CurrentUnitedHealthcarePolicy CS102NJ.H

Private Duty Nursing Services (for New Jersey Only)

Policy governing coverage and authorization criteria for Private Duty Nursing Services in the home for UnitedHealthcare members in New Jersey, including EPSDT, MLTSS, and DDD Supports Plus PDN programs.

Policy Summary

PayerUnitedHealthcare

PolicyPrivate Duty Nursing Services (for New Jersey Only)

Policy CodePolicy CS102NJ.H

Change TypeCoding clarification & housekeeping

Effective DateSep 1, 2025

Next Review Date

Key ActionDetermine PDN hours using the InterQual LOC and submit prior authorization with a physician-signed plan of care documented on CMS-485.

SourceLink

POLICY UPDATE CHANGES

Removed notation indicating HCPCS codes T1002 and T1003 are not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program.

Removed reference link to the Medical Policy titled Home Hemodialysis (for New Jersey Only) (retired Apr. 1, 2026).

Archived previous policy version CS102NJ.G.

16max PDN hours/24h (MLTSS)

2max beneficiaries per nurse (same household)

CMS-485form required

InterQualassessment tool

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Coverage and Medical Necessity Criteria

inv-01: EPSDT/PDN Medical Necessity

Covered when ANY of the following program-specific criteria are met:

EPSDT criteria: Either: (1) ALL of: dependence on mechanical ventilation; presence of an active tracheostomy; need for deep suctioning. OR (2) ANY of: need for around-the-clock nebulizer treatments with chest physiotherapy; gastrostomy feeding complicated by frequent regurgitation and/or aspiration; seizure disorder manifested by frequent prolonged seizures requiring emergency administration of anticonvulsants.

Based on N.J.A.C. 10:60-5.4.b and 5.4.c-d

inv-02: MLTSS/PDN & SPPDN Medical Necessity

Covered when ANY of the following are met:

MLTSS/SPPDN criteria: Either: (1) ALL of: dependence on mechanical ventilation; presence of an active tracheostomy; need for deep suctioning. OR (2) ANY of: need for around-the-clock nebulizer treatments with chest physiotherapy; gastrostomy feeding complicated by frequent regurgitation and/or aspiration; seizure disorder manifested by frequent prolonged seizures requiring emergency administration of anticonvulsants; need for other Skilled Nursing Interventions on an ongoing basis.

Based on N.J.A.C. 10:60-5.9.d

inv-03: Situational Criteria

When determining extent and authorized hours, consider ALL of the following situational factors:

Situational factors: Available primary caregiver support (including work- or sibling-care responsibilities and increased physical or mental demands), additional adult care support within the household, and alternative sources of nursing care.

N.J.A.C. 10:60-5.4.c and 5.9.f

inv-04: Primary Caregiver Responsibility

Approval requires ALL of the following:

Primary caregiver: A capable adult primary caregiver residing with the individual who accepts ongoing 24-hour responsibility; the caregiver agrees to be trained or has been trained in the care of the beneficiary and agrees to receive additional training for new procedures/treatments if directed by a State agency; and the member exhibits a severity of illness that requires complex Skilled Nursing Interventions on a continuous ongoing basis.

N.J.A.C. 10:60-5.3 and 5.8

Private Duty Nursing (PDN) services shall not include respite care or supervision, nor may PDN be used as a substitution for routine parenting tasks. PDN provided solely for school attendance or other activities outside the home, when the nursing need does not exist in the home, is not covered. PDN rendered while the member is outside the home during normal activities will be covered only when the services are needed in the home context.

The following services, by themselves, do not constitute medical necessity for PDN (EPSDT, MLTSS, or SPPDN) absent the Skilled Nursing Interventions listed in the criteria: beneficiary observation/monitoring/recording/assessment, occasional suctioning, uncomplicated gastrostomy feedings (unless complicated by frequent regurgitation/aspiration), and seizure disorders controlled with medication or consisting only of frequent minor seizures not in clusters or associated with status epilepticus.

Coding, Limits, and Related Rules

Applicable HCPCS/HCFA codesHCPCS

S9123	Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used).
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.
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.

Maximum PDN hours (MLTSS)

Maximum PDN hours (MLTSS)16 hours per 24-hour period (limit includes hours provided or paid by other sources)

Supplemental payment limitWhen PDN is provided/paid by another source, MLTSS shall supplement up to 16 hours per 24-hour period

Live-in caregiver requirementMLTSS PDN limited to 16 hours per 24-hour period per person; a live-in primary adult caregiver who accepts 24-hour responsibility is required unless PDN's sole purpose is IV therapy

Authorization, Documentation, and Provider Responsibilities

Prior Authorization

InterQual assessment required for hours authorization

Once coverage for Skilled Care is established, the number of Private Duty Nursing (PDN) hours must be determined using the InterQual® LOC: Home Care Q & A, Private Duty Nursing assessment.

Refer to InterQual® LOC: Home Care Q & A, Private Duty Nursing for hours authorization and LOC determination.

Denial Risk

Insufficient clinical complexity

Lack of sufficient clinical complexity alone is not a basis for PDN. Services that are solely patient observation/monitoring, occasional suctioning, uncomplicated gastrostomy feedings (unless complicated by frequent regurgitation and/or aspiration), or well-controlled seizure disorders (seizures controlled with medication or frequent minor isolated seizures not in clusters or associated with status epilepticus) do not by themselves meet the Skilled Nursing Interventions needed for PDN.

Observation, monitoring, or recording alone is insufficient for PDN.

Key Definitions

Private Duty Nursing (PDN) Services

DefinitionPrivate Duty Nursing (PDN) Services: individual and continuous nursing care, distinct from part-time intermittent care, for beneficiaries with severity of illness requiring complex Skilled Nursing Interventions on a continuous ongoing basis (N.J.A.C. 10:60-5.1(b)).

SettingProvided by licensed nurses in the home to beneficiaries receiving MLTSS, enrolled in DDD Supports Plus (SPPDN), or eligible EPSDT beneficiaries.

PurposeTo deliver continuous individualized nursing care that cannot be met by part-time or intermittent services due to ongoing complexity of skilled needs.

Skilled Nursing Interventions

DefinitionSkilled Nursing Interventions: procedures that require the knowledge and experience of a licensed registered nurse; services are of such complexity that RN skills (or LPN under RN supervision) are required and can be safely and effectively performed only by or under supervision of professional/technical personnel (N.J.A.C. 10:60-1.2).

Background and Scope

Private Duty Nursing (PDN) provides continuous, individualized nursing care in the home for beneficiaries who require complex Skilled Nursing Interventions on a continuous basis. Typical indications include dependence on mechanical ventilation, presence of an active tracheostomy, the need for frequent deep suctioning, around-the-clock nebulizer treatments with chest physiotherapy, complicated gastrostomy feedings with frequent regurgitation or aspiration, or seizure disorders with frequent prolonged seizures requiring emergency anticonvulsants. Program-specific criteria (EPSDT, MLTSS, and DDD SPPDN) and situational factors such as available primary caregiver support and alternative sources of nursing care are used to determine medical necessity and authorized hours.