Clinical UM Guideline

This document defines custodial care, a type of care that generally provides assistance in performing activities of daily living (ADL); for example, assistance walking, transferring in and out of bed, bathing, dressing, using the toilet, preparation of food, feeding and supervision of medication that usually can be self-administered. Custodial care essentially is personal care that does not require the continuing attention of trained medical or paramedical personnel.

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

• CG-MED-23 Home Health
• CG-MED-71 Chronic Wound Care in the Home or Outpatient Setting
• CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 Private Duty Nursing in the Home Setting

Care that does not meet the criteria for skilled nursing or skilled rehabilitation services is considered custodial.
Note: Not all benefit contracts/certificates include benefits for custodial services as defined by this document. Benefit language supersedes this document.

Definition of Custodial Care:

• Custodial care is that care which is primarily for the purpose of assisting the individual in the activities of daily living or in meeting personal rather than medical needs, which is not specific therapy for an illness or injury and is not skilled care.
• Custodial care serves to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, preparation of special diets, and supervision of medication that usually can be self-administered.
• Custodial care essentially is personal care that does not require the continuing attention or supervision of trained, medical or paramedical personnel.
• Custodial care is maintenance care provided by family members, health aides or other unlicensed individuals after an acute medical event, including behavioral health events, when an individual has reached the maximum level of physical or mental function.
• In determining whether an individual is receiving custodial care, the factors considered are the level of care and medical supervision required and furnished. The decision is not based on diagnosis, type of condition, degree of functional limitation or rehabilitation potential.

Note: Custodial care may occur in settings other than the home.

Examples of Custodial Care, include, but are not limited to, the following:

• Assistance in dressing, eating, and toileting;
• Periodic turning and positioning in bed;
• Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems;
• Stable bolus feeding by nasogastric, gastrostomy or jejunostomy tube (Note: skilled care, supervision or observation may be required if feedings are not stable);
• Routine care of the incontinent individual, including use of diapers and protective sheets;
• Routine services to maintain satisfactory functioning of indwelling bladder catheters (this would include emptying containers and cleaning them, and clamping tubing);
• General maintenance care of colostomy and ileostomy;
• General supervision of exercises, which have been taught to the individual and do not require skilled rehabilitation personnel for their performance. This includes, but is not limited to:
  • repetitive exercises to maintain function, improve gait, or maintain strength or endurance; or
  • passive exercises to maintain range of motion in paralyzed extremities, or
  • assisted walking.
• Daily supervision and assistance with dressing, eating and hygiene for an individual with severe and persistent mental illness with findings such as cognitive impairment, delusions and hallucinations that interfere with an individual’s ability to live in the community.
• Changes of dressings for non-infected postoperative or chronic conditions;
• General maintenance care in connection with a plaster cast (skilled supervision or observation may be required where the individual has pre-existing skin or circulatory conditions or needs to have traction adjusted);
• Routine care in connection with braces and similar devices;
• Use of heat as a palliative and comfort measure, such as whirlpool or steam pack;
• Routine administration of medical gases after a regimen of therapy has been established (i.e., administration of medical gases after the individual has been taught how to institute therapy);
• Administration of routine oral medications, eye drops, and ointments (the fact that an individual cannot be relied upon to take such medications himself/herself or that state law requires all medications be dispensed by a nurse to those individuals in an institutions would not change this service to a skilled service);
• Chronic uncomplicated oral or tracheal suctioning (Note: skilled care, supervision or observation may be required if suctioning is complicated).

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.

Institutional care that is below the level of care covered in a Skilled Nursing Facility (SNF) is custodial care. Some examples of custodial care in hospitals and SNFs include, but are not limited to:

• An individual who has had a stroke and is ambulatory, has no bladder or bowel involvement, no serious associated or secondary illnesses, does not require medical or paramedical care, and requires only the assistance of an aide in feeding, dressing, and bathing;
• An individual with a cardiac disorder who is stable and compensated and has reasonable cardiac reserve and no associated illnesses, but who because of advanced age has difficulty in managing alone in the home, and requires assistance in meeting the activities of daily living; and
• An individual with severe and persistent mental illness with findings such as cognitive impairment, delusions and hallucinations that interfere with an individual’s ability to live in the community and requires daily supervision and assistance with dressing, eating and hygiene.
• An individual with dementia who has diabetes which remains stabilized as long as someone sees to it that the individual takes his/her medication and adheres to a prescribed diet.

Acute Medical Event (includes behavioral health events): A relatively abrupt change in condition that requires medical services, intervention(s) intended to arrest and, hopefully, reverse the condition or conditions. Stabilization can be associated with limited ability to meet basic needs, which are addressed with custodial care.

Cardiac Disorder: Condition(s) that affect heart structures or function such as: coronary artery disease, heart attack, heart failure, abnormal heart rhythms, congenital heart disease, vascular disease or heart valve disease.

Severe and Persistent Mental Illness: A mental, behavioral or emotional disorder according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, in members 18 years and older, that results in functional impairment which substantially interferes with or limits one or more major life activities (e.g., maintaining interpersonal relationships, activities of daily living, self-care, employment, recreation) that have occurred within the last year. All of these disorders may have acute episodes as part of the chronic course of the disorder. An organization may also use its state's definition or the definition of another appropriate regulatory authority (National Committee for Quality Assurance [NCQA], 2014).

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 8. Coverage of Extended Care (SNF) Services under Hospital Insurance. Rev. 261, 10-04-19. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08pdf.pdf. Accessed on September 15, 2022.
2. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 16. General Exclusions from Coverage. Rev.198, 11-06-14. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf. Accessed on September 15, 2022.
3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 7. Home Health Services. Rev. 11447, 06-06-22. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed on September 15, 2022.

1. National Committee for Quality Assurance (NCQA). Definition of severe and persistent mental illness (SPMI). 2014. Available at: www.ncqa.org. Accessed on September 15, 2022.

Federal and State law, as well as contract language, and Coverage Guidelines take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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