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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 : 2.2.7 Bone Growth Stimulators : 2.2.7.2 Prior Authorization Criteria and Documentation Requirements for Bone Growth Stimulators

2.2.7.2
Procedure codes E0747, E0748, E0749, and E0760 require prior authorization. Additional bone growth stimulators may be considered for prior authorization with documentation that supports treatment of a different fracture.
A completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form prescribing the DME or medical supplies must be signed and dated by the prescribing physician familiar with the client prior to requesting authorization. The completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept in the physician’s medical record for the client.
To avoid unnecessary authorization denials, the physician must provide correct and complete information, including documentation for medical necessity of the equipment or supplies requested. The requesting provider may be asked for additional information to clarify or complete a request for the bone growth stimulator.
Documentation that supports medical necessity for a bone growth stimulator must be maintained by the ordering physician and requesting provider in the client’s medical record and is subject to retrospective review.
2.2.7.2.1
Documentation of one of the following is required for prior authorization of the external, electromagnetic bone stimulator (procedure code E0747):
Nonunions, failed fusions, and congenital pseudarthrosis where there is no evidence of progression of healing for three or more months despite appropriate fracture care.
Documentation must also indicate all of the following:
Documentation of one of the following is required for prior authorization of the external, electromagnetic bone stimulator for spinal application (procedure code E0748):
Other risk factors for fusion failure are present, including gross obesity, degenerative osteoarthritis, severe spondylolisthesis, current smoking, previous fusion surgery, previous disc surgery, or gross instability.
2.2.7.2.2
Documentation of one of the following is required for prior authorization of the surgically implanted bone growth stimulator (procedure code E0749):
Nonunion of long bone fractures (i.e., clavicle, humerus, radius, ulna, femur, tibia, fibula, and metacarpal, metatarsal, carpal, and tarsal bones). Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for three or more months prior to starting treatment with the bone growth stimulator. Serial radiographs must include a minimum of two sets of radiographs separated by a minimum of 90 days. Each set of radiographs must include multiple views of the fracture site.
2.2.7.2.3
Documentation of the following is required for prior authorization of the external, low-intensity ultrasound bone growth stimulator device (procedure code E0760):
Accompanied by a written interpretation by a physician who states that there has been no clinically significant evidence of fracture healing between the two set of radiographs.

Texas Medicaid & Healthcare Partnership
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