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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.38 Implantable Infusion Pumps

9.2.39.38
Implantable infusion pump (IIPs) are intended to provide long-term, continuous, or intermittent drug infusion. They may be medically necessary in the following circumstances:
An implantable infusion pump is not a benefit for the following uses:
All supplies associated with an IIP are included with the reimbursement for the surgery to implant the infusion pump and are not reimbursed separately.
Providers may be reimbursed for implantable infusion pumps using procedure codes E0782, E0783, and E0786. If procedure codes E0782 and E0783 are billed with the same date of service, only one may be reimbursed.
9.2.39.38.1
Implantable infusion pumps (procedure codes E0782, E0783, and E0786) require prior authorization.
Prior authorization is not required for the physician services associated with the insertion, revision, removal, refilling, or maintenance of the IIP.
Providers must request prior authorization through the Special Medical Prior Authorization (SMPA) department. The ASC or DME provider may submit a request for prior authorization using the Special Medical Prior Authorization (SMPA) Form, which must be completed and signed by a physician.
The completed, signed and dated SMPA form must be maintained by the provider and the prescribing physician in the client’s medical record.
The completed SMPA Form must include the procedure code and quantity for the services that are requested. Documentation that is submitted with the prior authorization request must indicate whether the IIP will be provided by the ASC or the DME provider.
To avoid unnecessary denials, the physician must provide correct and complete information, including documentation of medical necessity for the requested IIP. The requesting provider may be asked for additional information to clarify or complete a request for the IIP.
Documentation submitted with the prior authorization request must indicate the client or caregiver has:
As indicated in the following sections, supporting documentation that is based on the type of IIP requested must be included with the request for prior authorization. All of the documentation listed under the specific type of IIP must be included with the request for prior authorization.
9.2.39.38.2
The following documentation is required for prior authorization:

Texas Medicaid & Healthcare Partnership
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