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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 : 2.2.19.10 Home Mechanical Ventilation Equipment

2.2.19.10
Continuous use ventilators are used for 12 or more hours per day. Intermittent use ventilators are used for less than 12 hours per day. Mechanical ventilation is either provided by positive pressure ventilation (volume ventilator) or negative pressure ventilation (iron lung).
Prior Authorization
All ventilators require prior authorization. The completed, signed, and dated Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form must specify all ventilator settings and must be maintained by the DME provider and the prescribing physician in the client’s medical record.
Volume Ventilators
A volume ventilator may be operated in any of the following:
Ventilation Modes
Breath Types
The monthly ventilator rental includes all ventilator supplies, such as (but not limited to):
Note:
Prior authorization of a volume ventilator rental may be granted for clients who have a tracheostomy. For all ventilator procedure codes, providers must include documentation by the physician who is familiar with the client, which states that the client is compliant with the use of the equipment and that the treatment is effective.
Refer to:
Subsection 2.2.19.13, “Procedure Codes and Limitations for Respiratory Equipment and Supplies” in this handbook for additional information about ventilator procedure codes.
2.2.19.10.1
The ventilator rental includes all component parts (pillow, mattress, gaskets, etc.).
Application devices may be purchased following the initial three-month rental period depending on the physician’s predicted length of treatment and the client’s compliance.
The purchase of a chest shell (cuirass) and chest wrap is limited to a maximum of 1 every 5 years. Reimbursement for rental is limited to once per month for a total of 4 months.
Prior Authorization
Negative pressure ventilators may be prior authorized for rental only for individuals who have the ability to speak, eat, drink, and do not have a tracheostomy. One of the following devices may be prior authorized with a portable negative pressure ventilator using procedure codes E0457 and E0459. These devices may be reimbursed for an initial three-month rental period. Application devices may be prior authorized for rental of an initial period of three months.
2.2.19.10.2
A ventilator service agreement may be reimbursed only once per month. Providers must use procedure code A9900 when requesting the ventilator service agreement. The ventilator service agreement contract may be considered for renewal every six months.
The provider must agree to include all of the following components in the ventilator service agreement:
Provide monthly home visits by a certified respiratory therapist to verify proper functioning of the ventilator system and the client’s status (and maintain documentation of monthly visits)
Prior Authorization
A ventilator service agreement may be prior authorized for a client who owns their own ventilator, when documentation supports medical necessity/appropriateness for continued ventilator usage. A ventilator service agreement requires prior authorization, which must include submission of a completed Title XIX form and the ventilator service agreement. The completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form must include all ventilator settings.
The completed, signed, and dated Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form and the Ventilator Service Agreement form must be maintained by the provider and the prescribing physician in the client’s medical record. The client-owned ventilator must be functional at the time of the request for prior authorization and documentation must include the make, model number, serial number, and the date of ventilator purchase and all ventilator settings. Requests for a continued six-month prior authorization of a ventilator service agreement must include the above documentation and the following:

Texas Medicaid & Healthcare Partnership
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