Original Effective Date:
08/01/1994
Current Effective Date:
01/01/2015
The Precertification Request – Home IV Therapy should be used to precertify benefits prior to starting:
- Home Continuous Inotropic Infusion Therapy
- Intravenous Immune Globulin (IVIG)
- Home Infusion Pain Management Therapy
- Growth Hormone Therapy
Precertify benefits if therapy is expected to extend beyond the Standard Duration for the therapy. Precertify nursing visits during the extended therapy period.
Click here to access the Precertification Request – Home IV Therapy form.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 |
|