2.4.12.2

Prior Authorization and Documentation Requirements

Prior authorization is required for all DME and services provided through CCP, including any accessories, modifications, adjustments, replacements, and repairs to the equipment.

To be considered for prior authorization, the provider must include all of the following to support medical necessity:

•	The diagnosis, medical needs, treatments, developmental level, and functional skills of the child. A diagnosis alone is insufficient information to consider prior authorization of the requested equipment.

•	The age, length, and weight of the child.

•	A description of any other devices that have been used, the length of time used, and why they were ineffective.

•	How the requested equipment will correct or ameliorate the client’s condition beyond that of a standard child’s crib, regular bed, or standard hospital bed.

•	The name of the manufacturer and the manufacturer’s suggested retail price (MSRP).

A determination will be made by HHSC or its designee whether the equipment will be rented, purchased, repaired, or modified based on the client’s needs, duration of use, and age of equipment. All modifications, adjustments, and repairs within the first six months after delivery are considered to be part of the purchase price.

2.4.12.2.1 Hospital Beds and Safety Enclosure

A fixed height bed may be considered for prior authorization if the client requires the head of the bed to be elevated more than 30 degrees most of the time due to conditions such as congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been used and found to be ineffective.

A variable height hospital bed may be considered for prior authorization if the client meets the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to a chair, wheelchair, or standing position.

A semi-electric hospital bed may be considered for prior authorization if the client meets the criteria for a variable height bed and either requires frequent changes in body position or has a need for rapid changes in body position.

A fully-electric bed may be considered for prior authorization only for clients with paraplegia or partial hemiplegia when the fully electric bed will allow for functional independence. Documentation must include that the bed will allow for the client’s functional independence with self-care. A fully-electric bed will not be authorized for the convenience of the caregiver.

The safety enclosure frame/canopy/bubble top may be considered for prior authorization with documentation that the protective canopy top/bubble will provide for the client’s safety. Prior authorization will not be considered when it will be used as a restraint or for the convenience of family or caregivers.

2.4.12.2.2 Positioning Devices

Reflux slings or wedges may be considered for prior authorization for clients who are 11 months of age and younger. These may be used as positioning devices for infants who require the head of the bed or crib to be elevated greater than 30 degrees after feedings when prescribed by a physician as medically necessary and appropriate.

Positioning pillows and cushions may be considered for prior authorization with documentation of medical necessity that indicates the item will provide for or assist in the positioning needs of the client to maintain proper body alignment and skin integrity. Documentation must include what other devices have been used previously and why they proved to be ineffective.

Items used for physical therapy or rehabilitation in the home are provided by the therapist. Requests for authorization for these purposes will not be considered.

2.4.12.2.3 Repair or Replacement

Repairs require replacement of components that are no longer functional. Technician fees are considered to be part of the cost of the repair.

Repairs to client-owned equipment may be considered with documentation of medical necessity.

Providers are responsible for maintaining documentation in the client’s medical record specifying the repairs and supporting medical necessity.

Rental equipment may be considered during the period of repair. Routine maintenance of rented equipment is the provider's responsibility.

Pediatric hospital cribs and beds, enclosed beds, and safety enclosure frames/canopies/bubble tops that have been purchased are anticipated to last a minimum of five years.

Prior authorization for replacement may be considered within five years of purchase if one of the following occurs:

•	There has been a significant change in the client’s condition such that the current equipment no longer meets the client’s needs.

•	The equipment is no longer functional and cannot be repaired or it is not cost effective to repair.

Replacement equipment may also be considered if 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.