S5498 Hit simple cath care

Home infusion therapy, catheter care / maintenance, simple (single lumen), includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment, (drugs and nursing visits coded separately), per diem

Medicare pricing for S5498

Physician Fee Schedule (CY 2026, RVU26D)

Status I: not valid for Medicare (Medicare uses another code).

Payer policies and prior authorization for S5498

1 of 1 payer prior-auth lists that name S5498 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross and Blue Shield of TexasTexas PA exemption (gold card), outpatient, fully insuredTXprior auth requiredGold-card exemption availableJan 1, 2026BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)

Payer coverage policies that name S5498

S5498 appears in 12 coverage policies from Aetna, Anthem, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaNutritional Support (0061)
Enteral lactoferrin supplementation		covered if criteria are metJan 15, 2026payer document
AetnaSkilled Home Private Duty Nursing Care (0136)listed, no stance (range S5497-S5502)Apr 7, 2026payer document
AnthemHome Health (CG-MED-23)covered if criteria are met (range S5497-S5523)Nov 6, 2025payer document
UnitedHealthcareHome Health Care Services (for Kentucky Only) (CS137KY.12)listed, no stanceJul 1, 2026payer document
UnitedHealthcareHome Health, Skilled, and Custodial Care Services (MP.022.28)listed, no stanceJul 1, 2026payer document
UnitedHealthcareHome Health, Skilled, and Custodial Care Services (CS137.X)listed, no stanceJul 1, 2026payer document
UnitedHealthcareHome Health, Skilled, and Custodial Care Services (for Idaho Only) (CS137ID.D)listed, no stanceAug 1, 2026payer document
UnitedHealthcareHome Health, Skilled, and Custodial Care Services (for Kansas Only) (CS137KS.04)listed, no stanceSep 1, 2026payer document
UnitedHealthcareHome Health, Skilled, and Custodial Care Services (for Nebraska Only) (CS137NE.V)listed, no stanceJan 1, 2026payer document
UnitedHealthcareHome Health, Skilled, and Custodial Care Services (for New Mexico Only) (CS137NM.D)listed, no stanceSep 1, 2026payer document
UnitedHealthcareHome Health, Skilled, and Custodial Care Services (for Ohio Only) (CS137OH.E)listed, no stanceAug 1, 2026payer document
UnitedHealthcareHome Health, Skilled, and Custodial Care Services (for Tennessee Only) (CS137TN1.J)listed, no stanceJan 1, 2026payer document

Recent prior-auth changes

  • Apr 1, 2026: PA added, Blue Cross and Blue Shield of Texas

Medicaid fee-for-service

Prior authorization required or conditional in IN.

  • IL: $12.04 (dme), effective Jan 1, 2026
  • KY: $10.00 (dme), effective Jan 1, 2026
  • MA: $13.95 (dme_rates), effective Mar 1, 2026
  • ND: $0.00 (physician), effective Aug 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.