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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) : 2.6.10 Mobility Aids : 2.6.10.2 Prior Authorization and Documentation Requirements

2.6.10.2
Prior authorization is required for all mobility aids and related services, except travel safety restraints for clients with a medical condition requiring them to be transported in either a prone or supine position.
Mobility aid equipment that has been purchased is anticipated to last a minimum of five years and may be considered for replacement with prior authorization when five years have passed or the equipment is no longer repairable. Prior authorization for replacement of mobility aid equipment may also be considered when loss or irreparable damage has occurred. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent recurrence must be submitted.
When prior authorization of a mobility aid replacement is requested before five years have passed, the following information must be submitted with the request:
HHSC or its designee determines whether the equipment is rented, purchased, repaired, or modified based on the client’s needs, duration of use, and age of equipment.
Rental of equipment includes all necessary accessories, supplies, adjustments, repairs, and replacement parts.
2.6.10.2.1
Prior authorization is required and will be considered on a case-by-case basis for portable client electric lifts that can fold-up for transport and that are necessary for use outside the home setting.
The provider must submit a prior authorization request with the following documentation for consideration of medical necessity:
A description of the circumstances, including duration of need, when the client is required to attend health-related services requiring an overnight stay in a non-institutional setting.
The family member or caregiver(s) supporting the client in the use of the portable client lift when required to travel outside the home setting for health related visits.
2.6.10.2.2
A medical stroller does not have the capacity to accommodate the client’s growth. Strollers for medical use may be considered for prior authorization when all of the following criteria are met:
To request prior authorization for the purchase of procedure code E1035, the criteria must be met for the level of stroller requested:
Level One, Basic Stroller. The client meets the criteria for a stroller. Providers must use procedure code E1035.
Level Two, Stroller with Tray for Oxygen or Ventilator. The client meets the criteria for a level-one stroller and is oxygen- or ventilator-dependent. Providers must use procedure code E1035 with modifier TF.
Level Three, Stroller with Positioning Inserts. The client meets the criteria for a level-one or level-two stroller and requires additional positioning support. Providers must use procedure code E1035 with modifier TG.
The following supporting documentation must be submitted:
A completed Wheelchair/Stroller Seating Assessment Form that includes documentation supporting medical necessity. This documentation must address why the client is unable to ambulate a minimum of 10 feet due to his or her condition (including, but not limited to, AIDS, sickle cell anemia, fractures, a chronic diagnosis, or chemotherapy), or if able to ambulate further, why a stroller is required to meet the client’s needs.
If the client is three years of age or older, documentation must support that the client’s condition, stature, weight, and positioning needs allow adequate support from a stroller.
Note:
2.6.10.2.3
Modifications to custom equipment after the first six months from fitting and delivery may be considered for prior authorization should a change occur in the client’s needs, capabilities, or physical and mental capability, which cannot be anticipated.
Documentation supporting the medical necessity of the requested modification must include the following:
Description of the change in the client’s condition that requires accommodation by different seating, drive controls, electronics, or other mobility base components.
Major modifications to a wheeled mobility system also require that a new seating assessment be completed and submitted with the prior authorization request. A request for authorization of the QRP’s participation in the seating assessment for the major modification must be included with the prior authorization request for the major modification.
Minor modifications to a wheeled mobility system do not require the completion of a new seating assessment.
Requests for equipment submitted as a minor modification to a wheeled mobility system must be submitted with modifier RB.
2.6.10.2.4
Adjustments within the first six months after delivery, including adjustments to a wheeled mobility system within the first six months after fitting and delivery by a QRP will not be prior authorized.
A seating or positioning component alteration to accommodate a change in the client’s size (height or weight) that does not require replacement components is considered an adjustment and not a major modification.
A maximum of one hour of labor for adjustments may be prior authorized as needed after the first six months from delivery.
Documentation must include the date of purchase, the serial number of the current equipment, and the reason for adjustments.
2.6.10.2.5
Repairs to client owned equipment may be considered for prior authorization, as needed, with documentation of medical necessity. Technician fees are considered part of the cost of the repair.
HHSC or its designee reserves the right to request additional documentation about the need for repairs when there is evidence of abuse or neglect to equipment by the client, client’s family or caregiver. Requests for repairs when there is documented proof of abuse or neglect will not be authorized.
Requests for equipment submitted as a repair to a wheeled mobility system must be submitted with modifier RB.
Providers are responsible for maintaining documentation in the client’s medical record specifying the repairs and supporting medical necessity.
Documentation must include the date of purchase and serial number of the current equipment, the cause of the damage or need for repairs, the steps the client or caregiver will take to prevent further damage if repairs are due to an accident and, when requested the cost of purchasing new equipment as opposed to repairing current equipment.
2.6.10.2.6
A seating assessment performed by an occupational therapist, physical therapist, or a physician, with the participation of a QRP, does not require prior authorization. A seating assessment performed by a physician is considered part of the physician E/M service.
A seating assessment must be completed by a physician or licensed occupational therapist or physical therapist, who is not employed by the equipment supplier, before requesting prior authorization.
The seating assessment must clearly show that the equipment is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition.
The QRP’s participation in the seating assessment requires authorization before the service can be reimbursed. Authorization must be requested at the same time and on the same prior authorization request form as the prior authorization request for the QRP fitting and the wheeled mobility system or major modification to the wheeled mobility system.
Prior authorization requests for the QRP’s participation in the seating assessment will be returned to the provider if the seating assessment is requested separately from the prior authorization for the QRP fitting and the wheeled mobility system or major modification to the wheeled mobility system.
The QRP participating in the seating assessment must be directly employed by, or contracted with, the DME provider requesting the wheeled mobility system or major modification to a wheeled mobility system.
An authorization for the QRP’s participation in the seating assessment for a wheeled mobility system or major modification to a wheeled mobility system may be issued to the QRP in 15-minute increments, for a time period of up to one hour (4 units).
Documentation must include the following:
Anticipate changes in the client’s needs and include anticipated modifications or accessory needs, as well as the anticipated width of the medical stroller to allow client growth with use of lateral and thigh supports.
Include significant medical information pertinent to the client’s mobility and how the requested equipment will accommodate these needs, including intellectual, postural, physical, sensory (visual and auditory), and physical status.
Address trunk and head control, balance, arm and hand function, existence and severity of orthopedic deformities, any recent changes in the client’s physical or functional status, and any expected or potential surgeries that will improve or further limit mobility.
Include information on the client’s current mobility and seating equipment, how long the client has been in the current equipment, and why it no longer meets the client’s needs.
Seating measurements are required.
2.6.10.2.7
One portable and one threshold ramp for stroller access may be considered for prior authorization when documentation supports medical necessity and includes the following:
A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply.
Ramps may be considered for rental for short-term disabilities. Ramps may be considered for purchase for long-term disabilities.
Mobility aid lifts for vehicles and vehicle modifications are not reimbursed through Texas Medicaid according to federal regulations.
Note:
2.6.10.2.8
A special-needs car seat may be considered for prior authorization for a client who has outgrown an infant car seat and is unable to travel safely in a booster seat or seat belt. Consideration should be given to the manufacturer’s weight and height limitations, and must reflect allowances for at least 12 months of growth.
Car seat accessories available from the manufacturer may be considered for prior authorization when medically necessary for correct positioning.
A special-needs car seat must have a top tether installed. The top tether is essential for proper use of the car seat. The installer is reimbursed for the installation by the manufacturer. The provider must maintain a statement that has been signed and dated by the client’s parent or legal guardian in the client’s medical record that states the following:
To request prior authorization for a special-needs car seat or accessories, all of the following criteria must be met:
Accurate diagnostic information pertaining to the underlying diagnosis or condition as well as any other medical diagnoses or conditions, including the client’s overall health status.
A description of the client’s postural condition specifically including head and trunk control (or lack of control) and why a booster chair or seatbelt will not meet the client’s needs. The car seat must be able to support the head if head control is poor.
A copy of the manufacturer’s certification for the installer’s training to insert the specified car seat, such as Columbia Medical Manufacturing Corporation for Columbia products.

Texas Medicaid & Healthcare Partnership
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