Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

All home care requires pre-authorization.  The attending physician should communicate with QualChoice/QCA.

High Risk Prenatal Home Care will be covered if indicated and when ordered by a network Maternal-Fetal Medicine (Perinatology) provider.

To be eligible for High Risk Prenatal Home Care coverage, such care must be recommended after consultation with a Maternal-Fetal Medicine specialist, and one of the following must be present:

• A history of previous pre-term labor or delivery (O09.211 – O09.219, Z87.51) OR
• A current multiple gestation pregnancy (O30.001 – O30.019, O30.031 – O31.8X99) OR
• Bleeding from current pregnancy (O20.0 – O20.9, O26.851 – O26.859, O44.00 – O46.93, O67.0 – O67.9) OR
• Other complications of current pregnancy, including (but not limited to):
  • Pyelonephritis (O23.00 – O23.03)
  • Placenta Previa (O44.00 – O44.13)
  • Polyhydramnios (O40.1XX0 – O40.9XX9)
  • Premature labor (O60.00 – O60.23X9)

Coverage of monitored home care for a high risk OB patient will be based on the need for skilled prenatal nursing knowledge and skills.  Examples of skilled prenatal nursing care may include (but are not limited to):

• Education for the member to understand the importance of adherence to prenatal medical protocol (bed rest, hydration, reinforcement of oral tocolytic schedule).
• Education for the member in identification and timing of uterine contractions, symptoms that may indicate signs of pre-term labor (abdominal cramping, low back pain, changes in character or amount of vaginal discharge, vaginal pressure, etc).  A teaching flow sheet should be used for this education, and be kept with the clinical record.
• Nursing palpation and documentation of uterine activity.

• Nursing assessment and documentation of cervical changes and the timing of uterine contractions.
• Administration and monitoring of intravenous or subcutaneous tocolytic infusions.
• Charting of skilled nursing assessments in the member’s medical record and communication of any changes to the physician responsible for the prenatal care.

·       Home uterine monitoring using remote-channel devices.

Coverage shall be provided for the pre-term use of ambulatory tocodynamometers (uterine contraction devices) and for any home-care service when the next steps in care are determined primarily based on information obtained by such a device or service.

Consideration will be given to coverage of local hotel (or hostel) stay when care in a transient O/P status is in lieu of inpatient care for a non-Pulaski County resident.

• Tocolytic therapy is not recommended in patients prior to twenty weeks gestation.
• Coverage will terminate if member is not compliant with treatment requirements in the home.

Hospitalization is recommended when patients are experiencing progressive pre-term labor symptoms with no response to the home care treatment plan that is ordered by the attending Maternal-Fetal Medicine specialist.

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail.  State and federal mandates will be followed as they apply.