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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 : 2.2.19 Respiratory Equipment and Supplies : 2.2.19.9 Positive Airway Pressure System Devices

2.2.19.9
In addition to the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form, a Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy Form must be signed and dated by the physician familiar with the client and submitted by the provider for all positive pressure system devices. The original signed copy must be kept in the medical record.
2.2.19.9.1
Humidification devices require prior authorization. Documentation of medical necessity including the diagnosis and expected outcome must be submitted with the request for prior authorization.
2.2.19.9.2
Purchase is limited to a maximum of once every five years with medical necessity. Reimbursement for rental is limited to once per month and includes all supplies and accessories.
Headgear, tubing, and filters are considered part of the rental and will not be reimbursed separately.
Providers must use procedure code E0601 when requesting prior authorization for the rental or purchase of the CPAP system.
Adult CPAP (19 years of age and older)
CPAP may be approved initially for three months for adults if one of the following conditions are met:
Pediatric CPAP Criteria
One of the following AHI or oxygen saturation levels may be used for clients who are 18 years of age and younger:
2.2.19.9.3
The CPAP system requires prior authorization and may be prior authorized for rental or purchase depending on the physician’s predicted length of treatment. Headgear, tubing, and filters used with patient owned positive airway pressure devices require prior authorization. Humidifiers may be prior authorized when used with a CPAP with documentation of medical necessity. Clients who have a current prior authorization for a CPAP/BiPAP S may continue to rent these items until the prior authorization period expires. After the current prior authorization period expires, then the criteria in the following paragraph applies to any further prior authorizations of CPAP/BiPAP. Providers must supply a new CPAP/BiPAP to clients at the beginning of the new prior authorization period.
The CPAP system may be approved initially for a three-month rental period based on documentation supporting the medical necessity and appropriateness of the device.
CPAP Prior Authorization Renewal
Prior authorization for purchase after the initial three-month rental period may be granted if the client is continuing to use the equipment at a minimum of four hours per night and symptoms are improved as documented by a physician familiar with the client. This documentation of compliance and effectiveness must be provided with a new completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form and a Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy form. Rental of a CPAP/BiPAP system includes all supplies. CPAP/BiPAP S may be rented up to a maximum of 13 months. The equipment is considered purchased after 13 months rental.
2.2.19.9.4
Purchase is limited to a maximum of once every five years with medical necessity. Reimbursement for rental is limited to once per month and includes all supplies.
Providers must use procedure code E0470 when requesting prior authorization for the rental or purchase of the BiPAP S.
The BiPAP S may be approved initially for a three-month rental period based on documentation supporting the medical necessity and appropriateness of the device.
The BiPAP S may be approved initially for three months if the following conditions are met:
Rental of CPAP/BiPAP S includes all supplies. CPAP/BiPAP S may be rented up to a maximum of 13 months. The equipment is considered purchased after 13 months rental.
Prior Authorization
The BiPAP S requires prior authorization and may be reimbursed for rental or purchase depending on the physician’s predicted length of treatment. The BiPAP S will not be prior authorized once a CPAP is purchased. Clients who have a current prior authorization for a CPAP/BiPAP S may continue to rent these items until the prior authorization period expires. After the current prior authorization period expires, then the criteria in the following paragraph applies to any further prior authorizations of CPAP/BiPAP. Providers must supply a new CPAP/BiPAP to clients at the time of purchase, if the item is purchased after a rental period.
Prior authorization for purchase after the initial three-month rental period may be granted if the client is continuing to use the equipment at a minimum of four hours per night and symptoms are improved as documented by a physician familiar with the client. This documentation of compliance and effectiveness must be provided with a new completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form and a Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy form.
2.2.19.9.5
Purchase of a BiPAP ST is not a benefit. The BiPAP ST may be approved initially for a three-month rental period based on documentation supporting the medical necessity and appropriateness of the device. Providers must use either procedure code E0471 or E0472 when requesting prior authorization for the rental of the BiPAP ST.
BiPAP ST may be approved initially for three months if the following conditions are met:
The client has an arterial PO2 at or below 56 mm Hg, or an arterial oxygen saturation at or below 89 percent by transcutaneous oximetry associated with a diagnosis of neuromuscular respiratory insufficiency or failure (not COPD).
2.2.19.9.6
The rental of a BiPAP ST requires prior authorization and may be reimbursed only once per month.
Continued prior authorization for rental after the initial three-month rental period may be granted if the client is continuing to use the equipment at a minimum four hours per night and has a transcutaneous saturation greater than 88 percent while using the equipment as documented by a physician familiar with the client or 92 percent or less for clients who are 20 years of age and younger. This documentation of compliance and effectiveness must be provided with the above documentation plus a new completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form and a Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy form.

Texas Medicaid & Healthcare Partnership
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