Does T1031 require prior authorization?

Yes, T1031 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for T1031?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`T1031`, Nursing care, in the home, by licensed practical nurse, per diem

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Recommended (per ACOG guidance cited in the CPB) components of prenatal care that women considering home birth should be offered (not described as coverage documentation requirements): 'group B Strep screening and treatment, genetic screening, as well as HIV screening.'

Documentation of frequency and duration of services and that the 'treatment provided is appropriate for the member's condition including the amount of time spent providing the service as well as the frequency and duration of the services.'

Services must be 'ordered by a physician, physician assistant, or nurse practitioner and are directly related to an active treatment plan of care established by the provider' — documentation of the order and active plan of care is required.

Documentation that the member is homebound because of illness or injury (i.e., evidence that the member leaves home only with considerable and taxing effort and absences from home are infrequent or of short duration, or to receive medical care).

Clinical documentation demonstrating the service(s) are 'so inherently complex that it can be safely and effectively performed only by, or under the supervision of, a licensed nurse' (e.g., nursing assessments, skilled procedures, complexity of care).

Key Coverage Criteria

None — Aetna considers planned deliveries at home and associated services not medically appropriate.
Coverage of home births will be considered when mandated by law under plans subject to state mandates.
Skilled nursing care consists of those services that must be performed by a registered nurse or licensed practical (vocational) nurse, and meet all of the following criteria for skilled nursing services: Pursuant to physician orders, the service(s) is so inherently complex that it can be safely and effectively performed only by, or under the supervision of, a licensed nurse to achieve the medically desired result; and The skilled nursing care must be provided on an intermittent* or hourly** basi [...]
Covered home-visit services (CPT codes covered if selection criteria are met): 99500 (home visit for prenatal monitoring and assessment ...), 99501 (home visit for postnatal assessment and follow-up care), 99502 (home visit for newborn care and assessment), 99503 (home visit for respiratory therapy care), 99504 (home visit for mechanical ventilation care), 99505 (home visit for stoma care and maintenance), 99506 (home visit for intramuscular injections), 99507 (home visit for care and maintenanc [...]
Covered HCPCS services (if selection criteria are met): G0162 (skilled services by an RN in management & evaluation of plan of care, each 15 minutes), G0299 (direct skilled nursing services of an RN in the home health or hospice setting, each 15 minutes), G0300 (direct skilled nursing services of an LPN in the home health or hospice setting, each 15 minutes), G0493, G0494, G0495, G0496 (skilled observation/assessment and training/education codes, each 15 minutes), S9123 (nursing care in the home [...]
Subject to applicable benefit plan terms and limitations, Aetna considers skilled home health nursing services medically necessary when all of the following criteria are met: The member is homebound because of illness or injury (i.e., the member leaves home only with considerable and taxing effort and absences from home are infrequent, or of short duration, or to receive medical care); and The nursing services provided are not primarily for the comfort or convenience of the member or custodial i [...]

6 Active Policies

ANTHEM-CG-MED-71, Chronic Wound Care in the Home or Outpatient Setting

ANTHEM-CG-REHAB-08, Private Duty Nursing in the Home Setting

ANTHEM-CG-MED-23, Home Health

EVICORE-HPLAN-CIGNA_MEDICARE-7E679040BEBB, Cigna Medicare Advantage Home Health Code List - Effective 01/01/2025

AETNA-CPB-0329, Home Births

AETNA-CPB-0201, Skilled Home Health Care Nursing Services

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T1031, Nursing care, in the home, by licensed practical nurse, per diem