Criteria
I. Extended Hours Skilled Nursing
- Extended Hours Skilled Nursing in the home may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:
- The member has a skilled nursing care need that would otherwise be provided in a hospital or other active inpatient setting;
- The member has a condition that requires frequent (multiple times each day) nursing assessments and monitoring that result in changes in the plan of care and treatment goals in accordance with the individual's condition;
- The member's skilled care needs cannot be met through an intermittent Skilled Nursing visit;
- The complexity of the member's treatment plan requires the skills of a registered nurse (RN) or licensed practical nurse (LPN) working under the supervision of an RN;
- The required services are appropriate for the treatment of the illness or injury;
- The services are ordered by a physician, in accordance with his/her scope of practice (e.g., MD, DO) who has approved the written plan of care which includes all of the following:
- Disciplines providing care;
- Frequency and duration of all services;
- Demonstration of the need for services supported by all pertinent diagnoses;
- Member's functional level, medications, treatments, and clinical summary;
- Goals of care based on individualized needs of the member.
- The services are not provided in an inpatient or skilled nursing facility.
- Extended Hours Skilled Nursing in the home is provided to meet the skilled needs of the member only, not for the convenience of the family or caregiver.
II. Extended Hours Skilled Nursing - Ventilation Assistance/Ventilator Dependent
- Extended Hours Skilled Nursing in the home may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:
- The member meets all criteria in section I;
- The member is Ventilator Dependent at home for respiratory insufficiency;
- Mechanical ventilation for life support is needed for at least 6 continuous hours per day;
- Member is expected to be or has been Ventilator Dependent for 30 consecutive days;
- Member's physician has approved the home care plan;
- Member would otherwise require confinement to a skilled nursing or inpatient facility.
III. Ongoing Authorization
- Continued Extended Hours Skilled Nursing in the home may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following are met:
- All the criteria in section I or II continue to be met;
- Plan of care is updated at least each 60 days, which includes the following for indviduals age 18 or above:
- A statement of goals including long and short-term goals and need for continuing Medically Complex Home Care;
- The nursing and other adjunctive therapy progress notes indicating that necessary interventions or adjustments have been made;
- Expected course of the underlying disease and rehabilitation potential;
- Identification of current and potential ongoing Medically Complex Home Care needs;
- Reassessment and documentation of family or caregiver education and training including a review of the living environment and functionality with the goals of making the member and family or caregiver as independent as possible and gradually decreasing nursing care hours as the member's medical condition improves and/or the family or caregiver have been taught and demonstrate the skills and ability necessary to carry out the plan of care.
- A review of the developmental progress for neonates and pediatric indviduals must be reviewed in addition to meeting all elements of the care plan included in the criteria directly above (i.e., under Plan of care update) and criteria in section I or II.
IV. Discharge Criteria
- Extended Hours of Skilled Nursing in the home is considered NOT MEDICALLY NECESSARY AND APPROPRIATE when ONE OR MORE of the following have been met:
- The goals of treatment have been reached and the member no longer requires Extended Hours of Skilled Nursing care in the home.
- The family/caregiver have been taught the nursing services and have demonstrated the ability to carry out the plan of care.
- Medical and nursing documentation supports that the condition of the client is stable/predictable.
- Care becomes Custodial or Supportive including but not limited to the following:
- Routine individual care such as changing dressings, periodic turning and positioning in bed, administering oral medications
- Care of a stable tracheostomy (including intermittent suctioning)
- Care of a stable colostomy/ileostomy
- Care of a stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings
- Care of a stable indwelling bladder catheter (including emptying/changing containers and clamping tubing)
- Watching or protecting a member
- Respite care, adult (or child) day care, or convalescent care
- Institutional care, including room and board for rest cures, adult day care and convalescent care
- Help with the daily living activities, such as walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods
- Any services that a person without medical or paramedical training could be trained to perform
- Any service that can be performed by a person without any medical or paramedical training
- The plan of care does not require an RN or LPN to be in continuous attendance.
- Due to changes in the member's condition, care in an inpatient or skilled nursing facility, hospice, long-term acute care hospital or other facility is more appropriate.
V. Ineligible for Coverage as Extended Hours Skilled Nursing in the Home
- Member, family, and/or caregiver are unable or unwilling to comply with the plan of care, placing the member at risk of harm.
- Care provided solely for Respite of the family or caregiver.
- Care provided outside the home including but not limited to medical care in a clinic, outpatient facility, hospital, or skilled nursing or intermediate care facility, or licensed residential care facility except as stated in the benefit chart.
- Nursing care provided by the member's spouse, natural or adoptive child, parent, foster parent, brother, sister, grandparent or grandchild. This includes any person with an equivalent step or in-law relationship to the member.
- Care that is non-skilled in nature such as that performed by a companion or home health aide.
Documentation Submission
Written documentation by the physician specifying the medical necessity, according to the criteria above, is required. Requested documentation may include, but is not limited to:
- A completed Form CMS-485 - Home Health Certification and plan of care.
- Current physician's order:
- Renewed at least every 60 days if member's condition is not stable (i.e., member's status requires frequent changes in assessment or care plan); or
- Renewed at least every 6 months if the member's condition is stable.
- Home care records.
- Supporting documentation that describes the complexity and intensity of the member's care and the number and frequency of skilled nursing interventions needed.
