Notification of Policy Revisions Effective January 1, 2023 (Posted June 30, 2022)

Description updated. When Private Duty Nursing services are covered updated to reflect: “The services are ordered by a licensed physician (MD, doctor of medicine; or DO, doctor of osteopathic medicine) as part of a treatment plan for a covered medical condition, and The attending physician must approve a written treatment plan with short and long term goals specified, and The services provided are reasonable and necessary for care of a patient’s illness or injury or particular medical needs, and are within the accepted standards of nursing practice, and Provide care needed by the member when their condition stabilized.and The services are performed by a licensed nurse (i.e., Registered Nurse, RN; or Licensed Practical Nurse, LPN), and The services provided are within the scope of practice of a licensed nurse (RN or LPN), and The services require the professional proficiency and skills of a licensed nurse (RN or LPN), and The services are provided in the patient’s private residence, and The patient’s condition is such that a licensed professional is required to reinforce/educate and teach the caregiver the technical as well as basic care needs of the member. The length and duration of skilled nursing services in the home is considered intermittent and temporary in nature and not intended to be provided on a permanent ongoing basis. The member’s condition requires frequent nursing assessments and changes in the plan of care with MD collaboration. The member and caregivers must accept and be engaged in the Blue Cross Blue Shield of North Carolina Case Management process.” When Private Duty Nursing Services are not covered updated to reflect: “When the conditions above are not met.The nurse providing care must not be the patient’s spouse, natural or adoptive child, parent, or sibling, grandparent or grandchild. This also includes any person with an equivalent step or in-law relationship to the patient. PDN is not considered medically necessary if a caregiver is unavailable to assume the care needs of the member. PDN is not covered if the patient is in an acute inpatient hospital, inpatient rehabilitation hospital, skilled nursing facility, intermediate care facility or a resident of a licensed residential care facility. PDN is not covered for the convenience of the member/caregiver or to allow respite/sleep for caregivers or patient’s family. PDN is not covered to allow the patient’s family or caregiver to work or go to school. The time the nurse spends traveling to and from a patient’s home is included in the cost for providing the service. It is not covered separately. Maintenance care or custodial care is not considered PDN. (See Policy Guidelines below.) PDN in the home is not covered when provided at the same time as other home healthcare nursing services. Policy Guidelines and Medical Definitions updated for clarity. Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director review 5/2022. Notification given on 7/1/22 for effective date 1/1/2023.