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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.6 Durable Medical Equipment (DME) Supplier (CCP) : 2.6.4 Blood Pressure Devices : 2.6.4.2 Prior Authorization and Documentation Requirements

2.6.4.2
A CCP Prior Authorization Request Form, signed and dated by the physician, must be submitted with the documentation supporting medical necessity for the device. Supporting documentation of medical necessity must include the diagnosis.
2.6.4.2.1
Prior authorization is not required for manual and automated blood pressure devices except when the following situations apply:
Another blood pressure device is medically necessary within the same year. Replacement of equipment within the same year as the purchase requires prior authorization. When equipment needs to be replaced sooner than the anticipated lifespan, the provider must submit a copy of the police or fire report, when appropriate, and the measures to be taken to prevent reoccurrence.
The client has a diagnosis code other than those in the diagnosis table listed above. If the client has a diagnosis code other than those listed in the above table, a request for prior authorization for an initial or replacement device with all necessary documentation supporting medical necessity of the blood pressure device.
2.6.4.2.2
Prior authorization is required for the rental or purchase of a hospital-grade blood pressure device. A determination will be made by HHSC or its designee as to whether the equipment will be rented, purchased, repaired, or modified based on the client’s needs, duration of use, and age of the equipment. Repairs and modifications can only be performed on purchased equipment.
Documentation of medical necessity for the hospital-grade blood pressure device must support the client’s need for self-monitoring and address why an automated blood pressure device will not meet the client’s needs. The documentation must include:
A family or caregiver(s) who has an understanding of cause and effect and object permanence and who has agreed to accept the responsibility to be trained to use the hospital-grade monitor.
Prior authorization may be granted for a six-month rental period when the request is submitted with documentation of medical necessity supporting the client’s need for self-monitoring and addressing why an automated blood pressure device will not meet the client’s needs.
Recertification for an additional six-month period may be considered when the physician provides current documentation that supports the ongoing medical necessity for self-monitoring and confirms the client or family is compliant with its use.
A hospital-grade blood pressure device will not be considered for prior authorization of purchase until the client has completed a six-month trial period.
Purchase of a hospital-grade blood pressure device may be prior authorized when all of the following criteria are met:
Documentation of medical necessity supports the client’s need for ongoing self-monitoring and addresses why an automated blood pressure device will not meet the client’s needs.
2.6.4.2.3
Replacement of blood pressure cuffs and other components may be considered for purchase with prior authorization and documentation of medical necessity that explains the need for the replacement.
Repair of equipment must be prior authorized when irreparable damage has occurred and documentation exists that supports the need for repair. Repair of equipment will be considered after the factory warranty has expired.

Texas Medicaid & Healthcare Partnership
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