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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) : 2.4.14 Special Needs Car Seats and Travel Restraints : Prior Authorization and Documentation Requirements Special Needs Car Seats
A special needs car seat may be considered for reimbursement with prior authorization for a client who has outgrown an infant car seat and is unable to travel safely in a booster seat or seat belt. Consideration must be given to the manufacturer’s weight and height limitations and must reflect allowances for at least 12 months of growth.
The provider must maintain a statement that has been signed and dated by the client’s parent or legal guardian in the client’s medical record that states the following:
To request prior authorization for a special needs car seat or accessories, the following documentation must be provided:
The client’s weight must be at least 40 pounds, or the client’s height must be at least 40 inches.
Supporting documentation must include the following and must be submitted for prior authorization:
Accurate diagnostic information pertaining to the underlying diagnosis/condition as well as any other medical diagnoses/conditions, to include the client’s overall health status.
A description of the client’s postural condition specifically including head and trunk control (or lack of control) and why a booster chair or seatbelt will not meet the client’s needs (the car seat must be able to support the head if head control is poor).
A request for a client who does not meet the criteria may be considered on a case-by-case basis on review by HHSC or its designee. Travel Safety Restraints
A travel safety restraint and ankle or wrist belts may be considered for reimbursement through CCP without prior authorization for clients with a medical condition requiring them to be transported in either a prone or supine position. The DME provider and the prescribing physician familiar with the client must maintain documentation in the client’s medical record supporting the medical necessity of the travel safety restraint.

Texas Medicaid & Healthcare Partnership
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