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Private Duty Nursing Services
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Defines coverage rationale, benefit considerations, and documentation requirements for private duty nursing (PDN) services for UnitedHealthcare Commercial and Individual Exchange plans. Applies to providers requesting PDN services and to member plan determinations.
Expanded skilled care examples to add application of dressings involving prescription medications and aseptic techniques; enteral feeding that comprises at least 26% of daily calories and provides at least 501 mL/day; and heat treatments ordered by a physician requiring nursing observation.
Updated examples of custodial care to add 'general supervision of exercises which have been taught to the patient'.
References updated to current Code of Federal Regulations citation (42 CFR 409.33) and access date.
Coverage Criteria for Private Duty Nursing (PDN)
Covered Skilled PDN
Private duty nursing services with skilled care are covered according to the member specific benefit plan when ALL of the following apply:
Source: Skilled Care (42 CFR 409.33)
See Benefit Considerations; thresholds for enteral feeding specified
InterQual LOC: Home Care Q&A Private Duty Nursing referenced for determination of PDN hours
Coverage subject to member benefit plan terms
Prior authorization and coding guidance
Certain plans exclude coverage for private duty nursing (PDN) services. In addition, most UnitedHealthcare plans exclude custodial care; providers must refer to the member-specific benefit plan to confirm PDN coverage for an individual member. Examples of custodial care that are generally excluded include assistance with activities of daily living such as eating, dressing, bathing, transferring, and ambulating, and routine non-skilled health-related tasks (for example, routine administration of oral medications, eye drops and ointments; general maintenance care of colostomy and ileostomy; routine indwelling catheter care; changes of dressings for noninfected wounds; prophylactic/palliative skin care including bathing and application of creams; routine incontinence care; maintenance care for casts and braces; use of heat for comfort such as whirlpool/hydrocollator; routine administration of medical gases after an established regimen; assistance with toileting; periodic turning/positioning; and general supervision of previously taught exercises).
Services that are custodial or that can be safely and effectively performed by trained non-medical personnel are not considered skilled nursing and are not covered as skilled PDN. Custodial care includes non-health-related assistance with activities of daily living (e.g., eating, dressing, bathing, transferring, ambulating) and health-related services provided primarily to meet personal needs or maintain function rather than to improve clinical status. Specific examples include routine oral medication administration, routine ostomy or catheter maintenance, noninfected dressing changes, prophylactic skin care, routine incontinence care, general maintenance of casts/braces, periodic turning/positioning, and general supervision of exercises previously taught to the patient.
Coding and Service Thresholds
| T1000 | Private duty/independent nursing service(s), licensed, up to 15 minutes |
Provider Requirements, Authorization, and Denial Triggers
Obtain prior authorization / coverage determination for skilled PDN
Private duty nursing (PDN) with skilled care is covered only when the service meets the policy definition of skilled care and the member-specific benefit plan allows PDN; once coverage for skilled care is established, the number of PDN hours is determined using the InterQual LOC: Home Care Q&A Private Duty Nursing assessment.
- Coverage is contingent on meeting the policy’s Skilled Care definition.
- Refer to the member specific benefit plan to confirm PDN is a covered benefit.
- Use InterQual LOC: Home Care Q&A Private Duty Nursing assessment to determine approved hours.
Step therapy — none specified
No step therapy requirements are specified in this policy for private duty nursing services.
Submit CMS-485 with physician/authorized practitioner-signed plan of care
Document all requests using the Home Health Certification (CMS-485), which must include the plan of care signed by a physician (MD or DO) or an advanced practitioner (NP, CNS, or PA) in accordance with applicable law; medical records may be requested to verify clinical criteria are met.
- Include a physician-signed (MD/DO) or authorized advanced practitioner-signed plan of care on the CMS-485.
- Be prepared to provide additional medical record documentation if requested to demonstrate the clinical criteria for skilled PDN are met.
Denial triggers — custodial care, benefit exclusion, missing documentation
Requests may be denied if the services are custodial (non-skilled), the member’s benefit plan does not cover PDN, or required medical record documentation is not provided to demonstrate that clinical criteria are met.
- Custodial care (assistance with ADLs or tasks safely performed by non-medical personnel) is not considered skilled and is a denial trigger.
- Verify the member specific benefit plan includes PDN — plans may exclude PDN or custodial care.
- Failure to supply required documentation for clinical review may result in denial.
Key Definitions
Background
Private duty nursing provides skilled nursing, teaching, habilitation, and rehabilitation in the home when delivered or supervised by licensed technical or professional medical personnel and ordered by a physician. The distinction between skilled care and custodial care determines coverage: procedures and therapies that require clinical training and professional oversight are considered skilled when appropriately documented and authorized, whereas routine or maintenance tasks that do not require professional clinical skills are custodial and not covered as skilled PDN.
Revision History and Policy Changes
Added and clarified examples in Benefit Considerations: updated custodial care examples to include 'general supervision of exercises which have been taught to the patient'; expanded skilled care examples to add application of dressings involving prescription medications and aseptic techniques; enteral feeding threshold specified as at least 26% of daily calories and at least 501 mL/day; added physician-ordered heat treatments requiring nursing observation; and clarified 'intravenous injections' to 'intravenous or intramuscular injections'.
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