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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) : 2.6.11 Nutritional Products : Prior Authorization and Documentation Requirements
Prior authorization for nutritional products is not required for a client who meets at least one of the following criteria:
Prior authorization is required for nutritional products that are provided through CCP to clients who do not meet the criteria above and for all related supplies and equipment.
A completed CCP Prior Authorization Request Form that prescribes the nutritional product and/or related services must be signed and dated by a prescribing physician who was familiar with the client before requesting prior authorization. The completed CCP Prior Authorization Request Form must include the procedure codes and numerical quantities for the services requested. A copy of the completed, signed, and dated CCP Prior Authorization Form must be maintained by the provider in the client’s medical record. The completed CCP Prior Authorization Request Form with the original dated signature must be maintained by the prescribing physician in the client’s medical record.
Requests for prior authorization must include the following documentation:
Accurate diagnostic information pertaining to the underlying diagnosis or condition that resulted in the requirement for a nutritional product, as well as any other medical diagnoses or conditions, including:
Related supplies and equipment for clients who require nutritional products may be considered for prior authorization when the criteria for nutritional products are met and medical necessity is included for each item requested.
Prior authorization may be given for up to 12 months. Prior authorization may be recertified with documentation that supports the ongoing medical necessity of the requested nutritional products.
A retrospective review may be performed to ensure that the documentation included in the client’s medical record supports the medical necessity of the requested service.
Requests for prior authorization, when required, must include the necessary product information.
Enteral formulas consisting of semi-synthetic intact protein or protein isolates (procedure codes B4150 and B4152) are appropriate for the majority of clients who require enteral nutrition.
Special enteral formula or additives (procedure code B4104) may be considered for prior authorization with supporting documentation submitted by the client’s physician indicating the client’s medical needs for these special enteral formulas. Special enteral formula may be reimbursed with the following procedure codes:
Food thickener may be considered for clients with a swallowing disorder.
Prior authorization of nutritional pudding products may be considered for children who have a documented oropharyngeal motor dysfunction and receive greater than 50 percent of their daily caloric intake from a nutritional pudding product.
Requests for electrolyte replacement products, such as Pedialyte or Oralyte, require documentation of medical necessity, including:
Electrolyte replacement products are not indicated for clients with:
Nasogastric, Gastrostomy, or Jejunostomy Feeding Tube
Feeding tubes require prior authorization. Additional feeding tubes may be prior authorized if the submitted documentation supports medical necessity, such as documentation of an infection at the gastrostomy site, leakage, or occlusion.
Enteral Feeding Pumps
The prior authorization of the lease or purchase of enteral feeding pumps may be considered with documentation of medical necessity that indicates that the client meets the following criteria:
Enteral Supplies
Enteral supplies require prior authorization, with the exception of irrigation syringes (procedure code A4322) and percutaneous catheter/tube anchoring devices (procedure code A5200) within the allowable limits.
Additional enteral feeding supply kits beyond the stated benefit limitation may be considered for prior authorization on a case-by-case basis with documentation of medical necessity.
Procedure code B4034 will not be prior authorized for use in place of procedure code A4322 for irrigation syringes when they are not part of a bolus administration kit. Gravity bags and pump nutritional containers are included in the feeding supply kits and will not be prior authorized separately.
Specific items may be considered for prior authorization using miscellaneous procedure code B9998 and modifier U1, U2, U3, U4, or U5.
Requests for a backpack or carrying case for a portable enteral feeding pump will be considered for prior authorization for clients who meet all of the following medical necessity criteria:
The client requires enteral feedings that last more than eight continuous hours, or feeding intervals that are greater than the time that the client must be away from home to:

Texas Medicaid & Healthcare Partnership
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