CurrentAlaska MedicaidPolicy N/A

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.

Policy Summary

PayerAlaska Medicaid

PolicyPrivate-Duty Nursing (PDN) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization and ensure the treating physician documents the member's unstable condition and need for continuous skilled nursing care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21age limit

2021-05-01effective

O2 <85%rapid desat

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CurrentAlaska MedicaidPolicy N/A

Private-Duty Nursing (PDN) — Coverage Criteria

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Policy Summary

PayerAlaska Medicaid

PolicyPrivate-Duty Nursing (PDN) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization and ensure the treating physician documents the member's unstable condition and need for continuous skilled nursing care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21age limit

2021-05-01effective

O2 <85%rapid desat

Coverage Criteria for Private-Duty Nursing (PDN)

General eligibility and covered clinical indications

Covered when ALL of the following are met

Population and general requirement: Member is under 21 with a life‑threatening condition; without continuous skilled care would require admission to a general acute care hospital or long‑term care facility; services are temporary and recommended/provided under the direction of the member's primary care and/or treating physician who affirms the member's condition is unstable and requires skilled nursing care.

Clinical indications (any one qualifies): Member meets one of the listed clinical conditions that require constant supervision, visual assessment, and monitoring, including: invasive mechanical ventilation (start of use within last 6 months) with caregiver education need or unstable condition; active ventilator weaning requiring monitoring/intervention with stability criteria (ability to clear tracheal secretions; stable vital signs and blood gases; oxygen >92% and pulse oximetry >92%); recent tracheostomy removal requiring monitoring with same stability criteria (ability to clear secretions; not using accessory muscles; stable vital signs and blood gases; oxygen >92% and pulse oximetry >92%); oxygen administration with documented rapid desaturation (examples: pulse oximeter drop below 85% within 15–20 minutes, increased respiratory rate, increased heart rate, or skin color changes); or prolonged intravenous infusions including TPN, medications, or fluids.

Additional considered conditions

The Department will consider combinations of technologies and comorbidities for medical determinations for the following

Other qualifying needs: Tube feedings (nasogastric, gastric, gastric button, or jejunostomy), intermittent or continuous; tracheostomy without mechanical ventilation (not being weaned from a ventilator); oxygen supplementation without documented rapid desaturation; frequent chest physiotherapy or oral suctioning; skin and wound care needs (burn care; ostomy care at least once per day; postsurgical care within 45 days of surgery; wound management at least once per day); frequent nursing intervention/management for seizures (seizures lasting more than 5 minutes; clustered seizures; seizure activity without regaining consciousness).

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

Oxygen saturation threshold — rapid desaturation

ThresholdPulse oximeter drop below 85% within 15–20 minutes indicates rapid desaturation

Associated signsRespiratory rate increase, heart rate increase, or skin color changes may accompany rapid desaturation

ContextUsed to document need for oxygen administration and continuous skilled monitoring

Stable oxygenation criteria during ventilator weaning or after tracheostomy removal

Stable oxygen target (FiO2/oxygen)Oxygen > 92%

Stable pulse oximetryPulse oximetry > 92%

Clinical signs of stability

Provider Requirements and Authorization

Prior 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

Note

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

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

Private‑duty nursing (PDN) — definition and eligibility

DefinitionContinuous skilled nursing services provided to eligible individuals under 21 with life‑threatening conditions to avoid admission to an acute care hospital or long‑term care facility

Age limitEligible individuals: under 21 years of age

Service intentServices are temporary with the goal of training caregivers to provide necessary care independently

Physician directionServices must be recommended by and provided under the direction of the member's primary care and/or treating physician who affirms the member's conditions are unstable and require skilled nursing care