RetiredUnitedHealthcarePolicy CS102LA.B

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

Defines medical necessity, documentation, coding, and nursing acuity scoring for Medicaid-covered PDN/EHH services for beneficiaries in Louisiana (birth through 20 years) and prior authorization requirements.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS102LA.B

Change TypeRetired (Apr 1, 2026)prior routine review retained coverage

Effective DateJanuary 1, 2025 -March 31, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with required documentation and prescription specifying number of hours using HCPCS S9123, S9124, or T1000.

SourceLink

POLICY UPDATE CHANGES

Policy retired and Louisiana plan membership disenrolled on Apr. 1, 2026.

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

3+ hrs/dayminimum daily PDN/EHH service duration required for eligibility

birth–20EPSDT-eligible beneficiary age range

up to 60 daysprior authorization review period

S9123,S9124,T1000HCPCS codes for prior auth

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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

Age: Birth through 20 years (EPSDT eligible)
Order: Prescribed by a physician (or authorized clinician as allowed by state law)
Order must include number of hours
Clinical need: Medically complex condition with multiple, significant medical problems requiring a minimum of three (3) or more hours of skilled nursing care per day>= 3 hours/day
Hours determined using the Private Duty Nursing Acuity Scale

Place of service exclusions: Services may be provided in the beneficiary's place of residence, defined as the place where normal life activities take place; excludes hospitals, intermediate care facilities for individuals with intellectual disabilities, or settings where Medicaid payment covers inpatient room and board (CFR § 440.70).

Acuity scoring guidance: Approved number of hours will be assessed using the Private Duty Nursing Acuity Scale with scoring bands tied to hours/day: 15-25 points = 4-8 hours/day; 26-35 points = 8-12 hours/day; 36-45 points = 12-16 hours/day; 46-55 points = 16-20 hours/day (weekly hour caps apply).

PDN (EHH) is not considered medically necessary for care that is primarily respite or custodial in nature when the tasks can be performed by trained non-medical personnel. Requests for coverage that are intended to provide supervision, assistance with activities of daily living, or non‑skilled custodial support do not meet medical necessity criteria for PDN/EHH.

Services requested solely to provide respite or custodial care are not medically necessary. Authorization will not be supported when the primary purpose of the request is to relieve family caregivers or supply general supervision and non‑skilled assistance that could be performed by trained non‑medical personnel.

Coding and Acuity Scoring

PDN (EHH) HCPCS codes referenced for prior authorizationHCPCS

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

Acuity scoring bands — Nursing Acuity Scale

15-25 points4-8 hours/day; up to 56 hours/week

26-35 points8-12 hours/day; up to 84 hours/week

36-45 points12-16 hours/day; up to 112 hours/week

46-55 points16-20 hours/day; up to 140 hours/week

Provider Actions and Prior Authorization

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
Requests reviewed for up to 60 calendar days

Note

Submit a complete prior authorization request with all required documentation to avoid delays. Ensure the prescription and clinical records clearly indicate the level and number of hours of PDN (EHH) requested.

Definitions

Private Duty Nursing (PDN)/Extended Home Health (EHH) — core requirements

Minimum daily service durationMinimum of three or more hours per day

Eligible beneficiary ageBeneficiaries under age 21 (EPSDT eligible)

Condition for coverageServices must be determined medically necessary, ordered by a physician, and prior authorized

Background

Private Duty Nursing (PDN) or Extended Home Health (EHH) provides skilled nursing care in the home for beneficiaries with significant medical needs. These services are intended to meet clinical requirements that cannot be safely provided by non‑medical caregivers; they are not intended to replace routine caregiver responsibilities or to provide general custodial or respite support.