Clinical UM Guideline
This document provides clinical criteria for use of outpatient infusion therapy service in the hospital outpatient department or hospital outpatient clinic level of care for intravenous (IV) infusion and injectable therapy.
Note: Please see the following related documents for additional information:
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 level of care for the IV infusion and injectable therapy.
An outpatient IV infusion or injectable therapy service in the hospital outpatient department or hospital outpatient clinic level of care for the use of an infused pharmacologic or biologic agent is considered medically necessary when all of the following are present:
Not Medically Necessary:
All other uses of outpatient IV infusion and injectable therapy services in the hospital outpatient department or hospital outpatient clinic level 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.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Level of care
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.
|Reviewed||08/03/2017||Medical Policy & Technology Assessment Committee (MPTAC) review. Formatting updated in clinical indications section. Updated References section.|
|Reviewed||08/04/2016||MPTAC review. Updated formatting in clinical indications section. Updated Discussion, References and Index sections.|
|Revised||11/05/2015||MPTAC review. Clarified medically necessary and not medically necessary statement. Updated Description and References sections.|
|New||08/06/2015||MPTAC review. Initial document development.|