ModifiedUnitedHealthcarePolicy CS137NE.U

Home Health, Skilled; and Custodial Care Services (for Nebraska Only)

Defines coverage and applicable procedure codes for skilled home health services and custodial care in Nebraska; aligns medical necessity criteria to Nebraska Department of Health and Human Services guidance and lists applicable CPT/HCPCS/S codes. Applies only to Nebraska providers and members.

Policy Summary

PayerUnitedHealthcare

PolicyHome Health, Skilled; and Custodial Care Services (for Nebraska Only)

Policy CodePolicy CS137NE.U

Change TypeCode additions, removals, and reference update

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionReference Nebraska DHHS Code 471-9 for medical necessity clinical coverage criteria and ensure documentation aligns with state requirements.

SourceLink

POLICY UPDATE CHANGES

Replaced instruction to refer to Nebraska Department of Health and Human Services; Code 471-9-000 with reference to Code 471-9: Home Health Agencies and Skilled Nursing Services for medical necessity clinical coverage criteria.

Added HCPCS code T1005 to the Applicable Codes list.

Removed CPT/HCPCS codes 99512, S9128, S9129, and S9131 from the Applicable Codes list.

Revised description for HCPCS codes S5523 and S9123.

Updated References section to reflect the most current information.

100+listed procedure/HCPCS/S codes

Nebraskajurisdiction

T1005newly added code

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Coverage Criteria and Applicability

Medical necessity determination

Coverage is governed by state clinical criteria.

State-directed medical necessity: Medical necessity clinical coverage criteria are determined by the Nebraska Department of Health and Human Services

Providers must reference NE DHHS criteria (Title 471, Chapter 9: Home Health Agencies and Skilled Nursing Services) for specific medical necessity rules and authorized approved hours.

The following procedure and diagnosis codes are provided for reference only. Inclusion of a code does not imply the service described by the code is a covered or non-covered health service, nor does it guarantee reimbursement or payment. Benefit coverage is determined by applicable federal, state, or contractual requirements and laws; other policies and guidelines may also apply and may exclude coverage.

Home health care, including skilled care, are services rendered by licensed health care professionals and are clinical services delivered under professional licensure. As noted for informational purposes, these services are not subject to regulation by the U.S. Food and Drug Administration.

Listing a procedure or diagnosis code in this policy is for reference and administrative purposes only. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Providers must follow applicable federal, state, and contractual rules, and other UnitedHealthcare policies, when seeking authorization or payment for services.

Procedure and Billing Codes

Selected CPT Home Visit CodesCPT

99500	Home visit for prenatal monitoring and assessment to include fetal heart rate , non-stress test; uterine monitoring; and gestational diabetes monitoring.
99501	Home visit for postnatal assessment and follow-up care.
99502	Home visit for newborn care and assessment.
99503	Home visit for respiratory therapy care (e.g-, bronchodilator; oxygen therapy, respiratory assessment; apnea evaluation).
99504	Home visit for mechanical ventilation care.
99505	Home visit for stoma care and maintenance including colostomy and cystostomy.
99506	Home visit for intramuscular injections

Selected HCPCS G codesHCPCS

G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes.
G0300	Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes.
G0320	Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system.
G0321	Home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system.
G0322	The collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (i.e , remote patient monitoring).

Selected S codes (home infusion, therapy, training, per diem)HCPCS

H1004	Prenatal care, at-risk enhanced service; follow-up home visit.
S5035	Home infusion therapy, routine service of infusion device (e.g , pump maintenance).
S5036	Home infusion therapy, repair of infusion device (e.g: pump repair).
S5108	Home care training to home care client; per 15 minutes.
S9122	Home health aide or certified nurse assistant; providing care in the home; per hour.
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).
S9348	Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., Dobutamine); per diem.
S9364	Home infusion therapy, total parenteral nutrition (TPN); per diem (includes standard TPN formula).
S9500	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; per diem.
S9559	Home injectable therapy, interferon, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, per diem.

Applicable HCPCS/T CodesHCPCSCovered

S9500	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately) ; per diem.
S9501	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately) , per diem.
S9502	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately) , per diem.
S9503	Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately) , per diem.
S9504	Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately) , per diem.
S9537	Home therapy; hematopoietic hormone injection therapy (e.g , erythropoietin, G-CSF GM-CSF); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately) , per diem.
S9538	Home transfusion of blood product(s); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (blood products, drugs, and nursing visits).
S9542	Home injectable therapy, not otherwise classified, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately) , per diem.
S9559	Home injectable therapy, interferon, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately) , per diem.
S9560	Home injectable therapy; hormonal therapy (e.g , leuprolide, goserelin) , including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately) , per diem.

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Time unit (each 15 minutes)

Time unitServices frequently reported in 15-minute increments (each 15 minutes).

Examples of 15-minute codesG0299, G0300, G0493, G0494, G0496, G2168, G2169—all described as 'each 15 minutes' in the Applicable Codes list.

Applies toDirect skilled nursing, skilled observation/assessment, training/education, and therapy assistant services in the home setting when reported in time-based units.

Provider Responsibilities and Authorization Notes

Billing Rule

Applicable Codes — Reference and Authorization Note

The following procedure and diagnosis codes are provided for reference only and may not be all-inclusive. Listing a code in this policy does not imply that the service is covered or non-covered, nor does it guarantee reimbursement. Providers must follow applicable federal, state, and contractual rules when billing and seeking payment.

Examples of referenced CPT codes: 99500–99507, 99511, 99601–99602
Examples of referenced HCPCS codes: G0068, G0069, G0070, G0088, G0089, G0151–G0162

Prior Authorization

Conflicts with Plan / Federal / State Requirements

When there is any conflict between this policy and federal, state, or contractual coverage requirements, the federal, state, or contractual requirements govern. Before relying on this policy for coverage decisions, providers must verify the member’s plan terms and any applicable federal or state mandates. UnitedHealthcare’s Medical Policies are informational and do not replace the plan contract or legal requirements.

Background and Policy Scope

This policy defers to state-administered clinical coverage criteria for medical necessity determinations. Medical necessity clinical coverage criteria are determined by the Nebraska Department of Health and Human Services; providers should reference NE DHHS guidance (Title 471, Chapter 9: Home Health Agencies and Skilled Nursing Services) when documenting and requesting coverage. Authorized approvers and any permitted use of approved hours are governed by those state criteria and applicable contractual requirements.

Definitions and Operational Details

Authorized approved hours

Authorized approved hoursHours approved for home health services which may be used outside the home during those hours when the individual's normal life activities occur.

ScopeApplies to authorized home health hours as defined in medical necessity criteria (refer to NE DHHS for clinical rules).

Documentation noteUse authorized approved hours consistent with state-directed medical necessity criteria and the policy's coverage rationale.