CurrentUnitedHealthcarePolicy CS102KY.06

Private Duty Nursing Services (for Kentucky Only)

Defines coverage and requirements for Private Duty Nursing (PDN) services for UnitedHealthcare members in Kentucky, including reliance on Kentucky regulations and InterQual LOC for determining hours and skilled care criteria.

Policy Summary

PayerUnitedHealthcare

PolicyPrivate Duty Nursing Services (for Kentucky Only)

Policy CodePolicy CS102KY.06

Change TypeCoverage and documentation clarifications

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDocument PDN requests using Home Health Certification (CMS-485) with a physician-signed plan of care and ensure records fully support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Removed language indicating a Private Duty Nursing service may be covered in a setting other than in the member's home if the service is provided during a normal life activity of the member that requires the member to be out of his or her home.

Added instruction to refer to the Kentucky Administrative Regulations (KAR), Title 907, Chapter 013, Regulation 010 for service coverage provisions and requirements of Private Duty Nursing services.

Added detailed medical records documentation language specifying that benefit coverage is determined by federal, state, or contractual requirements, that documentation may be required to assess clinical criteria, and that records must fully support medical necessity and be legible and available upon request.

Kentucky-onlyjurisdiction

InterQual LOChours determination

T1000

Related Billing Codes

HCPCS-T1000-PRIVATE-DUTY-LICENSED-NURSING-15-MIN

HCPCS T1000: Private Duty Licensed Nursing, 15-Minute Units

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902 KAR 20:370definition source

Coverage Criteria for Private Duty Nursing (PDN)

Covered When ALL of the Following Are Met

Covered when ALL of the following are met:

Skilled Care Coverage Requirements: Member meets the definition of Skilled Care and Skilled Nursing Services; care is clinically appropriate and exceeds routine monitoring; provided continuously or part-time/short-term; includes skilled interventions provided directly by a licensed nurse; nursing reassessment no less than every ninety (90) days; expectation that the service will improve, restore, maintain function or slow declinesee Skilled Nursing Services definition

Once Skilled Care coverage is established, the number of Private Duty Nursing (PDN) hours is determined per InterQual LOC: Home Care Q&A, Private Duty Nursing Assessment; requests must be documented using Home Health Certification (CMS-485) including a plan of care signed by a physician (M.D. or D.O.) or an advanced practitioner in accordance with law.

Policy language that previously allowed coverage of Private Duty Nursing (PDN) in a non-home setting during a member’s normal life activities has been removed. Coverage for PDN is now limited to services provided in the member’s home. Refer to Kentucky Administrative Regulations (KAR), Title 907, Chapter 013, Regulation 010 for state-specific service coverage provisions and requirements related to Private Duty Nursing services.

Benefit coverage is determined by applicable federal, state, or contractual requirements and may require review of medical records to assess whether the member meets the clinical criteria for coverage. The patient’s medical record must contain documentation that fully supports the medical necessity for the requested services, including but not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation supporting medical necessity must be legible, maintained in the patient’s medical record, and made available upon request. Absence of required documentation or documentation that does not substantiate medical necessity may result in the service being denied or considered not medically necessary for coverage purposes.

Applicable Codes and Related Details

Applicable HCPCS CodesHCPCS

T1000

Private duty/independent nursing service(s), licensed, up to 15 minutes

Nursing reassessment interval

IntervalNursing reassessment no less than every ninety (90) days

PurposeEnsures plan of treatment is reassessed frequently and remains appropriate

Applies toSkilled Nursing Services provided by a Private Duty Nursing agency

Provider Responsibilities and Documentation Requirements

Note

InterQual-based hours determination and CMS-485 requirement

Coverage for Private Duty Nursing hours is determined after Skilled Care coverage is established using InterQual LOC: Home Care Q&A, Private Duty Nursing (PDN) Assessment. Refer to the InterQual criteria when requesting PDN hours.

InterQual LOC: Home Care Q&A, Private Duty Nursing (PDN) Assessment

Prior Authorization

Action required: Document requests on CMS-485

Requests for Private Duty Nursing must be documented using the Home Health Certification (CMS-485), which includes a physician-signed plan of care (M.D. or D.O.) or a plan signed by an advanced practitioner (NP, CNS, or PA) as allowed by applicable law and regulation.

Home Health Certification (CMS-485) with physician or authorized advanced practitioner signature

Definitions

Private Duty Nursing definition

DefinitionThe delivery of Skilled Nursing Services (902 KAR 20:370).

Regulatory source902 KAR 20:370

ContextPrivate Duty Nursing services are provided when skilled nursing care exceeding routine monitoring is required

Skilled Care definition

DefinitionHealth care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care (CMS Glossary).

UseEstablishes requirement that Skilled Care must be present before PDN coverage and hour determination

Relation

Background

Private Duty Nursing (PDN) delivers Skilled Nursing Services for patients who require nursing that exceeds routine monitoring. PDN may be provided continuously or on a part‑time/short‑term basis with the expectation to improve, restore, maintain function, or slow decline. Skilled interventions commonly provided in PDN include bowel and bladder care, medication administration and medication setups, infusion therapy, wound care, and ventilation support.

PDN is defined and governed by applicable regulations; in Kentucky refer to 902 KAR 20:370 and the state‑specific provisions cited in KAR Title 907, Chapter 013, Regulation 010 for details on service definitions and requirements.

Revision History & Material Changes

2026-05-01policy_revisionLatest

Removed language allowing Private Duty Nursing coverage in non-home settings during a member's normal life activity; narrowed allowed setting to home only.

2026-05-01policy_addition

Added instruction to refer to Kentucky Administrative Regulations (KAR), Title 907, Chapter 013, Regulation 010 for Private Duty Nursing service coverage provisions and requirements.

2026-05-01documentation_clarification

Policy Summary

PayerUnitedHealthcare

PolicyPrivate Duty Nursing Services (for Kentucky Only)

Policy CodePolicy CS102KY.06

Change TypeCoverage and documentation clarifications

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDocument PDN requests using Home Health Certification (CMS-485) with a physician-signed plan of care and ensure records fully support medical necessity.

SourceLink

On This Page

Documentation Required

PROVIDER ACTIONS — Requests should be documented using Home Health Certification (CMS-485) including a plan of care signed by a physician

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services (e.g., relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures). Documentation should be legible, maintained in the patient's medical record, and made available upon request. Note that medical record documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage.

Include relevant medical history, physical exam, and diagnostic test results
Documentation must be legible and available upon request
Medical record review does not guarantee coverage

Denial Risk

PROVIDER ACTIONS — Lack of documentation or inability to make records available may result in non-coverage or denial risk

Lack of documentation or inability to make records available upon request may result in non-coverage or denial of the requested services.

Missing or illegible documentation increases denial risk
Failure to produce records upon request may lead to claim denial

Referenced alongside Skilled Nursing Services to determine coverage criteria

Skilled Nursing Services

DefinitionNursing care that exceeds routine monitoring; is clinically appropriate; provided continuously or part-time/short-term; requires nursing reassessment no less than every ninety (90) days; involves frequent plan changes; and includes skilled interventions such as bowel/bladder care, medication administration, infusion therapy, medication setups, wound care, and ventilation (902 KAR 20:370).

Required elementsExceeds routine monitoring; clinically appropriate; continuous or part‑time/short‑term; reassessment ≥ every 90 days; expectation to improve/maintain/slow decline

Examples of skilled interventionsBowel/bladder care; administering medications or oxygen; infusion therapy; medication setups; treating decubitus ulcers/skin breakdown/wound care; ventilation care

Added detailed medical records documentation requirements specifying that coverage is determined by federal, state, or contractual requirements, that documentation may be required to assess clinical criteria, and that records must fully support medical necessity, be legible, and be available upon request.