Aetna considers the services of a home health aide medically necessary in selected cases when both of the following criteria are met:
The services of a home health aide are rendered in conjunction with intermittent skilled home health care services provided by a licensed practical or registered nurse, occupational therapist, physical therapist, or speech therapist; and
The services delivered by the home health aide directly support skilled home health care services. These may include:
Assisting with a prescribed exercise regimen
Assisting with activities of daily living
Changing non-sterile dressings that do not require the skills of a licensed nurse
Routine care of prosthetic and orthotic devices
Supervising the individual's adherence to prescribed, self-administered medication and/or special diets
Taking blood pressure and other health monitoring activities.
A home health aide is a provider who assists a member with non-skilled care to meet activities of daily living, thereby maintaining the individual in his or her home environment. Generally, the following services are considered not medically necessary:
House cleaning (except for maintaining the member's immediate area)
In Aetna's Beginning RightSM maternity program, there may be members at risk who require bed rest. In these cases, Aetna may consider home health services medically necessary to help with more routine household chores.
A home health aide is a provider who assists a member with non-skilled care to meet activities of daily living, thereby maintaining the individual in his or her home environment. The services of a home health aide are rendered in conjunction with intermittent skilled home health care services provided by a registered or licensed practical nurse, physical therapist, occupational therapist, or speech therapist.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
Other CPT codes related to the CPB:
97001 - 97799
99500 - 99507, 99510 - 99600
99601 - 99602
HCPCS codes covered if selection criteria are met:
Services of home health aide in home health or hospice setting, each 15 minutes
Home health aide or certified nurse assistant, providing care in the home; per hour
Services of a qualified nursing aide, up to 15 minutes
Home health aid or certified nurse assistant, per visit
Other HCPCS codes related to the CPB:
G0151 - G0155
Services of physical therapist, occupational therapist, speech and language pathologist, skilled nurse, or clinical social worker in home health or hospice setting, each 15 minutes
S9123 - S9124
Nursing care in the home; by registered nurse, or licensed practical nurse, per hour
S9128 - S9131
Speech therapy, occupational therapy, or physical therapy, in the home, per diem
S9208 - S9124
S9325 - S9379
Home or home infusion therapy
S9490 - S9810
Home infusion therapy, routine venipuncture for collection of specimen(s), home therapy, home transfusion of blood products, home injectable therapy
Nursing care, in the home, by registered nurse or licensed practical nurse, per diem
The above policy is based on the following references:
U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). HCFA Publication No. 10969. Baltimore, MD: HCFA; updated December 10, 1996.
Boland P. Making Managed Healthcare Work: A Practical Guide to Strategies and Solutions. New York, NY: McGraw Hill; 1991.
Kongstvedt P, The Managed Health Care Handbook. Gaithersburg, MD: Aspen; 1993.
Marrelli TM, Handbook of Home Health Standards. St. Louis, MO: Mosby Year Book; 1991.
Portnow J. Assistive technology in the home. Caring. 1994;13(9):58-61.
Harris MD. The home health aide as a member of the home healthcare team. Home Healthc Nurse. 1997;15(11):773-775.
Najera LK, Heavey BA. Nursing strategies for preventing home health aide abuse. Home Healthc Nurse. 1997;15(11):758-767; quiz 769-770.
Hays BJ, Willborn FH. Characteristics of clients who receive home health aide service. Public Health Nurs. 1996;13(1):58-64.
No authors listed. Medicare program; Medicare coverage of home health services, Medicare conditions of participation, and home health aide supervision--HCFA. Final rule. Fed Regist. 1994;59(243):65482-65498.
Grieco AJ. Physician's guide to managing home care of older patients. Geriatrics. 1991;46(5):49-55, 59-60.
Scharf JH, Lindner MK, Gordon J, et al. Making the relationship work. Management of a hospital-based home health agency and hospital for-profit home health aide service. Caring. 1990;9(4):62-65.
Cayla JS. The nurse, the nurses' aide, the practical nurse and the home health aide. Soins. 1989;525:59-60.
Aalberts N. Training home care paraprofessionals. Areas for consideration. Caring. 1989;8(2):26-27.
Najera LK. Enhancing home health aide training. Home Healthc Nurse. 1988;6(5):39-41.
Boies AH. Role of the home health aide in the rehabilitation process. Home Health Nurse. 1987;5(6):44-45.
Joseloff AW. The home health aide. A member of the hospice team. Caring. 1986;5(10):36-38.
Ferrell BR, Borneman T. Community implementation of home care palliative care education. Cancer Pract. 2002;10(1):20-27.
Murashima S, Asahara K. The effectiveness of the around-the-clock in-home care system: Did it prevent the institutionalization of frail elderly? Public Health Nurs. 2003;20(1):13-24.
Cucinotta D, Savorani G, Piscaglia F, et al. The chronically ill elderly patients discharged from the hospital: Interim report from a controlled study of home care attendance. Arch Gerontol Geriatr Suppl. 2004;(9):103-108.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.