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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 : 2.2.15 Nutritional (Enteral) Products, Supplies, and Equipment : 2.2.15.3 Documentation Requirements

2.2.15.3
To request prior authorization for nutritional formula, supplies, or equipment, the following documentation must be provided:
Accurate diagnostic information pertaining to the underlying diagnosis or condition as well as any other medical diagnoses or conditions, to include the client’s overall health status

Texas Medicaid & Healthcare Partnership
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