Currentsierra health and lifePolicy MP.017.20

Private Duty Nursing Services – Commercial and Individual Exchange Medical Policy (PDF) PDF Opens in new windowopens in a new tabopens in a new window

Defines coverage for private duty nursing services with Skilled Care for UnitedHealthcare Commercial and most Individual Exchange plans, contingent on member-specific benefit documents and meeting the definition of Skilled Care; references InterQual LOC: Home Care PDN Assessment for hours and CMS-485 for documentation.

Policy Summary

Payersierra health and life

PolicyPrivate Duty Nursing Services – Commercial and Individual Exchange Medical Policy (PDF) PDF Opens in new windowopens in a new tabopens in a new window

Policy CodePolicy MP.017.20

Change TypeRoutine review; no change

Effective DateAug 1, 2025

Next Review Date

Key ActionRequests should be documented using Home Health Certification (CMS-485) including the plan of care signed by a physician or advanced practitioner as allowed by law; medical record documentation may be requested to assess clinical criteria for coverage.

SourceLink

POLICY UPDATE CHANGES

08/01/2025 routine review; no change to coverage guidelines; archived previous policy version MP.017.19.

1Primary HCPCS code listed

Custodial Care ExcludedExclusion Status

InterQualExternal Criteria for Hours

Coverage Summary

This policy (MP.017.20) defines coverage for Private Duty Nursing (PDN) Services with Skilled Care for UnitedHealthcare Commercial and most Individual Exchange plans. Coverage is covered with criteria when services meet the policy’s Skilled Care definition, are ordered and documented appropriately, and hours are determined per the InterQual LOC assessment. Effective date: 2025-08-01; Last review: 2025-08-01.

Key Policy Facts

Policy NumberMP.017.20

Policy Title/SubjectPrivate Duty Nursing Services (PDN) with Skilled Care

PayerUnitedHealthcare Commercial and most Individual Exchange plans

Effective DateAugust 1, 2025

Last ReviewAugust 1, 2025

Coverage StanceCovered with criteria — PDN covered when member-specific plan allows and Skilled Care definition and documentation requirements are met; hours per InterQual LOC

Provider Actions / Prior Authorization & Documentation

Documentation Required

Use CMS-485 for Requests

Requests should be documented using Home Health Certification (CMS-485) which includes the plan of care signed by a physician (M.D. or D.O.) or signed by an advanced practitioner in accordance with applicable law and regulation; medical record documentation may be requested to assess clinical criteria for coverage.

CMS-485 (Home Health Certification)
Plan of care signed by a physician (or advanced practitioner as allowed by law)

Prior Authorization

Benefit and Medical Necessity Verification

Verify member-specific benefit plan for PDN and custodial care exclusions and confirm services meet the Skilled Care definition before authorization; refer to InterQual LOC (Home Care Q&A, Private Duty Nursing Assessment) for determination of the number of private duty nursing hours.

Verify member-specific benefit exclusions for PDN and custodial care
Use InterQual LOC (Home Care Q&A, PDN Assessment) to determine hours

Requests may require submission of medical record documentation to assess whether the member meets the clinical criteria for coverage; CMS-485 (Home Health Certification with plan of care signed by a physician or authorized advanced practitioner) is required for review.

Background, Evidence & Definitions

Scope: This policy governs coverage of private duty nursing services for UnitedHealthcare Commercial and most Individual Exchange plans. Coverage requires services to meet the policy’s Skilled Care definition, be ordered and documented appropriately, and the number of PDN hours is determined using the InterQual Level of Care (LOC) Home Care PDN Assessment.

Term	Definition
Custodial Care
Non-skilled services primarily for daily living activities or those that can be safely performed by trained non-medical personnel; examples include help with eating, dressing, bathing, transferring, ambulating, routine medication administration, general maintenance care of colostomy/ileostomy, routine catheter care, noninfected dressing changes, prophylactic/palliative skin care, routine incontinent care, cast/braces maintenance, use of heat for comfort, routine administration of medical gases after regimen established, assistance with toileting, and periodic turning/positioning.
Skilled Care
Skilled nursing, teaching, habilitation, or rehabilitation that: must be delivered or supervised by licensed technical or professional medical personnel to obtain the specified medical outcome and ensure patient safety; is ordered by a physician; is not provided for the purpose of assistance with activities of daily living (e.g., dressing, feeding, bathing, transferring); requires clinical training to be delivered safely and effectively; and is not custodial care. Examples include intravenous injections/feeding, nasopharyngeal and tracheostomy aspiration, insertion/sterile irrigation/replacement of suprapubic catheters, treatment of extensive decubitus ulcers or widespread skin disorders, initial phases of medical gas administration, and rehabilitation nursing procedures including teaching and supervision of bowel and bladder training programs.

Regulatory Reference: 42 CFR 409.33 (Examples of skilled nursing and rehabilitation services).

Policy Summary

Payersierra health and life

PolicyPrivate Duty Nursing Services – Commercial and Individual Exchange Medical Policy (PDF) PDF Opens in new windowopens in a new tabopens in a new window

Policy CodePolicy MP.017.20

Change TypeRoutine review; no change

Effective DateAug 1, 2025

Next Review Date

SourceLink

On This Page

OpenPayer

Private Duty Nursing Services – Commercial and Individual Exchange Medical Policy (PDF) PDF Opens in new windowopens in a new tabopens in a new window

Coverage Summary

Medical Necessity / Coverage Requirements

Excluded Services — Custodial Care

Coding

Provider Actions / Prior Authorization & Documentation

Background, Evidence & Definitions

Revision History