Section 414.408 - Continuous Skilled Nursing Services(A)Clinical Eligibility for Continuous Skilled Nursing Services. A member is clinically eligible for MassHealth coverage of CSN services when all of the following criteria are met: (1) there is a clearly identifiable, specific medical need for a nursing visit to provide nursing services, as described in 130 CMR 414.408(B), of more than two continuous hours;(2) the CSN services are medically necessary to treat an illness or injury in accordance with 130 CMR 414.409(C); and(3) the nurse has obtained prior authorization in accordance with 130 CMR 414.413.(B)Clinical Criteria for Nursing Services.(1) A nursing service is a service that must be provided by an RN or LPN to be safe and effective, considering the inherent complexity of the service, the condition of the patient, and accepted standards of medical and nursing practice.(2) Some services are nursing services on the basis of complexity alone (for example, intravenous and intramuscular injections). However, in some cases, a service that is ordinarily considered unskilled may be considered a nursing service because of the patient's condition. This situation occurs when only an RN or LPN can safely and effectively provide the service.(3) When a service can be safely and effectively performed (or self-administered) by the average nonmedical person without the direct intervention of an RN or LPN, the service is not considered a nursing service, unless there is no one trained and able to provide it.(4) The independent nurse must assess the member to ensure that continued nursing services are necessary. Medical necessity of services is based on the condition of the patient at the time the services were ordered and what was, at that time, expected to be appropriate treatment throughout the certification period.(5) A member's need for nursing care is based solely on their unique condition and individual needs, whether the illness or injury is acute, chronic, terminal, stable, or expected to extend over a long period.(C)Member Must Be under the Care of a Physician or Ordering Non-physician Practitioner. The MassHealth agency pays for CSN services only if the member's physician or ordering non-physician practitioner certifies the medical necessity for such services on an established individual plan of care in accordance with 130 CMR 414.412. A member may receive CSN services only if the member is under the care of a physician or ordering non-physician practitioner.(D)Safe Maintenance in the Community. The member's physician or ordering non-physician practitioner and the independent nurse must determine that the member can be maintained safely in the community with medically appropriate CSN services.Amended by Mass Register Issue 1478, eff. 9/16/2022.Amended by Mass Register Issue 1529, eff. 8/30/2024.