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43.4.5.5 Mobility Aids
Mobility aids and related supplies, including, but not limited to, strollers, special needs car seats, travel safety restraints, and thoracic-hip-knee-ankle orthoses (THKAO)/parapodiums are a benefit to assist clients to move about in their environment. Mobility aids equipment includes, but is not limited to, the items detailed below.
Mobility aids and related supplies may be considered for reimbursement through the THSteps-CCP for clients birth through 20 years of age that are THSteps-CCP eligible when the following criteria are met:
• The equipment requested must be medically necessary.
•FFP must be available.
•The client's mobility status would be compromised without the requested equipment.
•The requested equipment or supplies must be safe for use in the home.
Mobility aids may be considered through THSteps-CCP if the requested equipment is not available through Texas Medicaid (Title XIX) Home Health Services or the client does not meet criteria through Texas Medicaid (Title XIX) Home Health Services.
Mobility aid lifts for vehicles, and vehicle modifications are not reimbursed through the Texas Medicaid Program in accordance with federal regulations.
Note: Permanent ramps, vehicle ramps and home modifications are not a benefit of the Texas Medicaid Program.
Authorization
Prior authorization is required for all mobility aids and related services except travel safety restraints for clients with a medical condition requiring them to be transported in either a prone or supine position.
Note: Prior authorization is a condition for reimbursement, not a guarantee of payment.
A completed THSteps-CCP Prior Authorization Request Form prescribing the DME and/or medical supplies must be signed and dated by the prescribing physician familiar with the client before requesting prior authorization. All signatures must be current, unaltered, original, and handwritten. Computerized or stamped signatures and dates are not accepted. The completed THSteps-CCP Prior Authorization Request Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept in the physician's medical record for the client.
To avoid unnecessary denials, the physician must provide correct and complete information, including accurate documentation of the medical necessity for the equipment/services requested. The physician must maintain documentation of medical necessity in the client's medical record. The requesting provider may be asked for additional information to clarify or complete a request for the mobility aid. A determination is made by the THSteps-CCP nurses as to whether the equipment will be rented, purchased, repaired, or modified based on the client's needs, duration of use, and age of equipment.
A request for authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply.
Mobility aid equipment that has been purchased is anticipated to last a minimum of five years and may be considered for replacement when five years have passed and/or the equipment is no longer repairable. The DME may then be considered for prior authorization. Replacement of equipment may also be considered when loss or irreparable damage has occurred. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent reoccurrence must be submitted.
When prior authorization of a mobility aid replacement is requested before five years have passed, the following information must be submitted with the request:
•A statement from the prescribing physician or licensed occupational therapist (OT) or PT.
•Documentation supporting why the equipment no longer meets the client's needs.
HHSC or its designee determines whether the equipment is rented, purchased, repaired, or modified based on the client's needs, duration of use, and age of equipment.
DME Certification and Receipt Form
The DME Certification and Receipt Form is required and must be completed before reimbursement can be made for any DME delivered to a client. The certification form must include the name of the item, the date the client received the DME, and the signatures of the provider and the client or primary caregiver. This form must be maintained by the DME provider in the client's record.
Rental of equipment includes all necessary accessories, supplies, adjustments, repairs, and replacement parts.
Strollers (a multi-positional client transfer system with integrated seat, operated by care giver)
A stroller for medical needs may be considered under any of the following conditions:
•The client does not own another seating system, including, but not limited to, a wheelchair.
•The client's condition does not require another type of seating system, including, but not limited to, a wheelchair.
If the client does not meet criteria for a stroller, a wheelchair may be considered through Texas Medicaid (Title XIX) Home Health Services.
A medical stroller does not have the capacity to accommodate the client's growth. Strollers for medical use may be considered for prior authorization when the following criteria are met:
•The client weighs 30 pounds or more.
•The client does not already own another seating system, including but not limited to, a standard or custom wheelchair.
•The stroller must have a firm back and seat, or insert.
•The client is expected to be ambulatory within one year of request date or is not expected to need a travel chair or wheelchair within two years of request date.
The following supporting documentation must be submitted:
•A completed Wheelchair/Stroller Seating Assessment Form (B83) that includes documentation supporting medical necessity. This documentation should address why the client is unable to ambulate a minimum of 10 feet due to his/her condition (including, but not limited to, AIDS, sickle cell anemia, fractures, a chronic diagnosis, or chemotherapy), or if able to ambulate further, why a stroller is required to meet the client's needs.
•If the client is over two years of age, documentation must support that the client's condition, stature, weight, and positioning needs to allow adequate support from a stroller.
Note: A stroller may be considered on a case-by-case basis with documentation of medical necessity for a client who does not meet the criteria listed above.
A seating assessment must be completed by a physician or licensed OT or PT, who is not employed by the equipment supplier, before requesting prior authorization. If the seating assessment is completed by a physician, reimbursement is considered part of the physician's office visit and is not prior authorized. Other providers must use procedure codes 1-97001 and 1-97003 when billing for a seating evaluation.
The seating assessment must:
•Explain how the family will be trained in the use of the equipment.
•Anticipate changes in the client's needs and include anticipated modifications or accessory needs, as well as the anticipated width of the medical stroller to allow client growth with use of lateral/thigh supports.
•Include significant medical information pertinent to the client's mobility and how the requested equipment will accommodate these needs, including intellectual, postural, physical, sensory (visual and auditory), and physical status.
•Address trunk and head control, balance, arm and hand function, existence and severity of orthopedic deformities, any recent changes in the client's physical and/or functional status, and any expected or potential surgeries that will improve or further limit mobility.
•Include information on the client's current mobility/seating equipment, how long the client has been in the current equipment, and why it no longer meets the client's needs.
•Include the client's height, weight, and a description of where the equipment is to be used. Seating measurements are required.
•Include the accessibility of client's residence.
•Include manufacturer's information, including the description of the specific base, any attached seating system components, and any attached accessories.
To request prior authorization for procedure code J-E1035, the criteria must be met for the level of stroller requested:
•Level One: Basic Stroller. The client meets the criteria for a stroller. Providers must use procedure code J-E1035.
•Level Two: Stroller with Tray for Oxygen and/or Ventilator. The client meets the criteria for a level-one stroller and is oxygen- or ventilator-dependent. Providers must use procedure code J-E1035 with modifier TF.
•Level Three: Stroller with Positioning Inserts. The client meets the criteria for a level-one or level-two stroller and requires additional positioning support. Providers must use procedure code J-E1035 with modifier TG.
Stroller Ramps-Portable and Threshold
A portable ramp is defined as a ramp that is a unit able to be carried as needed to access a home and weighing no more than 90 pounds and/or measuring no more than ten feet in length. A threshold ramp is defined as a ramp that provides access over elevated thresholds.
Portable ramps exceeding the above criteria may be considered on a case-by-case basis with documentation of medical necessity and a statement that the requested equipment is safe for use.
Providers must use procedure code J-E1399 for portable and threshold stroller ramps.
One portable and one threshold ramp for stroller access may be considered for prior authorization when documentation supports medical necessity and includes the following:
•The date of purchase and serial number of the client's medical stroller or documentation of a medical stroller request being reviewed for purchase.
•Diagnosis with duration of expected need.
•Ramps may be considered for rental for short-term disabilities.
•Ramps may be considered for purchase for long-term disabilities.
•A diagram of the house showing the access point(s) with the ground-to-floor elevation and any obstacles.
A request for authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply. Prior authorization is a condition for reimbursement, not a guarantee of payment.
Mobility aid lifts for vehicles, and vehicle modifications are not reimbursed through the Texas Medicaid Program according to federal regulations.
Note: Permanent ramps, vehicle ramps, and home modifications are not a benefit of the Texas Medicaid Program.
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