CurrentAetnaPolicy 0136

Skilled Home Private Duty Nursing Care

Defines medical necessity, limitations, and documentation requirements for private duty home nursing (PDN) and medically fragile day care for Aetna members with private duty nursing benefits.

Policy Summary

PayerAetna

PolicySkilled Home Private Duty Nursing Care

Policy CodePolicy 0136

Change TypeNo material changes

Effective Date05/31/1996

Next Review Date02/08/2024

Key ActionObtain a physician order and document unstable condition with frequent nursing assessments and monthly physician order updates to qualify for PDN.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 weeksMax continuous ventilator nursing

60 daysMedicare recert interval

8 hrsDay care = PDN hours

8PDN criteria count

42 CFR 440.80Regulatory ref

Coverage Criteria for Private Duty Nursing and Medically Fragile Day Care

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Private Duty Home Nursing — Initial criteria

Covered when ALL of the following are met:

PDN initial medical necessity criteria: 1) The member has skilled needs; 2) The member is homebound; 3) The member needs skilled care that exceeds the scope of intermittent care; 4) Placement of the nurse in the home is done to meet the skilled needs of the member only, not for the convenience of the family caregiver; 5) Home nursing care is provided as part of a written short term, home care plan leading to the training of the primary caregiver(s) to deliver those services once the member’s condition is stabilized; 6) Home nursing is not meant to replace a parent or caregiver, but to provide skilled support to the member; 7) Services are provided at home when such services are medically necessary to properly attend the member; 8) The member is participating/engaged in case management with an Aetna case manager.

For Medicare Advantage members, LCDs apply where relevant; PDN services must be ordered following a face-to-face visit with recertification every 60 days by the ordering provider.

Medically Fragile Day Care

Covered when ALL of the following are met:

Medically fragile day care: 1) Care is not custodial; 2) It has been recommended following medical review; 3) It is in lieu of private duty nursing care that Aetna would routinely approve.

Transportation to/from facility is family's responsibility; one day of medically fragile day care is equivalent to 8 hours of private duty nursing. If member unable to attend due to acute illness, up to 8 hours of nursing per day in the home may be considered after 72 hours of illness.

Home Nursing for Patients on Ventilators

Ventilator management covered with conditions:

Ventilator home nursing: 1) Initial stabilization at home after discharge is a skilled need requiring home nursing care; 2) Continued ventilator management is not considered a skilled need requiring home nursing unless the member is unstable and needs close monitoring and frequent ventilator adjustments.up to 3 weeks for continuous nursing upon initial discharge

After stabilization, medically necessary nursing hours per day will decline as family/caregiver is instructed on routine ventilator care.

PDN Medical Necessity Criteria

Covered when ALL of the following are met

PDN qualification: 1) Services are ordered by a licensed physician as part of a treatment plan for a covered medical condition; 2) The attending physician has approved a written treatment plan with short- and long-term goals specified; 3) Services are medically necessary for the member's disease/illness/injury, within accepted standards of nursing practice, performed by a licensed nurse, within the nurse's scope of practice, and require the professional proficiency and skills of a licensed nurse; 4) The member's condition is unstable and requires frequent nursing assessments and changes in the plan of care such that needs cannot be met through intermittent skilled nursing visits alone.

Physician orders and progress notes must document frequent assessments and show changes/adjustments have been made at least monthly.

Limits on purpose: Need for nursing care solely to participate in activities outside the home is not a basis for authorizing PDN or expanding hours; PDN is not considered medically necessary solely because there is no caregiver available to assume the role; PDN is not covered while the member is in an inpatient, outpatient, hospital, physician office or other medical care setting.

A nurse may accompany the member for normal life activities (e.g., child attending school) only if medical needs meet PDN criteria; normal life activities do not include receiving care in medical facilities.

Private duty nursing (PDN) is not covered when the member is receiving care in a licensed inpatient or residential setting. Examples include an acute inpatient hospital, inpatient rehabilitation, skilled nursing facility (SNF), intermediate care facility, or when the member is a resident of a licensed residential care facility. (PDN coverage is intended for services delivered in the member’s private residence and does not apply while the member is institutionalized.)

PDN is not considered medically necessary solely because no caregiver is available to assume responsibility. Similarly, the need for nursing care only to enable participation in activities outside the home (for example, attending school) is not, by itself, a basis to authorize PDN or to expand PDN hours; the member’s medical needs must meet PDN criteria.

Services that can be provided safely and effectively by a nonclinical person do not become skilled nursing services merely because a caregiver is unavailable. If the member’s condition is stable, continuous licensed nurse attendance is not required, or hands‑on nursing interventions are unnecessary, the care is considered custodial and is not PDN.

PDN is not authorized for family convenience, solely because a caregiver is absent or unwilling, or merely to allow a family member to work or attend school. Likewise, PDN is not for routine participation in activities outside the home unless the member’s medical condition independently meets the criteria for PDN; PDN does not cover services provided while the member is receiving care in other medical settings (inpatient, outpatient, physician’s office, etc.).

Orders, Authorization, Documentation, and Denial Triggers

Prior Authorization

Ordering and Recertification Requirements

Ordering and recertification: Private Duty Nursing (PDN) must be ordered by the member’s primary care and/or treating physician as part of a treatment plan following a face-to-face visit when Medicare rules apply. Orders must include physician approval of a written treatment plan with short- and long-term goals. For Medicare Advantage members, the ordering provider must recertify every 60 days. Agencies/providers must be authorized to provide PDN and participate with traditional Medicare where applicable.

Physician order required (MD/DO)
Written treatment plan with short- and long-term goals
Medicare: face-to-face visit and recertification every 60 days
Agency/provider must be licensed and participate with Medicare when applicable

Prior Authorization

Prior Authorization / Qualification

Prior authorization / qualification: PDN is medically necessary only when the member has skilled needs, is homebound, requires skilled care exceeding intermittent visits, and placement of nursing is to meet clinical needs (not convenience). Services must be part of a short-term home care plan that leads to caregiver training and the member must be engaged in case management. Case managers should evaluate instability, frequency of skilled needs, caregiver ability, and plan for weaning as condition stabilizes.

Member must have skilled needs and be homebound
Care plan must aim to train caregiver(s) and transition care
Case management involvement required
Consider stability, number of skilled needs, and caregiver abilities when authorizing hours

Note

Weaning and Step‑Down Expectations

Weaning / step‑down expectations: PDN is intended as short‑term, skill‑based support with the explicit goal of training the primary caregiver and reducing nursing hours as the member improves. Case managers should set and communicate expectations about regression of nursing hours and eventual termination of services and ensure caregiver training and competency are documented.

Plan should include timeline/expectations for reduction of nursing hours
Document caregiver training and demonstrated competency
Case manager to coordinate input from hospital, agency, and treating physicians

Documentation Required

Required Documentation and Orders

Required documentation and orders: The attending physician must order PDN as part of a treatment plan and approve a written treatment plan with specific goals. Documentation must show services are medically necessary, within nursing scope of practice, performed by a licensed nurse, provided in the member’s private residence, and that the member’s condition is unstable requiring frequent assessments and plan changes.

Physician order and written treatment plan with goals
Services performed by licensed RN or LPN and within scope of practice
Documentation of medical necessity and that needs cannot be met by intermittent skilled nursing visits
Evidence of instability and frequent nursing assessments with plan changes

Documentation Required

Progress Notes and Ongoing Documentation

Progress notes and ongoing documentation: Nursing and adjunctive therapy progress notes must document frequent assessments, interventions, and adjustments to the plan of care. Physician orders should reflect changes or adjustments at least monthly. PDN eligibility requires documentation that needs could not be met through intermittent skilled nursing.

Progress notes documenting frequent assessments and care plan adjustments
Physician orders updated at least monthly to reflect changes
Documentation that PDN is required rather than intermittent skilled visits

Denial Risk

Triggers for Denial / Not Medically Necessary

Triggers for denial / Not medically necessary: PDN is not medically necessary when the service is solely for caregiver respite or convenience, to allow family to work or attend school, for maintenance or custodial care, when the member is in an inpatient or licensed residential facility, or solely because no caregiver is available or willing to assume responsibility. PDN is also not indicated solely to enable participation in activities outside the home.

Not covered if primary purpose is caregiver respite or convenience
Not covered solely to allow family/caregiver to work or attend school
Not covered for maintenance or custodial care (see criteria for transition to maintenance)
Not covered if member is in acute inpatient, inpatient rehab, SNF, intermediate care facility, or licensed residential care facility
Not medically necessary solely because no caregiver is available or willing to assume responsibility
Not authorized solely to enable participation in outside‑home activities

Note

Operational Clarifications

Operational note: PDN may accompany a member for normal life activities (e.g., school) when medically required, but coverage does not extend to services received in other medical settings. Ensure orders and documentation justify PDN during outside‑home activities.

Nurse may accompany member for normal life activities when criteria met
Coverage excludes PDN while member receives care in inpatient/outpatient medical settings
Orders must justify PDN during activities outside the home

Key Definitions

Custodial care — definition & exclusion

DefinitionServices primarily intended to help members meet personal needs (e.g., bathing, eating, companionship); considered custodial care.

Exclusion from PDNCustodial care is excluded from private duty nursing when the member's condition is stable and continuous attendance by a licensed nurse is not necessary.

ExamplesIncludes assistance with activities of daily living and non-skilled personal care provided by non-nurse caregivers ('sitters').

Private duty nursing (PDN) — definition

DefinitionContinuous skilled 1-on-1 nursing care in the home provided by registered nurses (RNs) or licensed practical nurses (LPNs), typically prescribed hourly.

DistinctionDistinct from intermittent skilled nursing visits provided by home care agencies and from non-skilled caregivers ('sitters').

Typical usePrescribed for tasks requiring continuous nursing care rather than per-visit skilled services.

Normal life activities — definition & scope

DefinitionMember's usual activities outside the home (e.g., a child attending school).

LimitationsA nurse may accompany the member for normal life activities only if the member's medical needs meet PDN criteria; such activities do not include receiving medical care in inpatient, outpatient, hospital, physician office, or other medical care settings.

Not a basis for PDNNeed for nursing care solely to participate in normal life activities is not a basis to authorize PDN or to expand hours unless medical necessity criteria are met.

94760-94762	Noninvasive ear or pulse oximetry for oxygen saturation.
99500	Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring.
99501	Home visit for postnatal assessment and follow-up care.
99502	Home visit for newborn care and assessment.
99503	Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation).
99504	Home visit for mechanical ventilation care.
99505	Home visit for stoma care and maintenance including colostomy and cystostomy.
99506	Home visit for intramuscular injections.
99507	Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral).
99509	Home visit for assistance with activities of daily living and personal care.

OpenPayer

Skilled Home Private Duty Nursing Care

Coverage Criteria for Private Duty Nursing and Medically Fragile Day Care

CPT / HCPCS and Regulatory Codes

Orders, Authorization, Documentation, and Denial Triggers

Key Definitions

Background

Revision History and Regulatory Dates