S9810, Home therapy; professional pharmacy services for provision of infusion,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical or genetic diagnostic documentation confirming the child has a disease/syndrome/disorder that includes low tone neuromuscular impairment, neurological impairment, or cognitive impairment.
- A written order from the prescribing physician stating the amino-acid–based elemental formula is medically necessary.
- Written order from the prescribing physician stating the amino-acid based formula is medically necessary for treatment of the enrollee.
- Physician or licensed pediatric provider prescription/order for human breast milk or human donor milk.
Key Coverage Criteria
- I. Home health services are consideredmedically necessarywhenallof the followingcriteriaA through Dare met:
- The individual is confined to the home:The individual’s overall physical/medical condition poses a serious and significant impediment to receiving intermittent or occasional, skilled, medically necessary services outside the home setting. In general, the condition of these individuals should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort;andIf the individual does in fact leave the home, the absences from t [...]
- The individual’s overall physical/medical condition poses a serious and significant impediment to receiving intermittent or occasional, skilled, medically necessary services outside the home setting. In general, the condition of these individuals should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort;and
- If the individual does in fact leave the home, the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. The following are examples of acceptable medical and non-medical absences (these examples are not all-inclusive and are provided as a means to illustrate the kinds of infrequent or unique events an individual may attend):Medical absences to receive health care treatment, including but not limited to [...]
- Medical absences to receive health care treatment, including but not limited to:Ongoing receipt of outpatient kidney dialysis;orReceipt of outpatient chemotherapy or radiation therapy;orParticipation in psychosocial or medical treatment in an adult day-care program that is licensed or certified by a state, or accredited, to furnish adult day-care services;or
- Ongoing receipt of outpatient kidney dialysis;or
6 Active Policies
ANTHEM-CG-MED-23, CG-MED-23 Home Health
MED201.011, Nutritional Support
BCBSIL-MED201.011, Nutritional Support
BCBSMT-MED201.011, Nutritional Support
BCBSNM-MED201.011, Nutritional Support
Related Codes
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