CurrentSan Francisco Health PlanPolicy N/A

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Private Duty Nursing (PDN) Medical Necessity Criteria

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Governs SFHP prior authorization and medical-necessity determinations for EPSDT private duty nursing services for Medi-Cal beneficiaries under age 21, using the Private Duty Nursing Acuity Grid to determine authorized shift-care hours.

Policy Summary

PayerSan Francisco Health Plan

PolicyEPSDT Private Duty Nursing Medical Necessity Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJune 1, 2020

Next Review DateN/A

Key ActionSubmit prior authorization requests with documented skilled nursing needs scored using the Private Duty Nursing Acuity Grid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Beneficiary age range

21–35Score range for up to 8 hours/day

8 h/dayMaximum daily care at 21–35 points

56+Score for up to 14 hours/day

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CurrentSan Francisco Health PlanPolicy N/A

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Private Duty Nursing (PDN) Medical Necessity Criteria

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Sign up for all sanfranciscohealthplan policy alerts

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Policy Summary

PayerSan Francisco Health Plan

PolicyEPSDT Private Duty Nursing Medical Necessity Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJune 1, 2020

Next Review DateN/A

Key ActionSubmit prior authorization requests with documented skilled nursing needs scored using the Private Duty Nursing Acuity Grid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Beneficiary age range

21–35Score range for up to 8 hours/day

8 h/dayMaximum daily care at 21–35 points

56+Score for up to 14 hours/day

Temporary extended care

Not coveredUnused hours

Private Duty Nursing Medical Necessity

Initial and recertification PDN medical necessity

Covered when ALL of the following requirements are met for the applicable certification period:

Core medical-necessity requirements

The member is an EPSDT beneficiary under age 21 and requires medically appropriate skilled nursing shift care with skilled management by a licensed nurse.Under 21 years of age
The skilled nursing need and services are documented in concurrent health records. For the first certification period, document the nurse's estimated services per shift; for recertification, document the average services actually performed per shift.
Document the frequency, complexity, and medical necessity of the nursing interventions performed.
Family members, guardians, or caregivers provide some of the nursing care.
Private duty nursing is not intended to replace all caregiver participation.

Acuity-grid scoring: Score the documented nursing needs using the applicable sections of the Private Duty Nursing Acuity Grid, including assessment; medication and IV delivery; nutrition and feeding; airway, suctioning, oxygen, ventilator, BiPAP/CPAP, nebulizer, and airway-clearance needs; elimination; seizures; therapies, orthotics, and casting; wound care; issues that interfere with care; and other issues or complications.Total score from all applicable sections

Within the applicable sections, select the documented frequency or severity options as directed by the grid; some sections permit multiple applicable items.

Authorized hours by total score: Apply the total acuity-grid score to the daily shift-care schedule: 21-35 points supports up to 8 hours per day; 36-45 points supports up to 10 hours per day; 46-55 points supports up to 12 hours per day; and 56 points or more supports up to 14 hours per day.21-35: up to 8 hours/day; 36-45: up to 10 hours/day; 46-55: up to 12 hours/day; 56 or more: up to 14 hours/day

A score of 20 points or less generally supports no hours. If the member is transitioning from 8 hours/day, 832 hours may be approved for the certification period.

Temporary 20-22-hour shift care

Twenty- to twenty-two-hour shift care may be covered for up to 2-3 days when ANY ONE of the following circumstances is documented:

Qualifying temporary extended-care circumstance

The member has been discharged after an initial hospitalization, and the family or caregiver needs supervision or training in home-care procedures.Up to 2-3 days of 20-22-hour shift care
The member has been discharged after a subsequent hospitalization, and the family or caregiver needs training regarding changes in home care.Up to 2-3 days of 20-22-hour shift care
Caregiver illness or temporary incapacity creates a need for an episode of supportive nursing care.Up to 2-3 days of 20-22-hour shift care

Continuation and increases in authorized hours

Additional hours above 8 hours per day require ALL of the following:

Increase above 8 hours/day

The member's condition has changed.More than 8 hours/day
The change in condition produces documented skilled nursing needs sufficient to meet the applicable higher acuity-grid criteria.
A stable condition alone does not support an increase in hours.

Banking, saving, or accumulating unused prior-authorization hours for later use or for the convenience of the family or home health agency is not covered.

20-22-hour shift care is not routinely available. It may be authorized for up to 2-3 days only when a qualifying circumstance is documented: post-hospitalization supervision or training in home-care procedures, training after changes in home care following a subsequent hospitalization, or temporary caregiver illness or incapacity requiring supportive nursing care.

Private duty nursing is not medically necessary when the documented acuity score is 20 points or less, unless the individual is transitioning from 8 hours per day. In that transition circumstance, 832 hours may be approved for the certification period; otherwise, no private duty nursing hours are approved.

An increase above 8 hours per day is not medically necessary when the member remains stable and there is no documented change in condition that produces skilled nursing needs sufficient to meet the applicable higher acuity-grid criteria.

Acuity Score and Authorized Care Levels

PDN acuity score: no routine hours

Score threshold20 points or less

Routine authorizationNo private duty nursing hours are approved unless the individual is transitioning from 8 hours per day

Transition exception832 hours may be approved for the certification period when transitioning from 8 hours per day

PDN acuity score: daily shift care

Score range21–35 points

Maximum shift careUp to 8 hours per day

Care type

Authorization and Documentation Requirements

Prior Authorization

PDN Acuity Grid Authorization Required

Submit the Private Duty Nursing (PDN) Acuity Grid with each PDN prior authorization request for EPSDT services. Use the grid to document the skilled nursing services required per shift and calculate the member’s total score.

For the first certification period, estimate skilled nursing services per shift.
For recertification periods, document the average skilled nursing services performed per shift using concurrent health records.

Unsupported block type: documentation

Policy Context

This policy addresses medically complex children and young adults under age 21 who require intermittent or continuous skilled nursing interventions in the home. The Private Duty Nursing Acuity Grid evaluates the frequency and complexity of needs such as assessment, medication and IV care, nutrition and feeding, airway and respiratory support, elimination, seizures, therapies, wound care, caregiver barriers, and other complications. The resulting score translates documented clinical acuity into the maximum number of daily private duty nursing hours.

Key Terms

Private Duty Nursing Acuity Grid

DefinitionA scoring tool used to evaluate the documented frequency and complexity of skilled nursing services

PurposeDetermines the medical necessity and amount of EPSDT private duty nursing

Authorization basisThe total score helps determine the number of private duty nursing hours a member may receive

Skilled nursing shift care

DefinitionMedically appropriate shift care provided in the home

Required managementSkilled management by a licensed nurse is required

Coverage population

Policy Summary

PayerSan Francisco Health Plan

PolicyEPSDT Private Duty Nursing Medical Necessity Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJune 1, 2020

Next Review DateN/A

Key ActionSubmit prior authorization requests with documented skilled nursing needs scored using the Private Duty Nursing Acuity Grid.

SourceLink

On This Page

PDN acuity score: daily shift care

Score range36–45 points

Maximum shift careUp to 10 hours per day

Care typeDaily shift care

PDN acuity score: daily shift care

Score range46–55 points

Maximum shift careUp to 12 hours per day

Care typeDaily shift care

PDN acuity score: daily shift care

Score threshold56 points and over

Maximum shift careUp to 14 hours per day

Care typeDaily shift care

Decannulation monitoring

Monitoring allowanceUp to 4 hours of nursing per day may be expected

Monitoring periodDuring the first 24–27 hours of the weaning process

Clinical circumstanceMember has been decannulated

Denial Risk

Low Score or Unsupported Increase in Hours

A score of 20 points or less generally does not support PDN hours, except when the member is being transitioned from 8 hours per day, in which case 832 hours may be approved for the certification period. An increase in hours after 8 hours per day requires a documented change in the member’s condition meeting the applicable criteria.

20 points or less: no PDN hours are approved unless the member is transitioning from 8 hours per day; the transition allowance is 832 hours for the certification period.
Once 8 hours per day is reached, support any increase with a qualifying change in condition and clinical documentation.
A stable condition alone does not support an increase in service hours.

Denial Risk

No Documented Skilled Nursing Need

PDN is not supported when the records do not establish that skilled management by a licensed nurse is required. Submit clinical records showing the skilled services, complexity, frequency, and ongoing need that cannot be met without licensed-nurse management.

Document the average skilled nursing services performed per shift.
Requests lacking evidence of a licensed-nurse skilled management need may be denied.

Unsupported block type: documentation

Billing Rule

Unused Hours Cannot Be Accumulated

Unused prior-authorization hours may not be banked, saved, or accumulated for later use for the convenience of the family or home health agency. Request and bill only for covered care provided during the authorized period.

Accumulation or later use of unused authorized hours is not covered.

Denial Risk

Extended Shift Care Is Limited

Care for 20–22 hours per day is limited to up to 2–3 days and is covered only in qualifying circumstances. The request must document the event and the caregiver-related need for supervision, training, or temporary supportive nursing.

After initial hospitalization discharge, document the family or caregiver’s need for supervision or training in home-care procedures.
After subsequent hospitalization discharge, document training needed for changes in home care.
For caregiver illness or temporary incapacity, document why an episode of supportive nursing care is needed.

Clients up to age 21 years old

20–22 hour shift care

DefinitionShort-term extended shift care provided for 20–22 hours per day

DurationUp to 2–3 days

Qualifying circumstancesInitial hospitalization discharge requiring family or caregiver supervision or training; subsequent hospitalization discharge requiring training on home-care changes; or caregiver illness or temporary incapacity requiring supportive nursing care