This policy version was replaced on August 2, 2021. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

This policy provides criteria to determine medical necessity of extended hours skilled nursing services in the home when such services are a covered benefit under the member’s benefit plan.  The goals of extended hours of home skilled nursing services are to manage the member’s medical conditions, prevent complications, and to empower the member’s family caregiver(s) to be able to manage the member’s medical conditions and prevent complications.

Definitions

Skilled Nursing is a service that requires the skills of an RN or an LPN working under the supervision of an RN to be safe and effective. These include but are not limited to activities to teach the member and/or member’s family caregiver(s) how to manage their treatment regimen. 

Medically Complex Home Care is care of a patient, in the home setting, that would otherwise be provided in a hospital, skilled nursing facility, or other active inpatient setting. Reasons for medically complex home care are high severity or life-threatening nature of illness. 

Custodial or Supportive Care: Services and supplies that are primarily intended to help members meet personal needs or to assist in activities of daily living, such as giving medicine that can usually be taken without help, preparing special foods, helping someone walk, get in and out of bed, dress, eat, bathe and use the toilet. These services do not seek to cure, are performed regularly as part of a routine or schedule, and do not need to be provided directly or indirectly by a health care professional.

Respite Care is short-term patient care provided to the member to relieve the family member or other persons caring for the individual.

Intermittent Skilled Nursing Care is defined as services of up to two consecutive hours per visit in the member’s home provided by a licensed registered nurse (RN) or licensed practical nurse (LPN) under the supervision of an RN who are employees of an approved home health care agency.

Extended Hours Skilled Nursing Services (skilled nursing services) are continuous and complex skilled nursing services greater than two (2) consecutive hours per date of service in the member’s home.

Two hours per day of intermittent skilled nursing services in the home, are generally adequate to meet the skilled care needs of most members. Extended hours skilled nursing care may be necessary in limited situations. Examples include:

• Transition of a member from an inpatient setting to home;
• When a member experiences an acute change in condition and additional skilled nursing care will prevent a hospital admission; or
• When transition to a skilled nursing facility is indicated, but no skilled nursing facility (SNF) bed is available.

I.    Extended Hours Skilled Nursing

Extended Hours Skilled Nursing in the home may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:

• Member has a condition that requires the skills, expertise, judgement, and decision making of a registered nurse (RN) or licensed practical nurse (LPN) working under the supervision of an RN; AND
• A written plan of care has been completed, which includes ALL of the following requirements:
  • Clinical summary, including the expected course of the member’s medical conditions;
  • Current functional level, current functional limitations;
  • Current medication doses, routes, and frequency of administration;
  • Current treatments, including the frequency of each treatment;
  • Vital signs, including the frequency of each vital sign;
  • Long term and short term goals of care based on individualized needs of the member;
  • Current disciplines providing care, including the hours per day for each discipline; (RN, LPN, physical therapist [PT], occupational therapist [OT], speech therapist [ST], home health aide [HHA] personal care assistant [PCA], certified medical assistant [CMA], etc.);
  • Demonstration of the need for services supported by all pertinent diagnoses.
• AND
• A professional practitioner (e.g., MD, DO, Advanced Practice Registered Nurse [APRN] or Physician Assistant [PA]) working within the scope of their practice has approved the written plan of care; AND
• The requested services are appropriate for the treatment of the member’s illnesses or injuries; AND
• The member’s treatment plan requires changes to the member’s treatment at least daily, or the member requires invasive mechanical ventilation at least 6 hours daily; AND
• Documentation stating reasons the member’s care needs cannot be met through intermittent skilled nursing visits; AND
• Documentation stating the specific reasons that the member’s care needs cannot be met by a trained family caregiver; Note: Extended hours of home skilled nurse services provided to train the family caregiver(s) is covered for a period of up to 90 days; AND
• The services are not provided in an inpatient facility or skilled nursing facility.

II.   Ongoing Authorization

Continued Extended Hours Skilled Nursing in the home may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following are met:

• The member has a condition that requires the skills, expertise, judgement, and decision making of an RN or LPN working under the supervision of an RN; AND
• Home care records include ALL of the following:
  • Flowsheets that document the following over the past 60 days
    • Vital signs
    • Patient care treatments and rationales for changes to treatments including ventilator settings if applicable
    • Current symptoms and physical findings
    • When the home nurse is on duty, documentation of who specifically is providing care and for what hours and in what location(s)
    • When the home nurse is not on duty, documentation of who specifically is providing care and for what hours
  • Identification of specific barriers to the caregivers’ ability to implement the plan of treatment with identification of specific strategies to overcome these barriers, implementation of these strategies, and ongoing assessment of the results of these strategies;
  • Documentation  that the ordered services were provided as prescribed in the written plan of care (described below);
• AND
  • Written plan of care updated at least each 60 days, which includes a clinical summary of member’s current health status over the past 60 days with ALL of the following:
    • Expected course of the member’s medical conditions;
    • Functional level and functional limitations;
    • Medication doses, routes, and frequency of administration;
    • Treatments, including the type and frequency of each treatment;
    • Vital signs, including the frequency that each vital sign must be measured;
    • Long term and short term goals of care based on individualized needs of the member;
    • Hours per day / week for each discipline providing care  (RN, LPN, PT, OT, ST, HHA, PCA, CMA, etc.);
    • Specific barriers to the member’s caregivers’ ability to implement the plan of care, the identification of specific strategies for this member’s caregivers to overcome these barriers, and the assessment of the results of these strategies;
    • Demonstration of the need for the frequency and hours per day of all services supported by the submitted medical records;
• AND
• A professional practitioner (e.g., MD, DO, Advanced Practice Registered Nurse [APRN]) or Physician Assistant [PA]) working within the scope of their practice has approved the written plan of care: AND
• The requested services are appropriate for the treatment of the member’s illnesses or injuries; AND
• One or both of the following:
  • The member’s treatment plan requires ongoing and daily assessment of the plan of care; OR
  • The member requires invasive mechanical ventilation at least 6 hours daily;
• AND
• Documentation stating the specific reasons that the member’s care needs cannot be met by a trained family caregiver; Note: Extended hours of home skilled nurse services provided to train the family caregiver(s) is covered for a period of up to 90 days. AND
• Documentation stating reasons the member’s care needs cannot be met through Intermittent skilled nursing visits; AND
• The medical need for the hours per day of home RN/LPN services is supported in the submitted medical records, including specific documentation of the severity of the medical conditions, the intensity of the home nurse services provided, and the reason(s) that these services could not have been provided by a trained family caregiver; AND
• The services are not provided in an inpatient facility or skilled nursing facility.

III.  Ineligible for Coverage as Extended Hours Skilled Nursing in the Home

• Care that can be provided by a trained family caregiver
• Caregiver is not available for training, or unable or unwilling  to comply with the plan of care
• Care provided solely for the convenience of, or respite for, the family caregiver
• Care provided by the member's spouse, natural or adoptive child, parent, foster parent, brother, sister, grandparent or grandchild. This includes any person with an equivalent step or in-law relationship to the member
• Help with daily living activities, such as walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating, or preparing foods 
• Routine patient care such as changing dressings, periodic turning and positioning in bed, administering oral medication 
• Care of a stable tracheostomy (including intermittent suctioning) 
• Care of a stable nasogastric tube/gastrostomy/jejunostomy - including intermittent or continuous feedings 
• Care of a stable colostomy/ileostomy 
• Care of a stable indwelling bladder catheter (including emptying/changing containers and clamping tubing)
• Falls prevention 
• Watching or protecting a member
  
• Care provided outside the home including but not limited to medical care in a clinic, outpatient facility, hospital, or skilled nursing or intermediate care facility, or licensed residential care facility except as stated in the benefit chart
• The member's care needs cannot be adequately and/or safely met in the home

Documentation Submission

Written documentation by the practitioner specifying the medical necessity, according to the criteria above, is required. Requested documentation may include, but is not limited to:

• A completed Form CMS-485 - Home Health Certification and plan of care;
• Current practitioner's order for the requested services;
• Daily home skilled nursing services log with the specific location and specific time of day; Example: 05/05/2020 7:00 AM – 8:15 AM home, 8:15 AM – 8:45 AM transport to Smith School, 8:45 AM – 3:15 PM Smith School, 3:15 PM – 3:45 PM transport to home, 3:45 PM – 5:30 PM home; 
• All home care records for the past 60 days, and for all days with a significant medical event from the time of the previous request to the current request, which include ALL of the following: 
  • Current flowsheets that document vital signs, ventilator settings including the rationale for changes to the ventilator settings, and treatments including the rationale for changes to the treatments; 
  • Current symptoms and physical findings; 
  • Who specifically is providing cares and for what hours and in what location(s) when the extended hours nurse is on duty; 
  • Who specifically is providing cares and for what hours when the extended hours nurse is not on duty; 
  • The ongoing identification of specific barriers to the caregivers’ ability to implement the plan of treatment, the identification of specific strategies to overcome these barriers, the implementation of these strategies, and the ongoing assessment of the results of these strategies.
• All professional practitioner (e.g., MD, DO, Advanced Practice Registered Nurse [APRN] or Physician Assistant [PA]) visit notes from the time of the previous request to the current request, with a current medication list; 
• Emergency room provider notes from all emergency room visits that have occurred from the time of the previous request to the current request; 
• Hospital history and physicals, hospital discharge summaries, and hospital progress notes from the final 7 days of all hospitalizations that have occurred from the time of the previous request to the current request.

Link to Pre-Authorization Form:  https://www.bluecrossmn.com/sites/default/files/DAM/2019-10/X18509R07_Pre-Authorization%20Request%20Form.pdf