Medical Necessity for Extended-Hour Nursing
Extended-Hour Nursing Services are covered only when all applicable skilled-care and medical-necessity requirements are met.
ALL of the following
The requested service is Private Duty Nursing or skilled nursing provided by an RN or LPN through a home health agency or in the member's home or current living arrangement.
The member requires continuous skilled nursing care to manage, observe, and evaluate the member's condition or to provide skilled nursing interventions.
The member's care needs must be provided by skilled nursing personnel in the absence of the caregiver or parents.
For a child, documented medical needs cannot be met through a traditional childcare provider system.
The requested services meet the applicable definition of Skilled Care and are not services provided in a hospital, skilled nursing facility, or nursing facility.
Medical necessity and covered-hour determinations are evaluated under the Nebraska Department of Health and Human Services, Code § 471-9: Home Health Agencies and Skilled Nursing Services, subject to any federal, state, or contractual definitions that supersede this policy.
Covered-Hour Determination
After medical necessity is established, the total number of Extended-Hour Nursing Services hours is determined using the applicable coverage criteria and clinical guideline.
ALL of the following
Medical necessity for Extended-Hour Nursing Services has been established under the applicable Nebraska clinical coverage criteria.
The requested hours are supported by the member's documented care needs and plan of care.
The InterQual® LOC: Home Care Q & A, Private Duty Nursing (PDN) Assessment is used as a guideline to determine the total number of hours needed by the member.
The request is documented using Home Health Certification (CMS-485), including a plan of care signed by a physician (M.D. or D.O.) or by an advanced practitioner (NP, CNS, or PA) in accordance with applicable law and regulation.
Night-Hour Nursing Coverage
Night-hour nursing may be authorized only when all of the following requirements are met.
ALL of the following
The client requires procedures on an ongoing basis throughout the night hours.
Night hours are the period after the client has gone to bed for the day; day and evening hours are the period before the client goes to bed for the day.
The required monitoring and treatments cannot be accomplished during day and evening hours.
The medical necessity for monitoring and treatments during night hours is reflected in orders from the physician, nurse practitioner, physician assistant, or clinical nurse specialist.
The nursing notes support the ongoing need for the monitoring and treatments during night hours, consistent with NAC 471 Chapter 9.
Exception for High-Risk Tracheostomy
Extended-Hour Nursing may be covered on a case-by-case basis for a member with an established tracheostomy when all of the following high-risk conditions and documentation requirements are met.
ALL of the following
The member has a high potential risk of clinical airway obstruction.
The member is unable to alert someone for assistance if the tracheostomy is dislodged or malfunctions.
An alternate awake and alert caregiver is not available.
A specialty physician documents the high-potential-risk assessment at least annually.
Objective evidence of airway pathology, such as a sleep study or bronchoscopy, is provided and documented at least every 2 years.
Coverage is subject to the member's state-specific contract and benefit plan. The following limitations and exclusions apply:
Requested services are excluded under the state-specific contract; exceed the plan benefits, including covered hours or days; or are requested when the member is no longer eligible for benefits under the state contract.
Requested services defined in the member's state contractual language as non-Skilled Care or custodial care are excluded. Authorization of services does not expand the member's contractual benefits or override eligibility requirements.
Continuous or bolus nasogastric (NG) or gastrostomy tube (GT) feedings, without other Skilled Care needs, are not covered as Extended-Hour Nursing Services.
A transition after discharge from an inpatient setting to the home may be considered medically necessary when the member's family or caregiver must be trained to administer NG or GT feedings, or when enteral feeding is associated with frequent regurgitation and aspiration.
The following activities and services do not require the skill of a licensed nurse and do not meet the medical-necessity requirements for Extended-Hour Nursing Services:
Observation of a member or routine monitoring in case an intervention is required; observation in case an intervention is required is not Skilled Care.
Help with activities of daily living, including walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating, or preparing food.
Institutional care, including room and board for rest cures, adult day care, and convalescent care; adult or child day care and convalescent care.
Routine administration of maintenance medications, including oral, subcutaneous, and intramuscular medications, including insulin.
Routine patient care, such as changing dressings, periodic turning and positioning in bed, administering oral medications, or watching or protecting a member.
Respite care that relieves the caregiver of the need to provide services to the member is not Extended-Hour Nursing Services. Respite care may be a covered benefit through the Nebraska Waiver or other applicable programs; members interested in respite care should contact the Nebraska Department of Health and Human Services.
Care of an established colostomy or ileostomy is not Skilled Care and is excluded.
Care of an established gastrostomy, jejunostomy, or nasogastric tube, including intermittent or continuous feedings, is excluded when it does not involve other Skilled Care needs.
Care of an established indwelling bladder catheter, including emptying or changing containers and clamping tubing, is excluded.
Chronic care and monitoring of an established tracheostomy, with or without intermittent suctioning, is excluded, except when the high-risk tracheostomy exception is satisfied.
Extended-Hour Nursing Services become maintenance or custodial care, and are not medically necessary, when the member's condition is stable, predictable, or controlled and a licensed nurse is not required to monitor the condition. Routine monitoring in case an intervention is required is not Skilled Care.
Services are also not medically necessary when the Plan of Care does not require a licensed nurse to be in continuous attendance or does not require hands-on nursing interventions.
Extended-Hour Nursing Services are not medically necessary when continuous licensed-nurse attendance or hands-on nursing interventions are not required by the Plan of Care. Observation or routine monitoring in case an intervention is required does not establish a need for continuous skilled nursing.
Care for a known seizure disorder with clinically insignificant seizure activity is typically not medically necessary and does not require skilled nursing care.
Extended-Hour Nursing may be considered medically necessary for a seizure disorder manifested by prolonged seizures that require emergent administration of anticonvulsant medication.
Services that duplicate care already provided by supply or infusion companies are excluded from Extended-Hour Nursing Services coverage.