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December 2016 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2 Texas Medicaid (Title XIX) Home Health Services : 2.2 Services, Benefits, Limitations and Prior Authorization : 2.2.4 Augmentative Communication Device (ACD) System : Prior Authorization
Prior authorization is required for ACD systems provided through Home Health Services. The prior authorization also includes all related accessories and supplies. The physician must provide information supporting the medical necessity of the equipment or supplies requested, including:
Accurate diagnostic information pertaining to the underlying diagnosis or condition and any other medical diagnoses or conditions, including the client’s overall physical and cognitive limitations.
Prior authorization for an ACD system and accessories (rental or purchase) must be requested using the following information:
Complete description of the ACD system with all accessories, components, mounting devices, or modifications necessary for client use (must include manufacturer’s name, model number, and retail price).
An evaluation and assessment must be conducted by a licensed SLP in conjunction with other disciplines, such as physical or occupational therapies. The prescribing physician must base the prescription on the professional evaluation and assessment.
The prior authorization request must include the specifications for the ACD system, all component accessories necessary for the proper use of the ACD, and all necessary therapies or training. It is recommended that the preliminary evaluation for an ACD system include the involvement of an occupational therapist or physical therapist to address the client’s seating/postural needs and the motor skills required to utilize the ACD system.
The prescribing physician familiar with the client must review the SLP evaluation of the client’s cognitive and language abilities and base the prescription and treatment plan on the SLP’s recommendations.
An evaluation and assessment by a licensed SLP must be signed and dated before the date on the physician’s prescription or the Title XIX form and include the following information:
Rationale for the recommended ACD system and each accessory, including a statement as to why the recommended device is the most appropriate and least costly alternative for the client and how the recommended system will benefit the client.
Treatment plan that includes training in the basic operation of the recommended ACD system necessary to ensure optimal use by the client (if appropriate, the client’s caregiver) and a therapy schedule for the client to gain proficiency in using the ACD system.
Description of the anticipated changes, modifications, or upgrades with projected time frames of the ACD system necessary to meet the client’s short- and long-term speech-language needs.

Texas Medicaid & Healthcare Partnership
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