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Medical Policy: 10.01.03
Original Effective Date: December 2007
Reviewed: November 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Home infusion therapy is the administration of prescription drugs via intravenous, intraspinal, epidural, or subcutaneous routes and all of the components of care such as, but not limited to, nursing services, durable medical equipment, supplies, prescription and non-prescription drugs and solutions, pharmacy compounding and dispensing, specimen collection, patient and family education, home delivery of drugs and supplies, and management of emergencies arising from said therapy.
Home infusion is a proven safe and effective alternative to inpatient care for many disease states and therapies. Medical conditions commonly treated with home infusion therapy include, but are not limited to:
- Infections including respiratory, urinary tract, soft-tissue, post-operative infections, and pneumonia
- Cancer and cancer-related pain
- Gastrointestinal diseases or disorders which prevent normal functioning of the GI system
- AIDS-related conditions such as anemia, malnutrition, and severe pain
- Congestive heart failure
- Immune deficiencies
- Hemophilia
- Thalassemia
- High-risk pregnancy
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Growth disorders
A thorough patient assessment and home assessment must be performed before initiating infusion therapy at home to ensure that the patient is an appropriate candidate and home is a safe and suitable setting. Infusion therapy is prescribed by a physician as part of a treatment plan for a covered medical condition. The drug must be medically necessary for the patient’s medical condition and covered under the patient’s policy. Home nursing services are also provided to ensure proper patient education and training and to monitor the care of the patient in the home; these may be provided directly by infusion pharmacy nursing staff or by a qualified home health agency.
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Prior Approval:
Subject to precertification
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Policy:
Home infusion therapy services which may be considered medically necessary fall into one of several categories:
- Self-administered drugs require no nursing supervision in the home because they can be administered by the patient and/or family, but may require initial administration instruction by a nurse. Such drugs include, but are not limited to growth hormone and Factor XIII or IX.
- Some drugs require limited nursing supervision for initiation of therapy but the patient and/or family can be trained in administration. Examples of home infusion therapy situations requiring limited nursing supervision include, but are not limited to: IV hydration for hyperemesis gravidarum, or rehydration of a chronically ill patient otherwise maintained at home; total parenteral nutrition (TPN); pain management in chronic disease states such as cancer, AIDS, or other end-stage disease.
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Some home infusion services require intensive nursing supervision for frequent assessment for adverse reaction and/or the presence of the nurse in the home until the infusion is complete. Examples of such drugs include, but may not be limited to, Amphotericin B, Dobutamine, certain antibiotics, and certain chemotherapy agents.
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Home infusion therapy is considered not medically necessary for short-term pain management post-operatively or for acute episodes of pain.
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Home infusion therapy services not prescribed by a physician as part of a treatment plan for a covered medical condition are considered not medically necessary.
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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Selected References:
- Home Infusion Therapy Guide. June 2011 edition. Wellmark Blue Cross Blue Shield.
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Policy History:
Date Reason Action
December 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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