Point32 Commercial Clinical Policy

Point32 Private Duty Nursing in the Home(Eff. beginning 1.1.24) Form

Effective Date

01/01/2024

Last Reviewed

10/18/2023

Original Document

  Reference



To be considered homebound, a Member does not have to be bedridden. However, the condition should be such that there exists a normal inability to leave the home, and consequently, leaving the home would require a considerable and taxing effort. If the Member can leave the home, the Member may be considered homebound if the absences from the home are infrequent, for periods of relatively short duration, or to receive medical treatment.

Clinical Guideline Coverage Criteria

The Plan may authorize coverage of private duty nursing for Members in the home, when ALL of the following criteria are met:

  1. The services are medically necessary
  2. The services are ordered by a physician
  3. The services are received in a Member's home for a Member who is homebound (see definition of homebound that is to be used for this benefit under "overview" above)
  4. The services are performed by a certified home health agency by a licensed nurse (RN or LPN)
  5. The Member requires continuous skilled nursing observation and intervention—_— .

Point32Health companies
2101518

Private Duty Nursing in the Home

Limitations

The Plan does not cover the following services as private duty nursing:

  1. When provided by a private duty nurse:
  • The primary duties are limited to bathing, feeding, exercising, homemaking, giving oral medications or acting as a companion or sitter
  • The duties are performed by a member of your household or when the cost of any care is being provided by the Member's relatives (by blood, marriage, or adoption)
  • The care is provided outside of the home (e.g., a school, nursing facility or assisted living facility)
  • The services duplicate or overlap services (e.g., when a person is receiving hospice care services or is receiving skilled nursing home care visits during the same hours)
  • The services are for observation only
  1. Services of a nurse's aide
  2. Care for a Member without an available caregiver in the home
  3. Maintenance care when the Member's condition has stabilized (including routine ostomy care or tube feeding administration) or if the anticipated need is indefinite
  4. Respite care (for example, care during a caregiver's vacation) or to allow a caregiver to work or attend school

Codes