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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 : 2.2.22 Total Parenteral Nutrition (TPN) Solutions : Documentation Requirements
Requests for prior authorization must include the following information:
The requesting provider may be asked for additional information to clarify or complete a request for TPN services.
Prior authorization requests for a portable parenteral nutrition infusion pump (procedure code B9004) must also include documentation of medical necessity demonstrating that:
Prior authorization for parenteral nutrition infusion pumps will be limited to one portable pump (procedure code B9004) or one stationary pump (procedure code B9006) at any one time, unless medical necessity for two infusion pumps is established. Supporting documentation for the additional pump must be included with the prior authorization request.
Prior authorization requests for miscellaneous procedure code B9999 must include the following:
Requests for a carrying case or backpack for the portable infusion pump will be considered for prior authorization under miscellaneous code B9999, for clients who meet the medical necessity criteria for the portable pump as outlined above. The following additional criteria apply:
Renewal of the prior authorization will be considered based on medical necessity.
Refer to:

Texas Medicaid & Healthcare Partnership
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