CurrentUnitedHealthcarePolicy CS1OZNE.P

Private Duty Nursing Services (for Nebraska Only)

Defines UnitedHealthcare coverage criteria, limits, documentation, and exclusions for private duty nursing and extended-hour skilled nursing services for members in Nebraska.

Policy Summary

PayerUnitedHealthcare

PolicyPrivate Duty Nursing Services (for Nebraska Only)

Policy CodePolicy CS1OZNE.P

Change TypeMaterial edits to documentation and respite guidance

Effective DateOct 1, 2025

Next Review Date

Key ActionObtain prior authorization with a physician- or advanced practitioner-signed plan of care (CMS-485) and document medical necessity to support requested hours.

SourceLink

POLICY UPDATE CHANGES

Added Medical Records Documentation Used for Reviews language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that documentation may be required to assess medical criteria but does not guarantee coverage.

Revised coverage limitations and exclusions for respite care replacing a categorical noncoverage statement with direction to Nebraska Waiver or other applicable programs.

Nebraska-onlyjurisdiction

S9123,S9124,T1001,T1002,T1003,T1030,T1031codes listed

2025-10-01effective

InterQual LOC

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria — Medical Necessity and Exclusions

Medical necessity for Extended-Hour / Private Duty Nursing

Covered when ALL of the following are met

Core coverage criteria: 1) Member is located in Nebraska (policy jurisdiction and state-specific contract applies).

Skilled need and setting: 2) The requested service is Extended-Hour or Private Duty Nursing and the client’s care needs must require skilled nursing personnel (RN or LPN) in the absence of caregiver/parents (i.e., continuous skilled nursing in the home).

Refer to NAC 471 Chapter 9 for state rules

Plan of care and orders: 3) Medical necessity is documented in a Home Health Certification (CMS-485) including a plan of care signed by a physician (MD or DO) or an appropriately licensed advanced practitioner (NP, CNS, or PA) in accordance with applicable law and regulation.

Physician or advanced practitioner signature required on CMS-485

Utilization guideline for hours: 4) InterQual Level of Care: Home Care Q&A Private Duty Nursing Assessment (or equivalent guideline) supports the number of hours requested and is used to determine total authorized Extended-Hour Nursing hours.

InterQual LOC referenced as guideline to determine hours

Services are excluded when they are explicitly excluded by the state-specific contract, when requested services exceed the member's plan benefits or eligibility, or when the service constitutes non-skilled or custodial care as defined in the state contract. Examples of custodial/non-skilled services include routine monitoring, maintenance medication administration, assistance with activities of daily living, established ostomy or indwelling catheter care, routine gastrostomy/NG feedings without other skilled needs, chronic monitoring of an established tracheostomy without skilled nursing need, and institutional room and board.

Requests for Extended-Hour or Private Duty Nursing that are beyond plan hours/days or for members not eligible under the state contract will be denied. Duplication of care already provided by supplies or infusion companies and routine patient care tasks such as changing dressings, periodic turning, or administering oral medications do not meet medical necessity for skilled nursing and are therefore excluded.

Respite care is not covered under this policy as a routine benefit; however, respite services may be available through the Nebraska Waiver or other state programs. Providers and families seeking respite options should contact the Nebraska Department of Health and Human Services to determine eligibility and available programs.

This policy replaces a prior categorical limit tied to active Extended-Hour Nursing; refer to state resources for program-specific coverage and authorization guidance.

Extended-Hour Nursing is not medically necessary when any one of the following applies: the plan of care does not require a licensed nurse in continuous attendance; the member's condition is stable, predictable, or controlled such that a licensed nurse is not required to monitor the condition; the plan of care does not require hands-on nursing interventions (observation or routine monitoring alone is insufficient); or services consist solely of routine monitoring or custodial care.

Concrete examples include ongoing routine administration of maintenance medications, care of an established colostomy/ileostomy or indwelling bladder catheter, routine gastrostomy/NG tube feedings without other skilled needs, chronic monitoring of an established tracheostomy without demonstrated skilled nursing need, care for clinically insignificant seizure disorders, and help with activities of daily living (walking, bathing, dressing, toileting, feeding) when no skilled nursing interventions are required.

Procedure Codes and Documentation Frequencies

Applicable procedure codesHCPCS

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.
T1001	Nursing assessment/evaluation.
T1002	RN services, up to 15 minutes.
T1003	LPN/LVN services, up to 15 minutes.
T1030	Nursing care, in the home, by registered nurse, per diem.
T1031	Nursing care, in the home, by licensed practical nurse, per diem.

Airway pathology documentation frequency and physician assessment interval

Documentation frequency for objective airway evidenceObjective evidence of airway pathology (e.g., sleep study, bronchoscopy) must be documented at least every 2 years.

Specialty physician assessment interval for high-risk airwayAssessment of high potential risk of clinical airway obstruction must be documented at least annually by a specialty physician.

Condition for Extended-Hour coverage related to airway riskExtended-Hour Nursing may be covered on a case-by-case basis when a member has high potential risk of clinical airway obstruction and is unable to alert for assistance and an alternate awake/alert caregiver is not available.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests should be documented using the Home Health Certification (CMS-485), which must include a plan of care signed by a physician (M.D. or D.O.) or signed by an advanced practitioner (NP, CNS, or PA) in accordance with applicable law and regulation. Extended-Hour Nursing Services are authorized only when the client's care needs must be provided by skilled nursing personnel in the absence of the caregiver or parents (NAC 471 Chapter 9). Once medical necessity for the requested service is determined using applicable clinical criteria (e.g., InterQual LOC: Home Care Q&A, Private Duty Nursing (PDN) Assessment), use that guidance to determine the total number of Extended-Hour Nursing Service hours needed by the member.

Submit CMS-485 with physician or authorized advanced practitioner signature
Include detailed, current plan of care and justification for skilled nursing requirement
Prior authorization review will consider InterQual PDN assessment guidance

Documentation Required

Provider Documentation Expectations

Background

Extended-Hour Private Duty Nursing provides continuous skilled nursing (RN or LPN) in the home when caregiver or parental absence coincides with medical needs that cannot be safely managed by typical childcare or non‑skilled caregivers. Night or extended‑hour authorization is limited to situations where ongoing nighttime procedures or monitoring cannot be accomplished during day or evening hours and must be explicitly documented in the orders and nursing notes.

Authorization and hours are based on documented medical necessity: a physician- or appropriately licensed advanced practitioner–signed plan of care (CMS‑485) is required, and InterQual Level of Care (Home Care Q&A Private Duty Nursing Assessment) or similar guidelines are used to determine and support the number of hours requested.

Definitions

Extended-Hour Nursing Services definition — continuous skilled nursing and authorization context

Definition of Extended-Hour Nursing ServicesContinuous skilled nursing care provided by RNs or LPNs via a home health agency or private duty nursing, authorized only when the client's care needs must be provided by skilled nursing personnel in the absence of the caregiver or parents; children must have documented medical needs not met by traditional childcare.

Night-hour authorization criteriaNight hours are authorized only if monitoring and treatments cannot be accomplished during day and evening hours; medical necessity must be reflected in orders and nursing notes (physician, NP, PA, or clinical nurse specialist).

Skilled Care / Skilled Nursing ServiceCare requiring skilled nursing or rehabilitation staff to manage, observe, and evaluate care, provided by a private duty nurse or a nurse employed by a home health agency in the member's home; does not include institutional services.

Provider types delivering Extended-Hour NursingRegistered Nurses (RNs) or Licensed Practical Nurses (LPNs) employed by a home health agency or providing private duty nursing.

Revision History & Material Changes

2025-10-01material_revisionLatest

Added and clarified 'Medical Records Documentation Used for Reviews' language specifying that benefit coverage is determined by federal, state, or contractual requirements; medical records may be required to assess clinical criteria but do not guarantee coverage; and detailed documentation requirements were specified.

2025-10-01material_revision

Revised coverage limitations for respite care by removing a prior allowance tied to active Extended-Hour Nursing and directing readers to Nebraska Waiver or other applicable programs for respite care options.