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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.10 Orthotic and Prosthetic Services (CCP) : 2.10.3 Cranial Molding Orthosis : 2.10.3.3 Prior Authorization and Documentation Requirements

2.10.3.3
Cranial molding orthoses do not require prior authorization for clients with a diagnosis of synostotic plagiocephaly. Documentation of medical necessity must be maintained in the client’s medical record.
Prior authorization requests for a cranial molding orthosis for congenital conditions that are not outlined in this section may be considered by the Medical Director on a case-by-case basis with documentation of medical necessity. Additional devices beyond the once-per-lifetime benefit may be considered for prior authorization with documentation of all of the following:
To facilitate determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including documentation of medical necessity for the equipment requested. The physician must maintain documentation of medical necessity in the client’s medical record. The requesting provider may be asked for additional information to clarify or complete a request for an additional cranial molding orthosis.
The completed CCP Prior Authorization Form, which includes the DME must be signed and dated by the prescribing physician familiar with the client’s condition. The completed CCP Prior Authorization Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept by the physician in the client’s medical record.

Texas Medicaid & Healthcare Partnership
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