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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.4 Durable Medical Equipment (DME) Supplier (CCP) : 2.4.7 Diabetic Equipment and Supplies : Services, Benefits, and Limitations
The tubeless external insulin infusion pump and supplies are a benefit of Texas Medicaid through the Comprehensive Care Program (CCP).
The tubeless external insulin pump must be ordered by, and the client's follow-up care must be managed by, a prescribing provider who has experience managing clients with insulin infusion pumps and who is knowledgeable in the use of insulin infusion pumps.
Providers must use procedure code E0784 and modifier U1 for the rental or purchase of the tubeless external insulin pump and procedure code A9274 for the tubeless external insulin pump supplies. Procedure code A9274 is limited to 15 per month.
A tubeless external insulin pump that has been purchased is expected to last a minimum of three years and may be considered for replacement when three years have passed or the equipment is no longer repairable. The replacement of the equipment may also be considered when it has been lost or irreparably damaged. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent a reoccurrence must be submitted. Additional services may be considered based on documentation of medical necessity.
Routine maintenance of rental equipment is the provider's responsibility.

Texas Medicaid & Healthcare Partnership
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