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2012 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2. Texas Medicaid (Title XIX) Home Health Services : 2.2 Services, Benefits, Limitations and Prior Authorization : 2.2.13 Intravenous (IV) Therapy Equipment and Supplies : 2.2.13.2 Documentation Requirements

2.2.13.2
To request prior authorization for IV supplies and equipment, the following documentation must be provided:
If additional supplies are needed beyond the standards listed, prior authorization may be considered with documentation supporting medical necessity.
For additional IV access catheters, supporting documentation must have evidence that includes, but is not limited to, the following:
For more frequent IV site changes, supporting documentation must have evidence that includes, but is not limited to, the following:
For more frequent IV tubing or add-on changes, supporting documentation must have evidence that includes, but is not limited to, the following:

Texas Medicaid & Healthcare Partnership
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