QUEST Integration – Home IV Therapy – Criteria for Coverage

Original Effective Date:

04/01/1999

Current Effective Date:

01/01/2015

Home infusion therapy is the administration of injectable prescription drugs and solutions under a treatment plan prescribed by a physician and supervised by a licensed registered nurse with IV certification.

The use of home therapy was developed as an alternative to hospitalization and is considered to be most cost effective when the therapy is begun in the hospital, with both training and identification of adverse reactions occurring prior to initiation of home therapy.

Benefit Coverage

Home IV and injection therapy will be covered by HMSA plans when:

• The patient meets the definition of homebound. Homebound is defined when due to illness or injury, a patient is unable to leave home, or when doing so requires a considerable and taxing effort, OR
• The patient requires continuous therapy after discharge from the hospital or other institution, OR
• Therapy can be safely and effectively provided at home in lieu of hospitalization.

In addition, all of the following criteria must be met:

• The home IV therapy or injection is prescribed by a licensed medical practitioner with the appropriative prescriptive authority as part of a treatment plan for a covered medical condition.
• The drug is medically appropriate to treat the patient’s medical condition and is covered under the QUEST Integration plan, and administration of the drug via home infusion or injection is sage and cost-effective.
• The patient and family/caregiver are capable of co-managing the home therapy and have been fully informed of the potential risks, and the home is adequately equipped to manage the services.

Limitations

HMSA will not cover home IV therapy or injection services for patients when any of the following is true:

• The therapy is being administered in the home setting for the convenience of the patient (e.g., the patient is able to commute to an outpatient facility for services, but the patient prefers to receive therapy at home).
• The drugs prescribed can be administered by alternative routes (e.g., oral) to achieve the same or equivalent therapeutic effect.
• If there is more than one medically appropriate method of treating a member’s medical condition, HMSA's benefit may be based on the lower-cost method, even if the health-care provider elects to treat the member by a more expensive method.
• The services are performed to administer an investigational or otherwise excluded drug.
• If the patient requires a drug that is hazardous and requires extensive monitoring, the drug should be administered in a facility that has appropriate provisions for acute intervention.

Notes

Some patients may require multiple services that can be delivered more cost-effectively in a facility (inpatient or outpatient) or in the physician’s office.

In general, certain types of chemotherapy are not appropriate in the home setting. If the patient does not meet the homebound criteria as described, or if part of the therapy requires direct physician supervision (as defined by product package information) in an office or outpatient treatment center, the therapy will not be approved for the home setting.

Revision History