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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.43 Mastectomy and Breast Reconstruction : 8.2.43.7 Prior Authorization Requirements for Mastectomy and Breast Reconstruction

8.2.43.7
Prior authorization is not required when all of the following criteria are met:
Prior authorization is required when any of the following criteria is met:
Exception:
Note:
If it becomes medically necessary to submit a noncovered diagnosis code that differs from the noncovered diagnosis code approved in the prior authorization, the authorization may be updated before claim submission.
For breast reconstruction procedures, the client does not have an established history of mastectomy procedure(s) reimbursed for the client by Texas Medicaid.
For complications related to breast reconstruction, the client does not have an established history of breast reconstruction procedure(s) reimbursed for the client by Texas Medicaid.
The request is for external breast prosthesis procedure code L8035 or L8039. The request must include documentation of medical necessity for the requested device.
Prior authorization requests for fee-for-service Medicaid clients must be submitted by the physician to the Special Medical Prior Authorization (SMPA) department. Documentation that supports medical necessity for the requested procedure must be included with the request. When required, the requests must include the physician’s original signature and the date signed. Stamped or computerized signatures and dates are not accepted. Without this information, requests will be considered incomplete.

Texas Medicaid & Healthcare Partnership
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