BlueCross and BlueShield of Montana Medical Policy/Codes
Infusion and Injectable Therapy in the Home
Chapter: Therapies
Current Effective Date: November 26, 2013
Original Effective Date: November 26, 2013
Publish Date: August 26, 2013
Description

Home Infusion Therapy (HIT) is the administration of prescription medications, nutrients or other solutions through intravenous, intraspinal, epidural or subcutaneous routes, or in the form of intramuscular, or subcutaneous injections.  These medications are prescribed and administered under the direction of a physician, and are supervised by a licensed Registered Nurse (RN) or Licensed Practical/Vocational Nurse (LPN/LVN), trained in IV drug administration.  Administration of home infusion therapy should be limited to a place of temporary or permanent residence that is used as the home, excluding a hospital, skilled nursing facility, clinic, ambulatory infusion therapy suite and/or physician’s office.

HIT includes all components related to infusion therapy, such as, but not limited to:

  • durable medical equipment and supplies; AND
  • solutions; AND
  • pharmacy compounding and dispensing fees; AND
  • specimen collection; AND
  • patient and family education; AND
  • delivery of drugs and supplies; AND
  • management of emergencies arising from therapy.

Nursing visits and drugs may be considered separately depending on provider contracting.

Home infusion drugs are often not readily available through standard pharmacies and are frequently high cost.  Most home infusion drugs are obtained through hospital pharmacies, licensed home infusion agencies, or mail-order discount drug supply companies that can express deliver the drugs directly to the patient’s home. 

Specific therapies provided may include, but are not limited to:

  • Anti-infectives; AND
  • Blood transfusions; AND
  • Chemotherapy; AND
  • Hydration therapy; AND
  • Immunotherapy; AND
  • Inotropic therapy; AND
  • Pain management; AND
  • Parenteral and enteral nutrition; AND
  • Tocolytic therapy; AND
  • Progesterone therapy high-risk of pre-term birth.
Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.  Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

Blue Cross and Blue Shield of Montana (BCBSMT) may consider intravenous (IV) solutions and/or injectable medications (intramuscular [IM], or subcutaneous [SC]) medically necessary when ALL of the following criteria are met:

  • Prescription drug is approved by the United States Federal Drug Administration (FDA) or the drug meets coverage criteria for off-Label drug use; AND
  • The provision of services in the home is not primarily for the convenience of the member, the member's caregivers or the provider; AND
  • Therapy is managed by a physician as part of a treatment plan for a covered medical condition; AND
  • Home care is provided by a home health care agency, specialized home infusion company, and/or medical specialty and community pharmacy; AND
  • Administration in the home must be safe and medically appropriate.

Agents that require extensive and extended monitoring should be administered in a facility that has the appropriate provisions for acute intervention.

Rationale

Until the 1980s, patients needing infusion therapy had no option but to remain in an inpatient setting until the completion of their therapy.  During the 1980’s the United States health care system was changed by the introduction of diagnosis related groups (DRGs) as a cost control measure.  With increased attention to cost effectiveness and cost containment in health care, clinicians began searching for alternate strategies to eliminate or reduce costly inpatient stays. Home care offered an alternative solution.   In the intervening years home infusion therapy has been proven to be a safe and effective alternative to inpatient care.

It is often the case that standard, orally-ingested medication does not effectively treat conditions such as cancer, gastrointestinal (GI) diseases, congestive heart failure and immune disorders.

Physicians often prescribe infusion therapy for these ailments.  The provision of infusion therapy in the home setting and technological advances in infusion systems support home infusion therapy as a viable option for the administration of a variety of drug therapies, from short term treatment with antibiotics to life-long therapy for the management of a variety of critical disease states.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

Refer to the ICD-9-CM manual.

Procedural Codes: S5035, S5036, S5497, S5498, S5501, S5502, S5517, S5518, S5520, S5521, S5522, S5523, S9061, S9208, S9209, S9211, S9212, S9213, S9214, S9325, S9326, S9327, S9328, S9329, S9330, S9331, S9335, S9336, S9338, S9339, S9340, S9341, S9342, S9345, S9347, S9348, S9349, S9351, S9353, S9355, S9357, S9359, S9361, S9363, S9364, S9365, S9366, S9367, S9368, S9370, S9372, S9373, S9374, S9375, S9376, S9377, S9379, S9430, S9490, S9494, S9497, S9500, S9501, S9502, S9503, S9504, S9537, S9538, S9542, S9559, S9560, S9810
References
  1. Guidelines for the Medical Management of the Home Care Patient. AMA Practice Parameters (1998 March): 1-26.
  2. Overview of Home Infusion Therapy.  National Home Infusion Association (Web site accessed 11/03/2003) http://www.nhianet.org .
  3. What is Infusion Therapy?  National Home Infusion Association.  Accessed (4/28/2006) http: //www.nhianet.org/faqs .    
  4. Brown, S.  Basic Considerations in Providing a Home Infusion Service.  U.S Pharmacist.  Accessed (4/28/2006) http://www.uspharmacist.com .
History
August 2013  New 2013 BCBSMT medical policy.
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Infusion and Injectable Therapy in the Home