Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 09/08/2004 Title: High Risk Prenatal Home Care
Revision Date: 10/01/2016 Document: BI071:00
CPT Code(s): None
Public Statement

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.


Medical Statement

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.


Application to Products

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.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.