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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 : 2.2.19 Respiratory Equipment and Supplies : 2.2.19.9 Continuous Positive Airway Pressure (CPAP) System

2.2.19.9
Continuous Positive Airway Pressure (CPAP) System
Purchase is limited to a maximum of once every five years with medical necessity. Reimbursement for rental is limited to once per month and includes all supplies and accessories.
Headgear, tubing, and filters are considered part of the rental and will not be reimbursed separately.
Providers must use procedure code E0601 when requesting prior authorization for the rental or purchase of the CPAP system.
2.2.19.9.1 Adult CPAP (19 years of age and older)
CPAP may be approved initially for three months for adults if one of the following conditions are met:
2.2.19.9.2 Pediatric CPAP Criteria
One of the following AHI or oxygen saturation levels may be used for clients who are 18 years of age and younger:
2.2.19.9.3 Prior Authorization
The CPAP system requires prior authorization and may be prior authorized for rental or purchase depending on the physician’s predicted length of treatment. Headgear, tubing, and filters used with patient owned positive airway pressure devices require prior authorization. Humidifiers may be prior authorized when used with a CPAP with documentation of medical necessity. Clients who have a current prior authorization for a CPAP/BiPAP S may continue to rent these items until the prior authorization period expires. After the current prior authorization period expires, then the criteria in the following paragraph applies to any further prior authorizations of CPAP/BiPAP. Providers must supply a new CPAP/BiPAP to clients at the beginning of the new prior authorization period.
The CPAP system may be approved initially for a three-month rental period based on documentation supporting the medical necessity and appropriateness of the device.
CPAP Prior Authorization Renewal
Prior authorization for purchase after the initial three-month rental period may be granted if the client is continuing to use the equipment at a minimum of four hours per night and symptoms are improved as documented by a physician familiar with the client. This documentation of compliance and effectiveness must be provided with a new completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form and a Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy form. Rental of a CPAP/BiPAP system includes all supplies. CPAP/BiPAP S may be rented up to a maximum of 13 months. The equipment is considered purchased after 13 months rental.

Texas Medicaid & Healthcare Partnership
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