RetiredUnitedHealthcarePolicy CS102LA.B

Private Duty Nursing (PDN) and Extended Home Health (EHH) Services (for Louisiana Only)

Defines Louisiana Medicaid coverage policy for PDN/EHH services for beneficiaries (birth through 20 years) including medical necessity, documentation, and prior authorization requirements; applies to UnitedHealthcare Community Plan in Louisiana.

Policy Summary

PayerUnitedHealthcare

PolicyPrivate Duty Nursing (PDN) and Extended Home Health (EHH) Services (for Louisiana Only)

Policy CodePolicy CS102LA.B

Change TypeRetired

Effective DateJan 1, 2025

Next Review Date

Key ActionObtain prior authorization using HCPCS codes S9123, S9124, or T1000 and submit required documentation including the prior authorization form, prescription with mandated content, and supporting clinical notes.

SourceLink

POLICY UPDATE CHANGES

Retired policy; Louisiana plan membership disenrolled on Apr. 1, 2026.

Routine review on 01/01/2025 with no change to coverage guidelines; archived previous policy version CS102LA.A.

3+ hrs/dayMinimum daily skilled nursing to qualify for PDN/EHH

up to 60 daysPrior authorization review period

birth–20 yrsAge range covered

S9123,S9124,T1000Required prior auth HCPCS codes

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Coverage Criteria for PDN / EHH

Medical necessity for PDN (EHH)

Covered when ALL of the following are met

PDN/EHH medical necessity criteria: 1) Beneficiary is a categorically eligible Medicaid beneficiary birth through 20 years of age (EPSDT eligible);

PDN/EHH medical necessity criteria: 2) PDN (EHH) has been prescribed by a physician;

PDN/EHH medical necessity criteria: 3) Beneficiary has a medically complex condition characterized by multiple, significant medical problems that require a minimum of three (3) or more hours of skilled nursing care per day in accordance with the Louisiana Nurse Practice Act (La. R.S. 37:911, et seq).minimum 3 hours/day

If services are determined to be medically necessary, the number of hours approved will be assessed using the Private Duty Nursing Acuity Scale.

Place-of-service limitation: PDN (EHH) services may be provided in the beneficiary's place of residence but not in a hospital, intermediate care facility for individuals with intellectual disabilities, or any setting in which payment is or could be made by Medicaid for inpatient services that include room and board (CFR § 440.70).

PDN (EHH) is not considered medically necessary for respite or custodial care when the care can be provided by trained non-medical personnel. Requests for authorization that describe services solely for respite or custodial needs should be evaluated and may be denied as not medically necessary.

PDN (EHH) may be provided only in the beneficiary’s place of residence, defined as where normal life activities occur. Services cannot be provided in a hospital, an intermediate care facility for individuals with intellectual disabilities (ICF/IID), or any setting in which Medicaid payment is or could be made for inpatient services including room and board.

The use of PDN (EHH) specifically for respite or custodial care is explicitly stated as not medically necessary. Documentation and requests that indicate the primary purpose is custodial support or respite should not meet medical necessity criteria for PDN (EHH).

Procedure Codes and Acuity-to-Hours Mapping

PDN (EHH) procedure codesHCPCS

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
T1001	Nursing assessment/evaluation

Minimum daily skilled nursing and Nursing Acuity Scale

Minimum daily skilled nursingMinimum 3 hours per day required to meet medical necessity for PDN/EHH.

Acuity 15-25 pointsAuthorizes 4–8 hours per day (up to 56 hours/week).

Acuity 26-35 pointsAuthorizes 8–12 hours per day (up to 84 hours/week).

Acuity 36-45 pointsAuthorizes 12–16 hours per day (up to 112 hours/week).

Acuity 46-55 pointsAuthorizes 16–20 hours per day (up to 140 hours/week).

Prior Authorization, Documentation, and Denials

Prior Authorization

Prior Authorization Required

PDN (EHH) services require prior authorization. Submit requests using HCPCS codes S9123, S9124, or T1000. Requests will be reviewed for a service period of up to 60 calendar days.

HCPCS S9123 — Nursing care, in the Home; by registered nurse, per hour
HCPCS S9124 — Nursing care, in the Home; by licensed practical nurse, per hour
HCPCS T1000 — Private duty/independent nursing service(s) - licensed, up to 15 minutes
Review period: up to 60 calendar days

Note

Provider action: complete and submit all required prior authorization materials before rendering PDN (EHH) services. Ensure the request clearly documents the clinical need, requested hours, and aligns with State of Louisiana ordering requirements.

Complete prior authorization form
Include specific number of PDN hours requested

Background

Private Duty Nursing/Extended Home Health (PDN/EHH) provides skilled home nursing services for medically complex pediatric beneficiaries who are birth through 20 years of age and EPSDT eligible. Medical necessity requires a physician’s prescription and evidence that the beneficiary’s condition requires a minimum of three (3) or more hours of skilled nursing care per day. When services meet medical necessity, the approved number of hours is determined using the Private Duty Nursing Acuity Scale to align hours authorized with clinical acuity.

Definitions

Private Duty Nursing (PDN)/Extended Home Health (EHH) — definition and applicability

DefinitionPrivate Duty Nursing (PDN)/Extended Home Health (EHH): Home health nursing services provided for a minimum of three or more hours per day to beneficiaries under the age of 21 when determined to be medically necessary, ordered by a physician, and prior authorized.

Minimum hoursServices require at least 3 hours per day of skilled nursing to meet coverage criteria.

Age applicabilityBeneficiaries birth through 20 years of age (under age 21) — EPSDT eligible.

Ordering and authorizationMust be prescribed by a physician and prior authorized; approved hours determined using the Private Duty Nursing Acuity Scale.