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December 2016 Texas Medicaid Provider Procedures Manual

Home Health Nursing and Private Duty Nursing Services Handbook : 4 Private Duty Nursing (PDN) Services - CCP : 4.1 * Services, Benefits, Limitations, and Prior Authorization : 4.1.1 Medical Necessity

4.1.1
Texas Medicaid defines medically necessary EPSDT services as health care, diagnostic services, treatments, and other measures necessary to correct or ameliorate any disability, physical or mental illness, or chronic conditions.
Medicaid clients who are 20 years of age or younger, and who are eligible for THSteps, are entitled to all medically necessary PDN services to promote independence and support the client living at home.
PDN services are considered medically necessary when a client has a disability, physical or mental illness, or chronic condition, and he or she requires continuous, skillful observations, judgments, and interventions to correct or ameliorate his or her health status.
The following elements should always be addressed in documentation submitted with a request for PDN services:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.