Private-Duty Nursing (PDN) — Coverage Criteria
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Defines Alaska Medicaid clinical eligibility and coverage criteria for private-duty nursing services for eligible individuals under 21 with life‑threatening conditions who require continuous skilled care to avoid hospital or long‑term care placement.
No material clinical or coverage changes in this revision.
Coverage Criteria for Private-Duty Nursing (PDN)
General eligibility and covered clinical indications
Covered when ALL of the following are met
Additional considered conditions
The Department will consider combinations of technologies and comorbidities for medical determinations for the following
PDN is not medically necessary when the member is residing in a facility at the time PDN would be provided. This includes residence in a nursing facility, hospital, residential care facility, or an intermediate care facility for individuals with intellectual developmental disabilities (ICF/IID).
Services that are provided after the member's condition has been stabilized or that are delivered only at a maintenance level are not considered medically necessary. PDN is also not covered when care is provided solely for the convenience of the caregiver, solely for respitesupplement family caregiving, or when the service functions only as a companion/sitter.
Clinical Thresholds and Coding-Related Criteria
Provider Requirements and Authorization
Prior Authorization Required
Prior authorization is required. Alaska Medicaid will consider reimbursement for private-duty nursing (PDN) only when all medical necessity criteria are met and services are authorized in advance.
- Authorization required before PDN services are delivered
- Services authorized only for eligible individuals under 21 with life‑threatening conditions
- Services are temporary and focused on caregiver training
Providers must ensure referral and authorization workflows are followed and that PDN is requested only when medically necessary per Alaska Medicaid criteria. Include complete supporting clinical documentation with authorization requests.
- Submit authorization requests with treating physician affirmation of instability and need for skilled nursing
- Include relevant clinical notes, equipment needs, and caregiver training goals
- Contact Tracy.Stephens@alaska.gov for questions
Physician Direction and Clinical Documentation
Services must be recommended by and provided under the direction of the member's primary care and/or treating physician who affirms the medical necessity and documents that the member's condition is unstable and requires skilled nursing care.
- Member must meet qualifying clinical criteria (e.g., invasive ventilator within last 6 months, active weaning from ventilator, recent tracheostomy removal, rapid desaturation without oxygen, prolonged IV infusions including TPN)
- Documentation must describe instability, monitoring needs, and caregiver training plan
Common Denial Scenarios
PDN services are not considered medically necessary in several common scenarios; claims or authorizations submitted for these situations are at high risk of denial.
- Member residing in a nursing facility, hospital, residential care facility, or ICF/IID at time of PDN service delivery
- Care provided solely for convenience, respite, to allow family to work/school/run errands, or as companion/sitter
- Care that is maintenance-level after stabilization or solely to supplement family caregiving
Background
Private-duty nursing (PDN) provides continuous, skilled nursing care for medically fragile children and other eligible individuals whose conditions are unstable and who would otherwise require hospitalization or placement in long-term care. Services are intended to be temporary, delivered under the direction of the member's treating physician, and to support training of caregivers so that skilled care can eventually be provided without ongoing PDN.
Key Definitions
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