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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 : Pulse Oximetry
Pulse oximeters are not a benefit of Title XIX Home Health Services. Pulse oximeters are a benefit of Texas Medicaid through CCP for clients who are birth through 20 years of age.
Refer to:
Subsection 2.6.6, “Pulse Oximeter” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information on pulse oximeters.
Pulse oximeter sensor probes (procedure code A4606) for client owned equipment are limited to four per month without prior authorization. If additional sensor probes are needed, prior authorization must be requested through Home Health Services with documentation supporting medical necessity.

Texas Medicaid & Healthcare Partnership
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