CG-MED-83 Site of Care: Specialty Pharmaceuticals

This policy addresses the site of care for outpatient IV infusion or injectable therapy of pharmacologic/biologic agents in a hospital outpatient department or clinic. Hospital-based administration is medically necessary only when all are met: the infusion’s complexity or risk requires skilled nursing supervision, the individual’s condition or therapy requires enhanced monitoring beyond routine infusion, and there is significant risk of sudden clinical deterioration requiring immediate access to hospital emergency services and possible admission/ICU. All other hospital outpatient use is not medically necessary; infusions should occur in lower-acuity settings when geographically accessible, with exceptions for factors such as first-dose reactions, complex drug profiles, pediatric needs, or environmental/caregiver barriers to safe administration elsewhere.

"An outpatient IV infusion or injectable therapy service in the hospital outpatient department or hospital outpatient clinic site of care for the use of an infused pharmacologic or biologic agent is..."