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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 : Documentation Requirements
To request prior authorization for nutritional formula, supplies, or equipment, the following documentation must be provided:
Accurate diagnostic information pertaining to the underlying diagnosis or condition as well as any other medical diagnoses or conditions, to include the client’s overall health status
Diagnosis or condition (including the appropriate International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] code)

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