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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) : 2.4.15 Total Parental Nutrition (TPN) : Prior Authorization and Documentation Requirements
Prior authorization is required for TPN solutions, lipids, supply kits, and infusion pumps that are provided through CCP. Renewal of the prior authorization will be considered on the basis of medical necessity.
TPN solutions, lipids, supply kits, and infusion pumps will be considered for the prior authorization of short-term or long-term nutritional therapy for clients who are CCP-eligible when documentation submitted clearly shows that it is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition. Documentation must include the following:
Severe, advanced bowel disease. Examples include short bowel syndrome (SBS), chronic intestinal pseudo-obstruction (CIPS), Hirshprungs disease (HD), Crohn’s disease, and ulcerative colitis
To facilitate determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including documentation of medical necessity for the equipment and supplies requested. The physician must also maintain documentation of medical necessity in the client’s medical record.
Prior authorization requests for TPN must include the following information:
Prior authorization requests for a portable parenteral nutrition infusion pump (procedure code B9004) must also include documentation of medical necessity that demonstrates at least one of the following:
Prior authorization for parenteral nutrition infusion pumps are limited to one portable pump (procedure code B9004) or one stationary pump (procedure code B9006) at any one time, unless medical necessity for two infusion pumps is established. Supporting documentation for the additional pump must be included with the prior authorization request.
Prior authorization requests for miscellaneous procedure code B9999 must include the following:
Requests for a backpack or carrying case for the portable infusion pump will be considered for prior authorization under miscellaneous code B9999, if the clients meet the medical necessity criteria for the portable pump that are outlined above. The following criteria also apply:
The requesting provider may be asked for additional information to clarify or complete a request for TPN services.
Retrospective review may be performed to ensure that the documentation supports the medical necessity of the TPN services.

Texas Medicaid & Healthcare Partnership
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