CurrentAnthemPolicy CG-REHAB-08

Private Duty Nursing in the Home Setting

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Defines when intermittent or temporary complex skilled private duty nursing by an RN or LPN/LVN in the home may be medically necessary, including skilled monitoring, treatment, transition-of-care support, and caregiver training. Benefit and contract language supersede the guideline.

Policy Summary

PayerAnthem

PolicyPrivate Duty Nursing in the Home Setting

Policy CodePolicy CG-REHAB-08

Change TypeAdministrative updateno material clinical or coverage change

Effective DateOctober 1, 2026

Last ReviewAug 13, 2026

Next Review DateNot scheduled

Key ActionSubmit authorization based on the individual's condition and demonstrated medical necessity.

SourceLink

POLICY UPDATE CHANGES

The 2026 review added a Summary for Members and Families section.

The 2026 review revised the Description, Discussion/General Information, References, and Websites sections.

The 2025 review revised the Discussion, Definitions, References, Websites, and not-medically-necessary statement.

RN/LPN-LVNQualified nursing professionals

6Initial Section A criteria

1 of 3Additional clinical pathways

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CurrentAnthemPolicy CG-REHAB-08

Private Duty Nursing in the Home Setting

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Policy Summary

PayerAnthem

PolicyPrivate Duty Nursing in the Home Setting

Policy CodePolicy CG-REHAB-08

Change TypeAdministrative updateno material clinical or coverage change

Effective DateOctober 1, 2026

Last ReviewAug 13, 2026

Next Review DateNot scheduled

Key ActionSubmit authorization based on the individual's condition and demonstrated medical necessity.

SourceLink

POLICY UPDATE CHANGES

The 2026 review added a Summary for Members and Families section.

The 2026 review revised the Description, Discussion/General Information, References, and Websites sections.

The 2025 review revised the Discussion, Definitions, References, Websites, and not-medically-necessary statement.

RN/LPN-LVNQualified nursing professionals

6Initial Section A criteria

1 of 3Additional clinical pathways

≥4 hrDeep suctioning threshold

≥5 minProlonged seizure threshold

11Routine services listed as not medically necessary

Private Duty Nursing Coverage Criteria

Initial private duty nursing services

Initial private duty nursing is medically necessary when both Section A and Section B are demonstrated in the clinical record.

Both Section A and Section B

Section A — all criteria required
- The services must be skilled and not custodial in nature.
- The attending physician must certify the medical necessity of private duty nursing.
- The attending physician must approve a written treatment plan specifying short- and long-term goals.
- Services must require the professional proficiency and skills of an RN or LPN/LVN. Private duty nursing performed by an LPN/LVN must be under RN supervision and follow a physician-developed plan of care developed with the individual, family/caregiver, and private duty nursing service.
- Services must be performed on a part-time or intermittent visiting basis according to the treatment plan and under physician direction.
- The service must be appropriate under standards of good medical practice and not provided solely for convenience.
Section B — unstable condition plus one clinical pathway
- Unstable condition: The individual's condition must be unstable, requiring frequent nursing assessments and changes in the plan of care. The needs must require more than a skilled nursing visit but be able to be met through private duty nursing.
- A physician must order ongoing nursing for constant monitoring and evaluation, including necessary treatment-regimen adjustments.
- Nursing and adjunctive therapy progress notes must document interventions or adjustments at least monthly and as necessary.
- At least one qualifying clinical pathway
  - Respiratory disorder
    The individual is dependent on mechanical ventilation.

Continuation therapy

Continuation of private duty nursing is medically necessary when both continuation criteria are met.

Both continuation criteria

Progress and caregiver transition documentation: A weekly written progress summary with measurable long-term and short-term goals and a plan of care must support determination of whether the individual has reached an optimal level of recovery and whether a caregiver has been taught to assume care.
Updates should occur at least monthly, at the discretion of the case manager.
Continued clinical eligibility: Section B.1 and at least one of Section B.2, B.3, or B.4 must continue to be met.

Private duty nursing for caregiver training

Private duty nursing for caregiver training is medically necessary when both criteria are met.

Both caregiver-training criteria

Complex medical needs: Private duty nursing is appropriate for short-term training of a caregiver for an individual with complex medical needs, with the intent that caregivers assume this role when the individual's medical condition becomes stable.
Caregiver responsibility: The primary caregiver accepts ongoing responsibility for the member's health and welfare.24-hour responsibility

Private duty nursing is not medically necessary when provided solely for convenience, for a stable medical condition, to allow family members to work or provide family respite, or as custodial care.

Services that do not require nursing skills are generally not medically necessary in the home. Examples include routine injury or illness prevention, routine medication administration or setup, eye drops, ointments and topical medications, routine maintenance medications including insulin, routine enteral feedings, routine colostomy care, chronic intermittent straight catheterization, custodial care by an LPN/LVN or RN, emotional support or counseling, nasopharyngeal or nasotracheal suctioning, and care duplicated by supply or infusion companies.

PDN in the home is not medically necessary when the applicable medical necessity criteria have not been met. This includes services furnished for a nonqualifying purpose or condition, such as convenience, family work or respite, a stable condition, or custodial care.

The listed routine services generally do not require nursing skills and are not medically necessary in the home. An exception may apply when documented comorbidities or complications require individual consideration.

Coding and Operational Thresholds

When services may be medically necessary when criteria are metHCPCSCovered

S9123	Nursing care, in the home; by registered nurse, per hour
S9124	Nursing care, in the home; by licensed practical nurse, per hour
T1000	Private duty/independent nursing service(s), licensed, up to 15 minutes
T1002	RN services, up to 15 minutes
T1003	LPN/LVN services, up to 15 minutes
T1030	Nursing care, in the home, by registered nurse, per diem
T1031	Nursing care, in the home, by licensed practical nurse, per diem

When services are not medically necessary if criteria are not metHCPCSNot Covered

S9123	Nursing care, in the home; by registered nurse, per hour
S9124	Nursing care, in the home; by licensed practical nurse, per hour
T1000	Private duty/independent nursing service(s), licensed, up to 15 minutes
T1002	RN services, up to 15 minutes
T1003	LPN/LVN services, up to 15 minutes
T1030	Nursing care, in the home, by registered nurse, per diem
T1031	Nursing care, in the home, by licensed practical nurse, per diem

Applicable diagnosis codesICD-10

All diagnoses

Deep suctioning for tracheostomy care

Clinical pathwayRespiratory disorder involving tracheostomy care

Required serviceDeep suctioning

Qualifying frequencyAt least every 4 hours

Continuous prolonged seizure activity

Seizure patternContinuous seizure activity

Qualifying duration5 minutes or longer

Related clinical requirement

Authorization and Documentation Requirements

Prior Authorization

Authorization Based on Medical Necessity

Obtain authorization based on demonstrated medical necessity. Private duty nursing (PDN) authorization may be short-term or long-term and must be supported by the individual's condition and documented medical necessity. Services are approved on a per-hour or per-shift basis.

Document the complex, chronic, or medically fragile condition and skilled interventions or monitoring required.
Show why the individual's needs exceed the scope or frequency of intermittent home health care.

Documentation Required

Initial Physician Certification and Treatment Plan

Before initial PDN begins, the attending physician must certify that the service is medically necessary and approve a written treatment plan developed in collaboration with the individual, family or caregiver, and PDN provider.

Policy Background

Private duty nursing (PDN) is physician-prescribed skilled nursing delivered in the home by a Registered Nurse (RN) or Licensed Practical/Vocational Nurse (LPN/LVN). It is intended for individuals with serious, complex, medically fragile, or unstable conditions who require close monitoring or skilled interventions beyond routine custodial care. Services are generally temporary or part-time and may support transition from hospital to home, complex respiratory or enteral care, seizure management, and caregiver training, with the goal of safe home care and transfer of appropriate responsibilities to trained caregivers.

Defined Terms

Bi-level positive airway pressure (BPAP)

TypeMechanical ventilation technique

Airway supportKeeps the airways open with pressurized air

Pressure levelsHigher pressure during inhalation and lower pressure during exhalation

Continuous positive airway pressure (CPAP)

TypeMechanical ventilation technique

Airway supportKeeps the airways open with continuous pressurized air

InterfaceMay be delivered through an invasive or noninvasive interface

Policy Summary

PayerAnthem

PolicyPrivate Duty Nursing in the Home Setting

Policy CodePolicy CG-REHAB-08

Change TypeAdministrative updateno material clinical or coverage change

Effective DateOctober 1, 2026

Last ReviewAug 13, 2026

Next Review DateNot scheduled

Key ActionSubmit authorization based on the individual's condition and demonstrated medical necessity.

SourceLink

On This Page

Tracheostomy care requires deep suctioning at least every 4 hours.at least every 4 hours

Enteral feeding

The individual is receiving continuous tube feeding, such as continuous nasogastric, gastrostomy-tube, or jejunostomy feeding, and requires initial caregiver training until caregiver competence is documented.
Enteral feeding, such as continuous nasogastric, gastrostomy-tube, or jejunostomy feeding, is complicated by frequent regurgitation, with or without aspiration.

Seizure disorder: The individual has a seizure disorder manifested by prolonged seizures requiring emergent administration of anticonvulsant medication.

Prolonged seizures requiring emergent administration of anticonvulsant medication

Repetitive prolonged seizures

Seizure patternRepetitive seizures

Qualifying duration15 minutes

Definition categoryProlonged seizures

Progress documentation

Written summaryRequired weekly

Required contentMeasurable long-term and short-term goals and a plan of care

Update frequencyAt least monthly, at the discretion of the case manager

Include specified short-term and long-term goals.

Ensure the plan of care identifies the ordered services and supports the individual's medically desired outcomes.

Documentation Required

Skilled Service and Delivery Requirements

PDN must be skilled, noncustodial care requiring the professional proficiency of an RN or LPN/LVN. Services must be provided part-time or intermittently, according to the treatment plan and under physician direction.

The RN-versus-LPN/LVN determination must reflect the type of services required.
An LPN/LVN must work under RN supervision and follow a physician-developed plan of care.
Services must meet standards of good medical practice and not be provided solely for convenience.

Documentation Required

Unstable-Condition Documentation

For an unstable condition, document frequent or rapid changes requiring ongoing monitoring, frequent nursing assessments, or treatment adjustments. The record must establish why the needs cannot be met through a skilled nursing visit but can be met through PDN.

The physician must order ongoing constant monitoring and evaluation and make necessary treatment-regimen adjustments.
Nursing and adjunctive-therapy progress notes must show that interventions or adjustments occurred at least monthly and as necessary.

Documentation Required

Continuation Progress Documentation

Continuation of PDN requires current progress documentation demonstrating ongoing medical necessity and progress toward the individual's optimal level of recovery and transfer of care.

Provide a weekly written progress summary with measurable short-term and long-term goals and an updated plan of care.
Updates must occur at least monthly, or more often at the case manager's discretion.
Document that the unstable-condition criterion and at least one qualifying respiratory, enteral-feeding, or seizure criterion continue to be met.

Documentation Required

Caregiver Training Documentation

PDN may be used for short-term caregiver training when the individual has complex medical needs and the goal is for caregivers to assume care after the condition stabilizes.

Document caregiver training and competence for continuous tube feeding or other complex care.
The primary caregiver must accept ongoing 24-hour responsibility for the member's health and welfare.

Unsupported block type: denial_riskอบුષો?

Denial Risk

Routine or Duplicative Services

Do not bill routine or duplicative services as PDN unless documented comorbidities or complications require individualized nursing skills and consideration.

Routine injury or illness prevention; oral medication administration or set-up; eye drops, ointments, or topical medications.
Routine maintenance medications, including insulin; routine enteral feedings; colostomy care; or ongoing intermittent straight catheterization for chronic conditions.
Custodial care, emotional support or counseling, nasopharyngeal or nasotracheal suctioning.
Care already provided by supply or infusion companies.

Denial Risk

Provider Relationship and Residence Restriction

PDN must be rendered by independent licensed clinical personnel who reside outside the individual's home. Services may not be provided by members of the individual's immediate family or by cohabitants.

Use an independent RN or LPN/LVN qualified for the ordered skilled services.
Verify the provider's residence and relationship to the individual before rendering or billing services.

Intubation

ProcedureA surgical procedure

Airway interventionA tube is placed in the trachea to keep the airway open

Tube approachesNasotracheal, orotracheal, or through a tracheostomy

Mechanical ventilation

CategoryA form of life support

DeviceA machine, or ventilator, supports breathing

UseSupports the work of breathing when an individual cannot breathe adequately independently

Invasive mechanical ventilation

CategoryMechanical ventilation

DeliveryProvided through an invasive interface

ExamplesNasotracheal, orotracheal, or endotracheal tube

Noninvasive mechanical ventilation (NIV)

Delivery methodA face mask connected to a ventilator

FunctionThe ventilator pushes air into the lungs

ExamplesHome CPAP, BiPAP, and a Cuirass Shell Ventilator

Prolonged seizures

Continuous activity threshold5 minutes or longer

Repetitive activity threshold15 minutes

DefinitionContinuous seizure activity lasting 5 minutes or longer, or repetitive seizures lasting 15 minutes

Tracheostomy

ProcedureA surgical procedure

OpeningA hole is created in the trachea

Purpose and durationA tube is inserted to exchange respiratory gases; the opening may be temporary or permanent

Unstable medical condition

PatternThe individual’s condition changes frequently or rapidly

Monitoring requirementConstant monitoring may be required

Treatment requirementFrequent adjustments of treatment regimens may be required

Ventilation

ProcessMoving respiratory gases into and out of the lungs

Common termAlso called breathing

Body functionRespiratory gas exchange through movement into and out of the lungs

Ventilator

Device typeMechanical device

Air deliveryProvides pressurized air with or without supplemental oxygen

Required capabilitiesProvides at least two of pressure support, rate support, or volume support