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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) : 2.6.12 Hospital Beds, Cribs, and Equipment : Prior Authorization and Documentation Requirements
Prior authorization is required for all DME and services provided through CCP, including any accessories, modifications, adjustments, replacements, and repairs to the equipment.
To be considered for prior authorization, the provider must include all of the following to support medical necessity:
The diagnosis, medical needs, treatments, developmental level, and functional skills of the child. A diagnosis alone is insufficient information to consider prior authorization of the requested equipment.
A determination will be made by HHSC or its designee whether the equipment will be rented, purchased, repaired, or modified based on the client’s needs, duration of use, and age of equipment. All modifications, adjustments, and repairs within the first six months after delivery are considered to be part of the purchase price.
Pediatric hospital beds and pediatric cribs (procedure codes E0300, E0316, E0328, and E0329) may be considered for prior authorization when the documentation submitted clearly shows that the requested bed or crib will correct or ameliorate the client’s condition. The documentation must meet at least one of the following criteria:
The client’s medical condition requires positioning of the body in ways that are not feasible in an ordinary bed, including, but not limited to, the need for positioning to alleviate pain.
The head of the bed must be elevated 30 or more degrees most of the time due to, but not limited to, congestive heart failure, chronic pulmonary disease, or problems with aspiration, and alternative measures, such as wedges or pillows, have been attempted but have failed to manage the client’s medical condition.
A semi-electric or fully electric hospital bed (procedure code E0329) may be considered for prior authorization when the submitted documentation shows that the client has a medical condition that requires frequent changes in body position or might require an immediate change in body position to avert a life-threatening situation.
The safety enclosure frame, canopy, or bubble top may be considered for prior authorization with documentation that the protective canopy top or bubble will provide for the client’s safety. Prior authorization will not be considered when it will be used as a restraint or for the convenience of family or caregivers.
Reflux slings or wedges may be considered for prior authorization for clients who are 11 months of age and younger. These may be used as positioning devices for infants who require the head of the bed or crib to be elevated greater than 30 degrees after feedings when prescribed by a physician as medically necessary and appropriate.
Positioning pillows and cushions may be considered for prior authorization with documentation of medical necessity that indicates the item will provide for or assist in the positioning needs of the client to maintain proper body alignment and skin integrity. Documentation must include what other devices have been used previously and why they proved to be ineffective.
Items used for PT or rehabilitation in the home are provided by the therapist. Requests for authorization for these purposes will not be considered.
Repairs require replacement of components that are no longer functional. Technician fees are considered to be part of the cost of the repair.
Repairs to client-owned equipment may be considered with documentation of medical necessity.
Providers are responsible for maintaining documentation in the client’s medical record specifying the repairs and supporting medical necessity.
Rental equipment may be considered during the period of repair. Routine maintenance of rented equipment is the provider’s responsibility.
Pediatric hospital cribs and beds, enclosed beds, and safety enclosure frames, canopies, or bubble tops that have been purchased are anticipated to last a minimum of five years.
Prior authorization for replacement may be considered within five years of purchase if one of the following occurs:
Replacement equipment may also be considered if loss or irreparable damage has occurred. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent reoccurrence must be submitted.

Texas Medicaid & Healthcare Partnership
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