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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 : 2.2.16 Nutritional (Enteral) Products, Supplies, and Equipment : 2.2.16.2 Prior Authorization Requirements

2.2.16.2
Prior authorization is required for most enteral products, supplies, and equipment provided through Home Health Services. Requests are reviewed for medically necessary amounts based on caloric needs as indicated by the client’s physician.
Enteral nutrition and related supplies and equipment may be considered for prior authorization for clients who are 21 years of age and older when all or part of the client’s nutritional intake is received through a feeding tube, and the enteral formula is:
An enteral tube feeding is considered the primary source of nutrition when it comprises more than 70 percent of the caloric intake needed to maintain the client’s weight.
The percent of calories provided by an enteral formula may be calculated by dividing the client’s daily calories supplied by the enteral formula by the daily caloric intake ordered by the physician to maintain the client’s weight. The result is multiplied by 100 to determine the percentage of calories provided by the enteral formula.
Related supplies and equipment may be considered for prior authorization when criteria for nutritional products are met, and medical necessity is included for each item requested.
Renewal of the prior authorization will be considered based on medical necessity.
Prior authorization may be given for up to 6 months. Prior authorization may be recertified with documentation supporting ongoing medical necessity for the nutritional products requested.
2.2.16.2.1
Enteral formulas require prior authorization. Requests for prior authorization 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 requiring enteral nutrition.
Special enteral formulas 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:
 
Pediatric nutritional products (procedure codes B4103, B4158, B4159, B4160, B4161, and B4162) are restricted to clients who are 20 years of age and younger.
Food thickener may be considered for clients with a swallowing disorder.
2.2.16.2.2
Feeding tubes require prior authorization.
Additional feeding tubes may be prior authorized if documentation submitted supports medical necessity, such as infection at gastrostomy site, leakage, or occlusion.
2.2.16.2.3
Enteral feeding pumps, with and without alarms, require prior authorization.
Enteral feeding pumps may be considered for prior authorization for lease or purchase with documentation of medical necessity indicating that the client meets the following criteria:
2.2.16.2.4
Enteral supplies require prior authorization, with the exception of irrigation syringes (procedure code A4322) and percutaneous catheter or tube anchoring devices (procedure code A4520) within the allowable limits.
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 modifiers U1, U2, U3, or U5.
Requests for a backpack or carrying case for a portable enteral feeding pump may be considered for prior authorization for purchase only, under miscellaneous code B9998, for clients who meet all of the following medical necessity criteria:
The client requires enteral feedings lasting greater than eight hours continuously, or feeding intervals exceed the time that the client must be away from home to:

Texas Medicaid & Healthcare Partnership
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