RETIRED: REVIEWED/Revised: 12/14; 10/15; 1/16; 9/16, 10/16, 5/17, 5/18, 9/18

Transcription

1 PAGE: 1 of 9 Scope Louisiana Healthcare Connections (LHCC) Medical Department Purpose To provide medical necessity criteria for obstetrical Home Health programs offered by vendors such as Optum Obstetrical Home Care (formerly Alere Women s and Children s Health, LLC). Policy The policy of LHCC is to provide home health services when the services are medically necessary for members who meet the following criteria: A. Obstetrical Nurse Assessment B. Metoclopramide or Ondansetron Infusion Therapy C. Hydration Therapy 1 to 4 liters D. Gestational Diabetes Clinical Program (case rate for Optum) E. Obstetrical Diabetes - Daily Insulin Injections F. Obstetrical Diabetes Insulin Pump G. Gestational Hypertension Program H. Preeclampsia Program I. Preterm Labor Program J. Non-Stress Test (NST)/Fetal Heart Rate (FHR) Monitoring K. Dietary Analysis L. Progesterone Injections for the Prevention of Preterm Labor A. Obstetrical Nurse Assessment Approve one obstetrical nurse assessment with each of the following programs/conditions listed below in items B-L approved per pregnancy. B. Metoclopramide or Ondansetron Infusion Therapy See CP.MP.34 Hyperemesis Gravidarum Treatment for medical necessity guidelines for metoclopramide or Ondansetron Therapy. C. Hydration Therapy 1 to 4 liters Hydration Therapy is medically necessary for members who could benefit from close surveillance for the onset of dehydration. Examples of diagnoses include the following: Hyperemesis Gravidarum Malabsorption Centene Medical Policy Statements represent technical documents developed by the Medical Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to Medical Staff personnel.

2 PAGE: 2 of 9 Diagnosis, such as flu or GI virus, which depletes the patient s ability to maintain fluid and/or food in the system. Authorize visits as necessary to prevent hospitalization from dehydration. D. Gestational Diabetes Clinical Program (case rate for Optum) The Gestational Diabetes Clinical Program is medically necessary for pregnant members with one of the following: Gestational diabetes with need for diet and exercise control with or without oral glycemic agents. Gestational diabetes is diagnosed in pregnant women who have at least two abnormal results during the 100 gram three hour oral Glucose Tolerance Test (GTT) with the following minimum lab values per either Carpenter and Coustan or National Diabetes Data Group Conversions: Plasma or Serum Glucose Level Carpenter & Coustan Conversion Plasma Level National Diabetes Data Group Conversion Status mg/dl mmol/l mg/dl mmol/l Fasting One hour Two hours Three hours Type 2 diabetes in pregnancy with need for diet and exercise control with or without oral glycemic agents and non-insulin dependent Approve 1 unit for the program case rate to be valid for 1 month. Optum program is 21 days in duration. E. Obstetrical Diabetes - Daily Insulin Injections Obstetrical Diabetes - Daily Insulin Injections is medically necessary for pregnant members with both: Gestational or pre-gestational diabetes unable to reach target goals through diet and activity. Insulin is administered by daily injections. Approve 7 visits for a 1 month span. Requests for additional visits must be accompanied by clinical documentation demonstrating continued Centene Medical Policy Statements represent technical documents developed by the Medical Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to Medical Staff personnel.

3 PAGE: 3 of 9 need for nurse monitoring that cannot be conducted by the MD or LHCC OB Care Manager. F. Obstetrical Diabetes Insulin Pump Obstetrical Diabetes - Insulin Pump is medically necessary for pregnant members who had a new insulin pump approved based on the appropriate medical necessity criteria. Approve 7 visits for 1 month span. Requests for additional visits must be accompanied by clinical documentation demonstrating a continuous need for nurse monitoring that cannot be conducted by the MD or LHCC OB Care Manager. G. Gestational Hypertension Program The Gestational Hypertension Program is medically necessary for members with one of the following: Elevated or unstable blood pressure Member who could benefit from education and surveillance for the potential onset of hypertension. These categories include the following: Family history of hypertension during pregnancy Previous episode of hypertension during previous pregnancy Chronic hypertension Multiple gestation Diabetes Mellitus Approve one visit for assessment and education to establish a selfmonitoring program Centene Medical Policy Statements represent technical documents developed by the Medical Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to Medical Staff personnel.

4 PAGE: 4 of 9 H. Preeclampsia Program The Preeclampsia Program is medically necessary for pregnant members who are diagnosed with preeclampsia characterized by the diagnostic criteria in 1 and 2 OR 1 and 3 below: 1. Blood pressure 140 mm Hg systolic or 90 mm Hg diastolic on two occasions at least 4 hours apart after 20 weeks gestation in a woman with a previously normal blood pressure; 160 mm Hg systolic or 110 mm Hg diastolic 2. Proteinuria 300 mg per 24-hour urine collection (or this amount extrapolate from a timed collection); Protein/creatinine ratio 0.3 mg/dl; Dipstick reading of 1+ (used only if other quantitative methods not available) 3. In the absence of proteinuria, new-onset hypertension with the new onset of any of the following: Thrombocytopenia indicated by a platelet count < 100,000/microliter; Renal insufficiency indicated by serum creatinine concentrations > 1.1 mg/dl or doubling of the serum creatinine concentration in the absence of other renal disease; Impaired liver function indicated by elevated blood concentrations of liver transaminases to twice normal concentration; Pulmonary edema; Cerebral or visual symptoms Authorize 3 visits for 1 week duration. Requests for additional visits must be accompanied by clinical documentation demonstrating a continuous need for nurse monitoring that cannot be conducted by the MD or LHCC OB Care Manager I. Preterm Labor Program The Preterm Labor Program is medically necessary for pregnant members diagnosed with preterm labor. Early signs and symptoms of preterm labor can include menstrual-like cramping; mild, irregular Centene Medical Policy Statements represent technical documents developed by the Medical Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to Medical Staff personnel.

5 PAGE: 5 of 9 contractions; low back ache; pressure sensation in the vagina; or vaginal discharge of mucus, which may be clear, pink, or slightly bloody. Authorize 3 visits for 1 week. Requests for additional visits must be accompanied by clinical documentation demonstrating a continuous need for nurse monitoring that cannot be conducted by the MD or Health Plan OB Care Manager. J. NST/FHR Monitoring See CP.MP.32 Antepartum Fetal Surveillance for medical necessity criteria and frequency of visits. K. Dietary Analysis A dietary Analysis is medically necessary for members with a diagnosis of obesity or malnutrition. Authorize one visit per pregnancy. L. Progesterone Injections for the Prevention of Preterm Labor Injectable progesterone is considered medically necessary for the prevention of preterm labor and does not require authorization. However, when given at home through a Home Health agency, an authorization for Home Health visits is required and should follow the algorithm below: Centene Medical Policy Statements represent technical documents developed by the Medical Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to Medical Staff personnel.

6 PAGE: 6 of 9 Centene Medical Policy Statements represent technical documents developed by the Medical Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to Medical Staff personnel.

7 PAGE: 7 of 9 It is the policy of LHCC that the following services provided by a home health vendor are considered not medically necessary: Betamethasone Therapy via Intermittent Injections Multiple Gestation Program (refer to individual program for identified risk factor) Continuous Heparin Infusion Therapy Patient Administered NST/FHR monitoring Gestational Diabetes Clinical Program w/oral Meds Preterm Premature Rupture of Membranes (PPROM) Program Background Optum OB Homecare programs include risk assessment and education for identifying pregnant women at risk for complications, Care and homecare services for high-risk pregnancies. Obstetrical homecare services include providers; diagnostics, devices and timely actionable information that assist women to create better healthcare decisions. Coding Implications The following codes are for informational purposes only. They are current at time of review of this policy. Inclusion or exclusion of any codes does not guarantee coverage Optum specific Description program codes (HCPCS) S9123 Obstetrical Nurse Assessment S9374 Hydration therapy, 1 liter S9377 Hydration therapy, 4 liters S9140 Gestational diabetes clinical management program S9214 Obstetrical diabetes management daily insulin injections S9653 Obstetrical diabetes management insulin pump S9211 Gestational hypertension S9213 Preeclampsia program S9208 Preterm labor management program S9470 Dietary analysis S9560 Home Injectable Therapy Centene Medical Policy Statements represent technical documents developed by the Medical Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to Medical Staff personnel.

8 PAGE: 8 of 9 References American College of Obstetricians and Gynecologists (ACOG). Task Force in Pregnancy. Hypertension in pregnancy ACOG Committee on Practice Bulletins Obstetrics. Gestational diabetes mellitus. Number 137, August Coustan DR, Jovanovic L. Medical management and follow-up of gestational diabetes mellitus. In: Up-to-date, Nathan DM, Greene, MF (Ed), Up-to-date, Philadelphia, PA, Coustan DR, Jovanovic L. Screening and diagnosis of diabetes mellitus during pregnancy. In: Up-to-date, Nathan DM, Greene MF (Ed), Up-to-date, Philadelphia, PA, Lee M-J, Guinn D. Antenatal corticosteroid therapy for reduction of neonatal morbidity and mortality from preterm delivery. In: Up-to-date, Lockwood CJ (Ed), Up-to-date, Philadelphia, PA, Lockwood CJ. Overview of preterm labor and birth. In: Up-to-date: Ramin SM (Ed), Up-to-date, Philadelphia, PA, Menato G, et al. Current management of gestational diabetes mellitus. Expert Rev of Obstet Gynecol. 2008; 3(1): Smith JA, Refuerzo JS, Ramin SM. Treatment and outcome of nausea and vomiting of pregnancy. In: Up-to-date, Lockwood, CJ (Ed), Up-to-date, Philadelphia, PA, Healthy Louisiana Performance Measures Submission Guide Preterm Birth (PTB), Page 15 Centene Medical Policy Statements represent technical documents developed by the Medical Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to Medical Staff personnel.

9 PAGE: 9 of 9 Revision Log Date No revisions 10/15 Removed the requirement for ultrasound for Progesterone 1/16 Injections at 16 weeks. Grammar edits, changed case to care Injectable progesterone algorithm changed 10/16 The Plan changed to LHCC Grammar edits in Purpose Changed Alere Women s Health to Optum Obstetrical Home Health 5/17 Updated List of Coding Implications (Covered Codes) Added clarification to Obstetrical Nurse Assessment criteria 5/18 Updated Progesterone Workflow- gestational weeks limit from 21 to 9/18 24 weeks to align with LDH Performance Measure Standards APPROVAL The electronic approval retained in Archer GRC, Centene's P&P management software, is considered equivalent to a physical signature. VP Medical : Electronic Signature on File Sr. VP Medical Affairs: Electronic Signature on File Centene Medical Policy Statements represent technical documents developed by the Medical Staff. Questions regarding interpretation of these policies for the purposes of benefit coverage should be directed to Medical Staff personnel.