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

43.4.5.13 Donor Human Milk

Donor human milk is a benefit of THSteps-CCP for eligible THSteps clients birth through 11 months of age meeting all of the following criteria:

•The requesting physician has documented medical necessity.

•The parent or guardian has signed and dated an informed consent form indicating that the risks and benefits of using banked donor human milk have been discussed with them.

•The donor human milk bank adheres to quality guidelines consistent with the Human Milk Bank Association of North America or such other standards as may be adopted by HHSC.

A Donor Human Milk Request Form must be completed every 180 days, and copies must be maintained in the client's records of both the ordering physician and the providing milk bank. The physician ordering the donor human milk must complete all fields in Part A of the original form, including the documentation of medical necessity. This information must be substantiated by written documentation in the clinical record. The physician must specify the quantity and time frame in the Quantity Requested field (e.g., cubic centimeters per day or ounces per month).

A copy of the Donor Human Milk Request Form must also be maintained in the client's records at the providing milk bank. The donor milk bank providing the donor human milk must complete all fields in Part B of the original form.

The milk bank must specify the quantity and time frame in the Quantity Provided field.

Refer to: "Donor Human Milk Request Form".

The physician's substantiating documentation of medical necessity and the signed and dated written informed consent form must be maintained in the client's clinical records. The clinical records are subject to retrospective review by HHSC or its designee.

A request for authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply.

The documentation must address all of the following criteria:

•Why the particular infant cannot survive and gain weight on any other formula (e.g., elemental, special, or routine formulas or food) or any enteral nutritional product other than donor human milk.

•Why donor human milk must be used.

•That a clinical feeding trial of an appropriate nutritional product has occurred every 180 days. If the infant is too fragile for a feeding trial, documentation must support the illness that makes the infant too fragile to test.

•That the informed consent details for the parent or guardian the risks and benefits of using banked donor human milk.

The physician must address the benefits and risks of using donor human milk, such as HIV, freshness, effects of pasteurization, nutrients, and growth factors to the parent. The physician also must address donor screening, pasteurization, milk storage, and transport of the donor milk. The physician may obtain this information from the donor milk bank.

Donor human milk is reimbursed only to a Texas Medicaid-enrolled donor milk bank and only for clients in the home setting. Donor human milk may be reimbursed for a maximum of six months per request.

Providers must use procedure code 9-B9998 to bill for donor human milk, per ounce. Donor human milk is reimbursed at $2.50 per ounce. Reimbursement for donor human milk provided in the inpatient setting is included in the DRG.