and nursing visits coded

separately), per diem

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UnitedHealthcare Commercial Medical Policy

Effective 05/01/2024

HCPCS Code

Description

S9494 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; 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 home infusion codes for hourly dosing

schedules S9497-S9504)

S9497

Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours; administrative

services, professional pharmacy services, care coordination, and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S9500 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative

services, professional pharmacy services, care coordination, and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S9501 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative

services, professional pharmacy services, care coordination, and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S9502

Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative

services, professional pharmacy services, care coordination, and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S9503 Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours; administrative services,

professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs

and nursing visits coded separately), per diem

S9504 Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours; administrative services,

professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs

and nursing visits coded separately), per diem

S9537

Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, G-CSF, GM-CSF);

administrative services, professional pharmacy services, care coordination, and all necessary supplies

and equipment (drugs and nursing visits coded separately), per diem

S9538 Home transfusion of blood product(s); administrative services, professional pharmacy services, care

coordination and all necessary supplies and equipment (blood products, drugs, and nursing visits coded

separately), per diem

S9542 Home injectable therapy, not otherwise classified, including administrative services, professional

pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing

visits coded separately), per diem

S9559

Home injectable therapy, interferon, including administrative services, professional pharmacy services,

care coordination, and all necessary supplies and equipment (drugs and nursing visits coded

separately), per diem

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

S9562 Home injectable therapy, palivizumab or other monoclonal antibody for RSV, including administrative

services, professional pharmacy services, care coordination, and all necessary supplies and equipment

(drugs and nursing visits coded separately), per diem

S9590

Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); including

administrative services, professional pharmacy services, care coordination, and all necessary supplies

and equipment (drugs and nursing visits coded separately), per diem

T1001 Nursing assessment/evaluation

T1002 RN services, up to 15 minutes

T1003 LPN/LVN services, up to 15 minutes

T1004 Services of a qualified nursing aide, up to 15 minutes

T1005 Respite care services, up to 15 minutes

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UnitedHealthcare Commercial Medical Policy

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HCPCS Code

Description

T1021 Home health aide or certified nurse assistant, per visit

T1022 Contracted home health agency services, all services provided under contract, per day

T1028

Assessment of home, physical and family environment, to determine suitability to meet patient's medical

needs

T1030 Nursing care, in the home, by registered nurse, per diem

T1031 Nursing care, in the home, by licensed practical nurse, per diem

T1502

Administration of oral, intramuscular and/or subcutaneous medication by health care

agency/professional, per visit

Description of Services

Home health care services are short-term services, prescribed by treating practitioner or specialist (M.D., D.O., P.A. or N.P.)

delivered within a health plan member’s residence and are designed to help a member recover after an illness, injury, hospital

stay, or surgery, or to help manage a chronic condition with the goal of preventing an unplanned hospitalization or prolonging a

current hospitalization. Home health care services are provided intermittently to restore or maintain a member’s maximal level

of function and health in lieu of receiving the services in an outpatient setting or in an acute or sub-acute health care setting.

Skilled care services are medically necessary services provided in the member’s Place of Residence by licensed health care

professionals and may include services such as medical or psychological evaluation, wound care, medication teaching, pain

management, disease education and management, physical therapy, speech therapy, or occupational therapy.

Custodial care services are non-medical services that provide assistance with personal care such as activities of daily living,

housekeeping, cooking, laundry, or supervision of self-administered medication that can reasonably and safely be provided by

non-licensed caregivers.

Benefit Considerations

The services being requested must also meet all of the following criteria:

A written treatment plan must be submitted with the request for specific services and supplies. Periodic review of the

written treatment plan may be required for continued skilled care needs and progress toward goals; and

Be ordered and directed by a treating practitioner or specialist (M.D., D.O., P.A. or N.P.); and

The care must be delivered or supervised by a licensed professional in order to obtain a specified medical outcome; and

Services are:

o Not custodial care in nature; and

o Not provided for the comfort and convenience of the member or the member’s family; and

o Provided in the home in lieu of skilled care in another setting (including but not limited to a nursing facility, acute

inpatient rehabilitation, or a hospital); and

o Clinically appropriate and not more costly than an alternative health service; and

o Intermittent and part time (typically provided for less than 4 hours per day)

Note: Intermittent care exceptions may be made in certain circumstances when the need for more care is finite and

predictable.

Additional Information

Skilled care in the member’s Place of Residence. Skilled care includes:

o Skilled nursing

o Skilled rehabilitation (physical therapy, occupational therapy, and speech therapy)

o Skilled teaching

For Skilled care to be covered in the member’s Place of Residence, the care provided must require clinical training in order

to be delivered safely and effectively

Eligible physical, occupational, and speech therapy:

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UnitedHealthcare Commercial Medical Policy

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o Received in the home from a home health agency is covered under the home health care benefit

o Received in the home from an independent physical, occupational or speech therapist (a therapist that is not affiliated

with a home health agency) is covered under the rehabilitation services - outpatient therapy benefit

Medical supplies and medications that are used in conjunction with a home health care visit are covered as part of that

visit. Examples include but are not limited to:

o Catheters

o Irrigation devices

o Surgical dressing

o Syringes

Refer to the member’s specific plan document for any applicable visit limitations.

Coverage Limitations and Exclusions

Covered pharmaceuticals, drugs, and durable medical equipment provided in connection with home health services may be

subject to separate benefit categories. Reference the durable medical equipment and the pharmaceutical products benefit

sections of the member specific benefit plan document. Home health care benefits do not include:

Custodial care

Domiciliary care

Private duty nursing

Respite care

Rest cures

Homemaker services such as home meal delivery services (e.g., Meals-on-Wheels) or transportation services (e.g., Dial-a-

Ride)

Independent nurse hired directly by the family/member

Services provided by personal care attendants, family members, or caregivers who are not properly licensed and qualified

by law

Home health services beyond benefit limits (e.g., number of visits)

UnitedHealthcare will determine if benefits are available by reviewing both the skilled nature of the service and the need for

Physician-directed medical management. A service will not be determined to be "skilled" simply because there is not an

available caregiver.

U.S. Food and Drug Administration (FDA)

This section is to be used for informational purposes only. FDA approval alone is not a basis for coverage.

Home health care, including skilled care are services rendered by licensed health care professionals and, therefore, not subject

to regulation by the FDA.

References

National Institute on Aging. Residential Facilities, Assisted Living, and Nursing Homes. U.S. Department of Health & Human

Services; May 01, 2017a.

National Institute on Aging. What Is Respite Care? U.S. Department of Health & Human Services; May 01, 2017b.

UnitedHealthcare Insurance Company Generic Certificate of Coverage 2018.

Policy History/Revision Information

Date

Summary of Changes

05/01/2024

Routine review; no change to coverage guidelines

Archived previous policy version MP.022.22

Home Health, Skilled, and Custodial Care Services (for Commercial Only)

Page 11 of 11

UnitedHealthcare Commercial Medical Policy

Effective 05/01/2024

Instructions for Use

This Medical Policy provides assistance in interpreting UnitedHealthcare standard benefit plans. When deciding coverage, the

member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from

the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using this policy,

please check the member specific benefit plan document and any applicable federal or state mandates. UnitedHealthcare

reserves the right to modify its Policies and Guidelines as necessary. This Medical Policy is provided for informational

purposes. It does not constitute medical advice.

This Medical Policy may also be applied to Medicare Advantage plans in certain instances. In the absence of a Medicare

National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare coverage guidance, CMS

allows a Medicare Advantage Organization (MAO) to create its own coverage determinations, using objective evidence-based

rationale relying on authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5).

UnitedHealthcare may also use tools developed by third parties, such as the InterQual

criteria, to assist us in administering

health benefits. UnitedHealthcare Medical Policies are intended to be used in connection with the independent professional

medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.