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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) : 2.6.6 Pulse Oximeter : 2.6.6.2 Prior Authorization and Documentation Requirements

2.6.6.2
A pulse oximeter requires prior authorization.
A pulse oximeter may be considered for prior authorization for clients who are birth through 20 years of age who 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 the following for the level requested:
Level One. Basic level monitoring capable of spot checks and heart rate or capable of continuous monitoring, alarm, memory, and correction of motion artifact. Applicable if there is a caregiver or medical provider identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way and the client meets at least one of the following criteria:
Client has other medically necessary condition(s) requiring monitoring of oxygen saturation or needs continuous monitoring of oxygen saturation during sleep or to maintain optimal levels.
Level Three. Providers must use modifier TG if the oximeter device is for a serious condition and there is critical need for continuous monitoring. Applicable if the client meets all the following criteria:
There is a caregiver or medical provider identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way.
For all requests providers must:
A pulse oximeter rental includes the system, the sensor probes, and all necessary supplies.
Pulse oximeter sensor probes (procedure code A4606) for client-owned equipment are limited to four per month without prior authorization. Providers may obtain additional probes for clients who are birth through 20 years of age with documentation of medical necessity. Additional probes require prior authorization through CCP.

Texas Medicaid & Healthcare Partnership
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