TMPPM 2008 > Texas Medicaid Services > Texas Health Steps (THSteps) > THSteps-Comprehensive Care Program (CCP)

43.4.5.12 Medical Nutritional Products

Medical nutritional products for clients birth through 20 years of age are available only through THSteps-CCP.

Medical nutritional products may be approved for clients who are THSteps-CCP-eligible, birth through 20 years of age, and have specialized nutritional requirements. Medical nutritional products must be prescribed by a physician and be medically necessary. FFP for the medical nutritional product must also be available.

Documentation that supports medical necessity must include one of the following:

•Identification of a metabolic disorder requiring a medically necessary nutritional product.

•Indication that part or all nutritional intake is through a tube (e.g., nasogastric or gastrostomy/jejunostomy).

•Identification/explanation of the medical condition resulting in the requirement for a medical nutritional product.

Prior authorization is not required for the following:

•Nutritional products developed for use in metabolic disorders for those clients with a documented metabolic disorder. (Claims must include the diagnosis indicating the metabolic disorder, and the nutritional product must be for use in metabolic disorders, or the claim is denied.).

•Nutritional products used for clients receiving part or all of their nutritional intake through a tube. Claims submitted for nutritional products not covered by THSteps-CCP are denied. Claims submitted must indicate the client has a feeding tube, or the claim is denied.

Mandatory prior authorization is required for any request that does not meet the above criteria. To request prior authorization, submit the THSteps-CCP Prior Authorization Request Form and documentation to support medical necessity. Documentation may include the following:

•Height and weight.

•Growth history.

•Why the client cannot be maintained on an age-appropriate diet.

•Other formulas tried and why they did not meet the client's needs.

Note: Prior authorization is a condition for reimbursement, not a guarantee of payment.

Authorization may be given for up to 12 months.

THSteps-CCP will not cover the following:

•Nutritional products for clients that could be sustained on an age-appropriate diet.

•Products traditionally used for infant feeding.

•Pudding products (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product).

•Nutritional products for the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth. Documentation should describe the medical condition that led to these conditions.

•Nutritional products for infants younger than 12 months of age unless medical necessity is documented and other criteria are met. A request for authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply.

Generic medical nutritional products that have been approved by the U.S. Department of Agriculture (USDA) for use in the Special Supplemental Nutrition Program for WIC may be approved for use by THSteps-CCP clients. Reimbursement is determined using the Red Book, less 10.5 percent. Reimbursement for products not listed in the Red Book is based on the same methodology using the AWP supplied by the manufacturer of the product. The provider is responsible for obtaining and submitting necessary product information with the request for products.

Enteral Nutritional Products

All enteral nutritional products paid under the Texas Medicaid Program are paid based on units of 100 calories (as documented by the manufacturer) with the appropriate "B" code (as documented by the Statistical Analysis Durable Medical Equipment Regional Carrier [SADMERC] Product Classification List for Enteral Nutrition in effect at the time) and with the appropriate modifier based on the product's AWP less 10.5 percent (as documented by the Red Book).

It is the provider's responsibility to know the correct "B" code, the correct units of 100 calories, and the modifier for requesting prior authorization and payment. Supporting documentation for these components must be maintained in the provider's records and be made available upon request by HHSC or its designee. The documentation must include number of cans delivered, number of ounces in each can, and number of calories in each can or how many ounces equal 100 calories, so substantiation of the units billed may be ascertained.

Payment is based on the lower of billed charges or the Medicaid allowed fee, with the Medicaid allowed fee based on the appropriate "B" code, modifier, and units of 100 calories.

It is the provider's responsibility to know when products are discontinued by the manufacturer, when container sizes change, and when names change. Submit requests for prior authorization and payment accordingly.

A written request must be submitted when using procedure code 9-B9998 to request generic medical nutritional products that require prior authorization.

Note: The Palmetto GBA SADMERC Product Classification List is located on the website www.palmettogba.com.

The following procedure codes and/or modifiers should be used if indicated as necessary on the Palmetto GBA SADMERC Product Classification list for that medical nutritional product.