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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 : 2.2.23 Wound Care Supplies or Systems : 2.2.23.4 Prior Authorization

2.2.23.4
Prior authorization is required for all wound care supplies and wound care systems addressed below with the exception of procedure code A4455.
Note:
The requesting provider may be asked for additional information to clarify or complete a prior authorization request for the wound care supplies or wound care system.
Retrospective review may be performed to ensure documentation supports the medical necessity of the requested wound care supplies or system.
Recertification will be considered based on medical necessity, with a new prior authorization request.
Providers should only bill for a one month supply at a time, even though prior authorization may be granted for up to six months.
2.2.23.4.1 Wound Care Supplies
Nonsterile/clean wound care supplies may be considered for prior authorization for use in the home setting when documentation supports medical necessity.
Note:
Sterile wound care supplies, other than those required with a wound care system, may be considered for prior authorization for use in the home setting when documentation supports medical necessity and justifies that nonsterile/clean wound care supplies will not meet the client's needs.
Note:
Established tracheostomies or gastrostomies/buttons are not considered wounds, therefore dressing supplies will not be considered for prior authorization. Dressing supplies for tracheostomies or gastrostomies may be considered for prior authorization with documentation of medical necessity.
Nonsterile gloves may be considered for prior authorization when a family member or friend is performing the medical wound care.
2.2.23.4.2 Wound Care System
Prior authorization for a wound care system may be considered for reimbursement for an initial 30-day period.
Medically necessary prior authorized recertifications may be considered for additional 30-day periods at a time, up to a maximum of four, when documentation supports continued significant improvement in wound healing. Wound care systems may be considered for reimbursement beyond four months of treatment on a case-by-case basis after review of the medical necessity documentation by the medical director or designee.
Wound care system supplies are limited to a maximum of:
15 dressing kits or supplies per wound per month unless documentation supports that the wound size requires more than one dressing kit for each dressing change, or if the physician has ordered more frequent dressing changes.
Note:
When documentation supports evidence of high-volume drainage, defined as greater than 90 milliliters (ml) per day, a stationary pump with the largest capacity canister must be used. Extra canisters related to the equipment failure are not considered medically necessary.
Wound care systems and related supplies will not be prior authorized nor considered for reimbursement when:
A wound care system was used for four months or more in the inpatient setting prior to discharge, except when documentation supports continued significant improvement in wound healing.

Texas Medicaid & Healthcare Partnership
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