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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) : 2.6.5 Cardiorespiratory (Apnea) Monitor : Prior Authorization and Documentation Requirements
Prior authorization for the purchase of an apnea monitor with or without recording features may be considered for use in the home with one of the diagnosis codes listed in the table above.
Prior authorization is required for rental of an apnea monitor, and may be considered for clients who are birth through 20 years of age that are CCP-eligible when documentation submitted clearly shows that the equipment is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition. Documentation must include one of the following:
Clients who are five months of age and older must have demonstrated an apparent life-threatening event, tracheostomy, anatomic abnormality of the airway, chronic lung disease requiring oxygen or ventilatory support, or other diagnoses based on documented medical necessity.
Prior authorization must be obtained in writing and must include all of the following:
Apnea monitors are not prior authorized if the documentation does not support medical necessity.

Texas Medicaid & Healthcare Partnership
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