CurrentPremera BluecrossPolicy N/A

Skilled Hourly Nursing Care in the Home

Defines medical necessity criteria, exclusions, documentation, coding, and guidelines for coverage of skilled hourly nursing (medically intensive/home ventilator/tracheostomy) provided in the home by licensed nurses under a home health agency. Applies per-member contract and state-specific mandates.

Policy Summary

PayerPremera Bluecross

PolicySkilled Hourly Nursing Care in the Home

Policy CodePolicy N/A

Change TypeAnnual review; guideline statements unchanged

Effective DateMar 1, 2026

Next Review Date

Key ActionMaintain a physician-approved written treatment plan with specific short- and long-term goals; include requested number of hours and anticipated duration.

SourceLink

POLICY UPDATE CHANGES

Annual review approved February 9, 2026; UM guideline reviewed and references added. Guideline statements unchanged.

8-12Typical coverage hours

16Subsequent ventilator max

24x3wInitial ventilator transition

6+Ventilator threshold for added services (hrs/day)

Coverage Summary

Skilled hourly nursing (medically intensive home nursing) provides complex hourly nursing services in the home for >4 hours per day as an alternative to inpatient care or to support transition from acute settings. The goals are caregiver training, stabilization, and gradual reduction of nursing hours over time, with services delivered by licensed nurses under a licensed home health agency. Scope: Defines medical necessity criteria, exclusions, documentation, coding, and guidelines for coverage of skilled hourly nursing (including home ventilator and tracheostomy care) provided in the home. Subject: Skilled hourly nursing care in the home. Effective date: 2026-03-01; Last review: 2026-02-09.

Ventilator and coverage thresholds

Ventilator useAt least 6 hours per day

Initial home ventilator transition max hoursUp to 24 hours per day for no longer than 3 weeks

Subsequent ventilator management max hoursUp to 16 hours per day for continued instability requiring close monitoring and frequent ventilator adjustments

Typical skilled hourly coverage per dayIn most cases 8 to 12 continuous hours per day (less than 16 hours)

Physician review for continuationPhysician must review and renew written treatment plan at least every six months

Medical-Necessity Criteria

Medically Necessary - Skilled hourly nursing care in the home

Skilled hourly nursing care in the home may be considered medically necessary when ALL of the following criteria are met:

ALL of the following

The skilled nursing services are performed in the home as an alternative to a more acute care setting (eg, hospital, skilled nursing facility), or to assist with a transition of care from an acute care setting.
The skilled nursing services are ordered by a licensed physician as part of a treatment plan for a covered medical condition.
There is a physician approved, written treatment plan with specific short- and long-term goals.
The skilled nursing services provided are reasonable and necessary for the care of an individual's illness or medical needs and are performed and require the proficiency and skills of a licensed nurse (RN, LPN, or LVN) working under a licensed home health agency within accepted standards and scope of practice.
The nursing services can safely be provided in the individual's private residence.
There is a primary caregiver in the home who is willing and able to be trained to care for the individual and assume and be responsible for the individual's care when the nurse is not in the home or once the individual's condition has stabilized.

Medically Necessary addition: Home ventilator and/or tracheostomy care

When the medical necessity criteria for skilled hourly nursing care above are met, addition of home ventilator and/or tracheostomy care may be considered medically necessary when:

ALL of the following

The treating physician has agreed to the home care plan.
The individual is on a ventilator at least 6 hours per day.at least 6 hours per day

Continuation of care

For continuation of skilled hourly nursing care:

ALL of the following

The medical necessity criteria for skilled hourly nursing care continue to be met as documented in the nursing progress notes.
The physician has reviewed and renewed the written treatment plan with any updated short- and long-term goals, including discharge planning, at least every six months.at least every six months

Not Medically Necessary (Denial) - Skilled hourly nursing care in the home

Skilled hourly nursing care is NOT medically necessary when ANY of the following are present:

ANY of the following

The above medical necessity criteria are not met.
There is no caregiver in the home that has the ability and is available to be trained to care for the individual and assume a portion of the care.
Once the family or caregivers have been taught the nursing services and have demonstrated the skills and ability to carry out the plan of care.
Once the medical condition of the individual has stabilized or is predictable or controlled and a licensed nurse is not required to monitor the condition.
Continuous or bolus nasogastric or gastrostomy tube feedings are required but there are no other skilled needs.

Non-skilled services excluded from coverage (examples)

The following services are considered custodial/non-skilled and are excluded:

ANY of the following

Administration of oxygen, intermittent positive pressure breathing (IPPB) treatments and nebulizer treatments.
Administration of suppositories and/or enema.
Application of eye drops, ointments, or topical medications.
Assistance with bathing, eating, dressing, or preventing a person from self-harm.
Heat treatments that can be self-administered (whirlpool, paraffin baths, heating pads, heat lamps).

Provider Actions & Billing

Documentation Required

Provide physician-approved written treatment plan

Keep and maintain a physician‑approved, written treatment plan that includes specific short- and long-term goals, the number of skilled nursing hours requested, and the anticipated duration of services.

Requested number of skilled nursing hours
Anticipated duration of services
Specific short- and long-term goals (physician‑approved)

Documentation Required

Document ongoing medical necessity in nursing notes

For continuation requests, submit nursing progress notes that document ongoing medical necessity and that skilled criteria continue to be met. Ensure the physician reviews and renews the written treatment plan with any updated short- and long-term goals, including discharge planning, at least every six months.

Nursing progress notes documenting continued need and skilled criteria
Physician review and renewal of treatment plan at least every six months

Billing Rule

Use appropriate HCPCS hourly codes

Report skilled hourly nursing services using the appropriate HCPCS hourly codes. Use S9123 for registered nurse hours and S9124 for licensed practical nurse hours. Do not use S9123 when CPT codes 99500–99602 are applicable.

S9123 — Nursing care, in the home; by registered nurse, per hour
S9124 — Nursing care, in the home; by licensed practical nurse, per hour

Denial Risk

Denial risk if custodial/non-skilled only

Claims may be denied if the services are custodial or non‑skilled in nature, provided by family or other non‑professional caregivers, or if there is no caregiver in the home available and able to be trained to assume portions of care.

Documentation Required

Document caregiver availability and training plan

Document that a primary caregiver in the home is willing and able to be trained and will assume portions of care when the nurse is not present. Include supporting evidence of caregiver availability and training plans.

Statement of a primary caregiver willing/able to be trained
Caregiver training plan and schedule
Evidence of caregiver participation in care and competency demonstrations

Background

Skilled hourly nursing care (medically intensive home nursing) refers to complex hourly nursing services provided by a licensed nurse in the individual's home for more than 4 hours/day. These services are intended as an alternative to a more acute care setting (for example, hospital or skilled nursing facility) or to assist with transition from an acute setting, and include care such as ventilator, tracheostomy, IV therapies, and other intensive interventions.

Definitions: see Definitions section for terms such as medically intensive home care, medically fragile, and private duty nursing. This service is an alternative to inpatient care and the policy emphasizes that the goal is to train family/caregivers and gradually decrease nursing care hours over time, with most cases covered for 8 to 12 continuous hours per day (less than 16 hours) unless transitional ventilator/tracheostomy exceptions apply.

Definitions

OpenPayer

Skilled Hourly Nursing Care in the Home

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions & Billing

Background

Revision History

S9123	Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used)
S9124	Nursing care, in the home; by licensed practical nurse, per hour