Clinical UM Guideline

This document provides clinical criteria for use of outpatient infusion therapy service in the hospital outpatient department or hospital outpatient clinic site of care for intravenous (IV) infusion and injectable therapy.

Note: In some plans, “level of care,” “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts, or other materials instead of or in addition to “site of care” and, in some plans, these terms may be used interchangeably.

Note: Please see the following related documents for additional information:

• CG-MED-23 Home Health
• CG-SURG-10 Ambulatory or Outpatient Surgery Center Procedures
• CG-SURG-52 Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services

Note: The medical necessity of the infused pharmacologic or biologic agent may be separately reviewed against the appropriate criteria. This guideline is for determination of the medical necessity of hospital outpatient site of care for the IV infusion and injectable therapy.

Medically Necessary:

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 considered medically necessary when all of the following are present:

1. The inherent complexity or risk of the infusion required by an individual is such that it can be performed safely and effectively only by or under the general supervision of skilled nursing personnel; and
2. The individual's medical status or therapy is such that it requires enhanced monitoring beyond that which would routinely be needed for infusion therapy; and
3. The potential changes in the individual’s clinical condition are such that immediate access to specific services of a medical center/hospital setting, having emergency resuscitation equipment and personnel, and inpatient admission or intensive care is necessary, for example, the individual is at significant risk of sudden life-threatening changes in medical status based on clinical conditions including but not limited to:
   1. Concerns regarding fluid overload status; or
   2. History of anaphylaxis to prior infusion therapy with a related pharmacologic or biologic agent; or
   3. Acute mental status changes.

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 considered medically necessary when there are no other geographically accessible appropriate alternative sites for the individual to undergo the IV infusion or injectable therapy service.

Not Medically Necessary:

All other uses of outpatient IV infusion and injectable therapy services in the hospital outpatient department or hospital outpatient clinic site of care for the infusion of pharmacologic and biologic agents are considered not medically necessary.

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Infusion therapy (pharmacologic or biologic agents) has been proven to be safely and effectively administered in an office-based setting, infusion center or the home setting. Home-based infusion, when appropriate and available, may in some cases be supported by member preference (Chataway, 2006; Milligan, 2006; Riazi, 2011). Hospital outpatient administration of IV medications may be appropriate for complex infusions requiring direct observation or the minimization of certain treatment risks that require hospital based therapy when criteria are met.

The hospital outpatient department or hospital outpatient clinic is part of a hospital, but is designed for the treatment of outpatients; that is, individuals who do not require hospital admission.

The potential for severe infusion reactions poses a significant safety risk to certain individuals with a history of previous severe infusion reactions, including anaphylaxis to prior infusion therapy with a related pharmacologic or biologic agent and should be considered when identifying the appropriate site of care for the administration an IV infusion or injectable therapy service. The risk assessment should include consideration whether immediate access to specific services of a medical center/hospital setting, including emergency resuscitation equipment and personnel are needed, as well as the need for inpatient admission or intensive care services.

Geographically accessible: Refers to the ease of reaching a destination; the concept takes into account multiple factors, including, but not limited to: distance to and time required to get to a specific location and the logistical complexity of transport.

Peer Reviewed Publications:

1. Chataway J, Porter B, Riazi A, et al. Home versus outpatient administration of intravenous steroids for multiple-sclerosis relapses: a randomized controlled trial. Lancet Neurol. 2006; 5(7):565-571.
2. Gutierrez-Aguirre CH, Ruiz-Arguelles G, Cantu-Rodriguez OG, et al. Outpatient reduced-intensity allogeneic stem cell transplantation for patients with refractory or relapsed lymphomas compared with autologous stem cell transplantation using a simplified method. Ann Hematol. 2010; 89(10):1045-1052.
3. Mank A, van der Lelie J, de Vos R, Kersten MJ. Safe early discharge for patients undergoing high dose chemotherapy with or without stem cell transplantation: a prospective analysis of clinical variables predictive for complications after treatment. J Clin Nurs. 2011; 20(3-4):388-395.
4. Milligan A, Hughes D, Goodwin S, et al. Intravenous enzyme replacement therapy: better in home or hospital? Br J Nurs. 2006; 15(6):330-333.
5. Riazi A, Porter B, Chataway J, et al. A tool to measure the attributes of receiving IV therapy in a home versus hospital setting: the Multiple Sclerosis Relapse management Scale (MSRMS). Health Qual Life Outcomes. 2011; 9:80.
6. Teuffel O, Ethier MC, Alibhai SM, et al. Outpatient management of cancer patients with febrile neutropenia: a systematic review and meta-analysis. Ann Oncol. 2011; 22(11):2358-2365.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Allergy Asthma and Immunology. Guidelines for the site of care for administration of IGIV therapy. December 2011. Available at: http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20Resources/Guidelines-for-the-site-of-care-for-administration-of-IGIV-therapy.pdf. Accessed on June 1, 2013.
2. Broyles AD, Banerji A, Barmettler S, et al. Practical guidance for the evaluation and management of drug hypersensitivity: Specific drugs. J Allergy Clin Immunol Pract. 2020; 8(95):S16-S116.
3. Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: ASCO Guideline Update. J Clin Oncol. 2020; 38(24):2782-2797.
4. NCCN Clinical Practice Guidelines in Oncology^®. © 2023 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on May 26, 2023.
   • Antiemesis (V.2.2023). Revised May 24 2023.
   • Prevention and Treatment of Cancer-Related Infections. (V.3.2022) Revised October 28, 2023.

1. National Home Infusion Association. About home and specialty infusion. Available at: https://www.nhia.org/about-infusion-therapy/. Accessed on. August 7, 2023.

Infusion therapy
Injectable therapy
Site of care
Specialty pharmaceuticals

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.