Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook

 

1 General Information

The information in this handbook is intended for Texas Medicaid durable medical equipment (DME) supplier and medical supply company providers. This handbook provides information about the Texas Medicaid benefits, policies, and procedures that are applicable to these providers.

This handbook contains information about Texas Medicaid fee-for-service benefits. For information about managed care benefits, refer to the Texas Medicaid Managed Care Handbook.

Managed care carve-out services are administered as fee-for-service benefits. A list of all carve-out services is available in section 9, “Carve-Out Services” in the Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

All providers are required to report suspected child abuse or neglect as outlined in subsection 1.6.1.2, “Reporting Child Abuse or Neglect” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

Important:All providers are required to read and comply with “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information). In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide health-care services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 Texas Administrative Code (TAC) §371.1659. Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure, at all times, to deliver health-care items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance.

Refer to:  “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about enrollment procedures.

1.1Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission

According to the three-day and one-day payment window reimbursement guidelines, most professional and outpatient diagnostic and nondiagnostic services that are rendered within the designated timeframe of an inpatient hospital stay, and are related to the inpatient hospital admission, will not be reimbursed separately from the inpatient hospital stay if the services are rendered by the hospital or an entity that is wholly owned or operated by the hospital.

These reimbursement guidelines do not apply in the following circumstances:

The professional services are rendered in the inpatient hospital setting.

The hospital and the physician office or other entity are both owned by a third party, such as a health system.

The hospital is not the sole or 100-percent owner of the entity.

Refer to:  Subsection 3.7.3.8, “Payment Window Reimbursement Guidelines” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for additional infor­mation about the payment window reimbursement guidelines.

2 Texas Medicaid (Title XIX) Home Health Services

2.1Enrollment

All DME providers must be Medicare-certified before applying for enrollment in Texas Medicaid.

Providers that render custom DME wheeled mobility systems to Texas Medicaid clients must enroll in Texas Medicaid as a specialized/custom wheeled mobility group provider and must have at least one qualified rehabilitation professional (QRP) performing provider.

Certified QRP providers must enroll in Texas Medicaid as performing providers under DME provider groups.

To enroll in Texas Medicaid as a QRP performing provider, individual professionals must be certified by the National Registry of Rehabilitation Technology Suppliers (NRRTS) or Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) and must enroll as a performing provider under a Specialized /Custom Wheeled Mobility group.

Providers may download the Texas Medicaid Provider Enrollment Application at www.tmhp.com or request a paper application form by contacting Texas Medicaid & Healthcare Partnership (TMHP) directly at 1-800-925-9126.

Providers may also obtain the paper enrollment application by writing to the following address:

Texas Medicaid & Healthcare Partnership
Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
1-800-925-9126
Fax: 1-512-514-4214

Providers may request prior authorization for home health services by contacting:

Texas Medicaid & Healthcare Partnership
Home Health Services
PO Box 202977
Austin, TX 78720-2977
1-800-925-8957
Fax: 1-512-514-4209

2.1.1Pending Agency Certification

DME providers that submit claims before the enrollment process is complete or without prior authori­zation for services issued by the TMHP Home Health Services Prior Authorization Department will not be reimbursed. The effective date of enrollment is the date on which all Medicaid provider enrollment forms have been received and approved by TMHP.

Upon the receipt of notice of Medicaid enrollment, the supplier must contact the TMHP Home Health Services Prior Authorization Department before rendering to a Medicaid client, services that require a prior authorization number. Prior authorization cannot be issued before Medicaid enrollment has been completed. Regular prior authorization procedures are followed at that time.

Providers must not submit home health services claims for payment until they have received their Medicaid certification and a prior authorization number has been assigned.

Refer to:  Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA)” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

2.1.2Surety Bond Requirements

All newly enrolling and re-enrolling durable medical equipment (DME) providers must, as a condition of enrollment and continued participation into Texas Medicaid, obtain a surety bond that complies with Title 1, Texas Administrative Code (TAC) §352.15.

Important:Surety bonds obtained for the purpose of accreditation in the Medicare program, which lists the Centers for Medicare & Medicaid Services (CMS) as obligee, do not fulfill the surety bond requirement for Texas Medicaid.

The surety bond submitted to Texas Medicaid must meet the following requirements:

A bond in an amount of no less than $50,000 must be provided for each enrolled location.

Note:Only one surety bond is required if the provider has multiple Medicaid DME provider numbers related to the same location. For example, if the provider has a TPI with a suffix for DME and a second suffix for Specialized Custom Wheeled Mobility all for the same practice location, only one surety bond is required.

The bond must be submitted on the State of Texas Medicaid Provider Surety Bond Form. No other form will be accepted. The use of this form designates the Health and Human Services Commission (HHSC) as the sole obligee of the bond. Instructions are included with the form.

The bond must be issued for a term of 12 months. Bonds for longer or shorter terms are not acceptable.

The bond must be in effect on the date that the provider enrollment application is submitted to TMHP for consideration. The effective date stated on the bond must be:

No later than the date that the provider enrollment application is submitted.

No earlier than 12 months before the date that the provider enrollment application is submitted.

The bond must be a continuous bond. A continuous bond remains in full force and effect from term to term unless the bond is canceled.

Important:An annual bond that specifies effective and expiration dates for the bond, is not acceptable.

At the time of enrollment or re-enrollment, providers must submit the surety bond form with original signatures and a copy of the Power of Attorney document from the surety company that issued the bond.

Note:Surety companies may refer to Texas Department of Insurance (TDI) file #9212562912 or TDI link #132456 when filing the bond.

2.1.2.1Proof of Continuation

DME providers must maintain a current surety bond to continue participation in Texas Medicaid. Each year, providers must submit documentation that shows proof of continuation of the bond for a new 12-month term. The document may be submitted on the surety bond company’s form and must include the following components:

Bond number

Principal’s name, address, and Tax ID or Medicaid provider number (Texas Provider Identifier)

Surety’s company name and address

Date of the original bond

New “good through” date

To avoid losing Medicaid enrollment status, providers must submit the proof of continuation to the TMHP Provider Enrollment before the expiration date of the bond that is currently on file. The completed proof of continuation document must include the original signatures of the authorized corporate representative of the DME provider (principal), and the attorney-in-fact of the surety company. Providers may submit a copy of the proof of continuation (i.e., scan, FAX, photocopy) pending the submission of the original document.

Submission Information

The surety bond must be submitted to the TMHP Provider Enrollment Department at the following address:

Texas Medicaid & Health Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
Fax: 1-512-514-4214

2.2Services, Benefits, Limitations and Prior Authorization

Home health services include home health skilled nursing (SN), home health aide (HHA), physical therapy (PT) and occupational therapy (OT) services; DME; and expendable medical supplies that are provided to eligible Medicaid clients at their place of residence.

Refer to:  The Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (Vol. 2, Provider Handbooks) for more information about therapy services.

The Home Health Nursing and Private Duty Nursing Services Handbook (Vol. 2, Provider Handbooks) for more information about nursing services.

2.2.1Home Health Services

The benefit period for home health professional services is up to 60 days with a current plan of care (POC). For all DME and medical supplies with or without prior authorization requirements, providers must complete a Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form except as outlined in subsection 2.2.11, “Diabetic Equipment and Supplies” in this handbook. In chronic and stable situations, the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form is valid for up to, but no more than, 6 months from the date of the physician’s signature on the form, unless otherwise noted in this handbook. If necessary, DME and supplies that are ordered on a Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form may be prior autho­rized for up to 6 months with medical necessity determination. Because Medicaid clients have a one-month eligibility period, providers must bill for a one month supply at a time, even though prior autho­rization may be granted for up to 6 months. This extended prior authorization period begins on the date that clients receive their first prior-authorized home health service. Texas Medicaid allows additional DME or supplies that have been determined to be medically necessary and have been prior authorized by TMHP Home Health Services Prior Authorization Department. Providers must retain all orders, signed and dated Title XIX forms, delivery slips, and corresponding invoices for all supplies provided to a client and must disclose them to HHSC or its designee on request. These records and claims must be retained for a minimum of five years from the date of service (DOS) or until audit questions, appeals, hearings, investigations, or court cases are resolved. Use of these services is subject to retrospective review.

2.2.1.1Client Eligibility

Home health clients do not have to be homebound to qualify for services.

To qualify for home health services, the Medicaid client must be eligible on the DOS and must:

Have a medical need for home health professional services, DME, or supplies that is documented in the client’s POC and considered a benefit under home health services.

Receive services that meet the client’s existing medical needs and can be safely provided in the client’s home.

Receive prior authorization from TMHP for most home health professional services, DME, and medical supplies.

Unless otherwise noted in this handbook, certain DME/supplies may be obtained without prior autho­rization although providers must retain a Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form that has been reviewed, signed, and dated by the treating physician for these clients.

Refer to:  “Automated Inquiry System (AIS)” in “State, Federal, and TMHP Contact Informaiton” (Vol. 1, General Information).

“Section 6: Claims Filing” (Vol. 1, General Information) for more information on clients who are 20 years of age and younger.

2.2.1.2Prior Authorization Requests for Clients with Retroactive Eligibility

Retroactive eligibility occurs when the effective date of a client’s Medicaid coverage is before the date on which the client’s Medicaid eligibility is added to TMHP’s eligibility file, which is called the “add date.”

For clients with retroactive eligibility, prior authorization requests must be submitted after the client’s add date and before a claim is submitted to TMHP.

For services provided to fee-for-service Medicaid clients during the client’s retroactive eligibility period (i.e., the period from the effective date to the add date), prior authorization must be obtained within 95 days of the client’s add date and before a claim for those services is submitted to TMHP. For services provided on or after the client’s add date, the provider must obtain prior authorization within three business days of the date of service.

The provider is responsible for verifying eligibility. The provider is strongly encouraged to access AIS or TexMedConnect to verify eligibility frequently while providing services to the client. If services are discontinued before the client’s add date, the provider must still obtain prior authorization within 95 days of the add date to be able to submit claims.

Refer to:  “Section 4: Client Eligibility” (Vol. 1, General Information).

2.2.1.3Prior Authorization

Prior authorization must be obtained for some supplies and most DME from TMHP within three business days of the DOS. Although providers may supply some DME and medical supplies to a client without prior authorization, they must still retain a copy of the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form that has Section B completed, signed, and dated by the client’s attending physician, unless otherwise noted in this handbook.

The following prior authorization requests can be submitted on the TMHP website at www.tmhp.com:

External Insulin Pump

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form

Home Health Services POC

Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy

Medicaid Certificate of Necessity for Chest Physiotherapy Device Form—Initial Request

Medicaid Certificate of Necessity for Chest Physiotherapy Device Form—Extended Request

Statement for Initial Wound Therapy System In-Home Use

Statement for Recertification of Wound Therapy System In-Home Use

Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health Services) (Attachments will be sent separately due to size and detailed information)

Refer to:  Subsection 5.5.1, “Prior Authorization Requests Through the TMHP Website” in “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for more infor­mation, including mandatory documentation requirements.

If a client’s primary coverage is private insurance and Medicaid is secondary, prior authorization is required for Medicaid reimbursement. If the primary coverage is Medicare, Medicare approves the service, and Medicaid is secondary, prior authorization is not required. TMHP will pay only the coinsurance or deductible according to current payment guidelines. If Medicare denied the service, then Medicaid prior authorization is required. TMHP must receive a prior authorization request within 30 days of the date of Medicare’s final disposition. The Medicare Remittance Advice Notice (MRAN) containing Medicare’s final disposition must accompany the prior authorization request. If the service is a Medicaid-only service, prior authorization is required within three business days of the DOS. The provider is responsible for determining whether eligibility is effective by using AIS, TexMedConnect, or an electronic eligibility inquiry through the TMHP EDI gateway.

The provider must contact the TMHP Home Health Services Prior Authorization Department within three business days of the DOS to obtain prior authorization for DME and medical supplies.

If inadequate or incomplete information is provided or medical necessity is lacking, the provider will be asked to furnish any required or additional documentation so that a decision about the request can be made. Because the documentation must often be obtained from the client’s physician, providers have two weeks to submit the requested documentation. If the additional documentation is received within the two-week period, prior authorization can be considered for the original date of contact. If the additional documentation is received more than two weeks after the request for the documentation, prior authorization is not considered before the date on which the additional documentation is received. It is the DME supplier’s responsibility to contact the physician to obtain the requested additional documentation. The physician must maintain documentation of medical necessity in the client’s record.

TMHP Home Health Services toll-free number is 1-800-925-8957.

Refer to:  Subsection 2.2.2.2, “Prior Authorization” in this handbook for DME prior authorization information.

Subsection 2.3.1, “Medicaid Relationship to Medicare” in this handbook.

Client eligibility for Medicaid is for one month at a time. Providers should verify their client’s eligibility every month. Prior authorization does not guarantee payment.

2.2.2* Durable Medical Equipment (DME) and Supplies

Texas Medicaid defines DME as:

Medical equipment or appliances that are manufactured to withstand repeated use, ordered by a physician for use in the home, and required to correct or ameliorate a client’s disability, condition, or illness.

Since there is no single authority, such as a federal agency, that confers the official status of “DME” on any device or product, HHSC retains the right to make such determinations with regard to DME benefits of Texas Medicaid. DME benefits of Texas Medicaid must have either a well-established history of efficacy or, in the case of novel or unique equipment, valid, peer-reviewed evidence that the equipment corrects or ameliorates a covered medical condition or functional disability.

Requested DME may be a benefit when it meets the Medicaid definition of DME. The majority of DME and expendable supplies are covered home health services. If a service cannot be provided for a client who is 20 years of age or younger through home health services, these services may be covered through CCP if they are determined to be medically necessary.

To be reimbursed as a home health benefit:

The client must be eligible for home health benefits.

The criteria listed for the requested equipment or supply must be met.

The requested equipment or supply must be medically necessary, and Federal Financial Partici­pation (FFP) must be available.

The client’s health status would be compromised without the requested equipment or supply.

The requested equipment or supplies must be safe for use in the home.

The client must be seen by a physician within one year of the DOS.

The provider must sign and have the client sign DME Certification and Receipt Form on the TMHP website at www.tmhp.com for any purchased DME for Medicaid clients before submitting a claim for payment. The client’s signature means the DME is the property of the client. The certification form must include the date the client received the DME, the name of the item, and the printed names and signatures of the provider and the client or primary caregiver. This form must be maintained by the DME provider in the client’s record.

The signed and dated DME Certification and Receipt Form must be submitted to TMHP for claims and appeals for DME that meet or exceed a billed amount of $2,500.00. The form must also be submitted when multiple items that meet or exceed a total billed amount of $2,500.00 are billed for the same DOS. The form is required in addition to obtaining prior authorization, when applicable.

If the DME Certification and Receipt Form is not submitted to TMHP, the claim payment or appeal will be reviewed and will be eligible for recoupment. Incomplete forms will be returned to the provider for correction and resubmission.

TMHP will contact clients that received DME that meets or exceeds a billed amount of $2,500.00 to verify that services were rendered. If the delivery of the equipment cannot be verified by the client, the claim payment will be eligible for recoupment.

The provider must keep all Home Health Services (Title XIX) DME/Medical Supplies Physician Order Forms and Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Forms on file. Providers must retain delivery slips or corresponding invoices and the signed and dated DME Certification and Receipt Form documenting the item and date of delivery for all DME provided to a client and must disclose them to HHSC or its designee on request.

The DME must be used for medical or therapeutic purposes, and supplied through an enrolled DME provider in compliance with the client’s POC.

These records and claims must be retained for a minimum of five years from the DOS or until audit questions, appeals, hearings, investigations, or court cases are resolved. Use of these services is subject to retrospective review.

Note:All purchased equipment must be new upon delivery to client. Used equipment may be utilized for lease, but when purchased, must be replaced with new equipment.

HHSC/TMHP reserves the right to request the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form or Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form at any time.

DME must meet the following requirements to qualify for reimbursement under Home Health Services:

The client received the equipment as prescribed by the physician.

The equipment has been properly fitted to the client or meets the client’s needs.

The client, the parent or guardian of the client, or the primary caregiver of the client, has received training and instruction regarding the equipment’s proper use and maintenance.

DME must:

Be medically necessary due to illness or injury or to improve the functioning of a body part, as documented by the physician in the client’s POC or the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

Be prior authorized by the TMHP Home Health Services Prior Authorization Department for rental or purchase of most equipment. Some equipment does not require prior authorization. Prior autho­rization for equipment rental can be issued for up to six months based on diagnosis and medical necessity. If an extension is needed, requests can be made up to 60 days before the start of the new prior authorization period with a new Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

Meet the client’s existing medical and treatment needs.

Be considered safe for use in the home.

Be provided through an enrolled DME provider or supplier.

Note:Texas Health Steps (THSteps)-eligible clients who qualify for medically necessary services beyond the limits of this home health benefit will receive those services through CCP.

DME that has been delivered to the client’s home and then found to be inappropriate for the client’s condition will not be eligible for an upgrade within the first six months following purchase unless there has been a significant change in the client’s condition, as documented by the physician familiar with the client. All adjustments and modifications within the first six months after delivery are considered part of the purchase price.

All DME purchased for a client becomes the Medicaid client’s property upon receipt of the item. This property includes equipment delivered which will not be prior authorized or reimbursed in the following instances:

Equipment delivered to the client before the physician signature date on the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form or Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

Equipment delivered more than three business days before obtaining prior authorization from the TMHP Home Health Services Prior Authorization Department and meets the criteria for purchase.

Additional criteria:

A determination as to whether the equipment will be rented, purchased, replaced, repaired, or modified will be made by HHSC or its designee based on the client’s needs, duration of use, and age of the equipment.

Periodic rental payments are made only for the lesser of either the period of time the equipment is medically necessary, or when the total monthly rental payments equal the reasonable purchase cost for the equipment.

Purchase is justified when the estimated duration of need multiplied by the rental payments would exceed the reasonable purchase cost of the equipment or it is otherwise more practical to purchase the equipment.

If a DME/medical supply provider is unable to deliver a prior authorized piece of equipment or supply, the provider should allow the client the option of obtaining the equipment or supplies from another provider.

Items or services are reimbursed at the lesser of:

The provider’s billed charges

The published fee determined by HHSC

Manual pricing as determined by HHSC based on one of the following:

The manufacturer’s suggested retail price (MSRP) less 18 percent

The provider’s documented invoice cost

If an item is manually priced, providers must submit documentation of one of the following for consid­eration of purchase or rental with the appropriate procedure codes:

The MSRP or average wholesale price (AWP), whichever is applicable

The provider’s documented invoice cost

2.2.2.1Modifications, Adjustments, and Repairs

Modifications are the replacement of components because of changes in the client’s condition, not replacement because the component is no longer functioning as designed. All modifications and adjust­ments within the first six months after delivery are considered part of the purchase price.

Modifications to custom equipment may be prior authorized should a change occur in the client’s needs, capabilities, or physical and mental status which cannot be anticipated.

Documentation must include the following:

All projected changes in the client’s mobility needs

The date of purchase, and serial number of the current equipment

The cost of purchasing new equipment versus modifying the current equipment

All modifications within the first six months after delivery are considered part of the purchase price.

Adjustments do not require supplies. Adjustments made within the first six months after delivery will not be prior authorized. Adjustments made within the first six months after delivery are considered part of the purchase price. A maximum of one hour of labor for adjustments may be prior authorized as needed after the first six months following delivery.

Repairs to client-owned equipment may be prior authorized as needed with documentation of medical necessity. Technician fees are considered part of the cost of the repair. Repairs require the replacement of components that are no longer functional. Providers are responsible for maintaining documentation in the client’s medical record specifying the repairs and supporting medical necessity.

A DME repair will be considered based on the age of the item and cost to repair it.

A request for repair of DME must include an itemized estimated cost list from the vendor or DME provider of the repairs. Rental equipment may be provided to replace purchased medical equipment for the period of time it will take to make necessary repairs to purchased medical equipment.

Repairs will not be prior authorized in situations where the equipment has been abused or neglected by the client, client’s family, or caregiver. Routine maintenance of rental equipment is the provider’s responsibility. For clients requiring wheelchair repairs only, the date last seen by physician does not need to be filled in on the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

2.2.2.1.1Accessories

Equipment accessories including, but not limited to, pressure support cushions, may be prior authorized with documentation of medical necessity.

2.2.2.2Prior Authorization

Prior authorization is required for most DME and supplies provided through Home Health Services. These services include accessories, modifications, adjustments, and repairs for the equipment.

Providers must submit a completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form to the TMHP Home Health Services Prior Authorization Department.

Unless otherwise noted in this handbook, a completed Home Health Services (Title XIX) Durable Medical Equipment (DME) or Medical Supplies Physician Order Form prescribing the DME or supplies must be signed and dated by a physician and by the representative of the DME/Medical Supply provider familiar with the client before requesting prior authorization for all DME equipment and supplies. A current signature and date is valid for no more than 90 days prior to the date of the requested prior authorization or the initiation of service. The completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form must include the procedure codes and numerical quantities for services requested.

The completed, signed, and dated form must be maintained by the DME provider and the prescribing physician in the client’s medical record. The completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form with the original dated signature must be maintained by the prescribing physician.

To complete the prior authorization process by paper, the provider must fax or mail the completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form to the Home Health Services Prior Authorization Department and retain a copy of the signed and dated form in the client’s medical record at the provider’s place of business.

To complete the prior authorization process electronically, the provider must submit the prior authori­zation requirements through any approved electronic methods and retain a copy of the signed and dated Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form in the client’s medical record at the provider’s place of business.

Retrospective review may be performed to ensure that the documentation included in the client’s medical record supports the medical necessity of the requested services.

The date last seen by the physician must be within the past 12 months unless a physician waiver is obtained. The physician’s signature on the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form is only valid for 90 days before the initiation of services. The requesting provider may be asked for additional information to clarify or complete the request.

Providers must obtain prior authorization within three business days of providing the service by calling the TMHP Home Health Services Prior Authorization Department or faxing the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

To facilitate a determination of medical necessity and avoid unnecessary denials when requesting prior authorization, the physician must provide correct and complete information supporting the medical necessity of the equipment or supplies requested, including:

Accurate diagnostic information pertaining to the underlying diagnosis or condition as well as any other medical diagnoses or conditions, to include the client’s overall health status.

Diagnosis or condition causing the impairment resulting in a need for the equipment or supplies requested.

Purchased DME is anticipated to last a minimum of five years, unless otherwise noted, and may be considered for replacement when the time has passed or the equipment is no longer functional or repairable. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent reoccurrence must be submitted.

Prior authorization for equipment replacement is considered within five years of equipment purchase when one of the following occurs:

There has been a significant change in the client’s condition such that the current equipment no longer meets the client’s needs.

The equipment is no longer functional and either cannot be repaired or it is not cost-effective to repair.

Replacement of equipment is also considered when loss or irreparable damage has occurred. The following must be submitted with the prior authorization request:

A copy of the police or fire report, when appropriate

A statement about the measures to be taken in order to prevent reoccurrence

Payment may be prior authorized for repair of purchased DME. Maintenance of rental equipment (including repairs) is the supplier’s responsibility. The toll-free number for the TMHP Home Health Services Prior Authorization Department is 1-800-925-8957. Requests for repairs must include the cost estimate, reasons for repairs, age of equipment, and serial number.

2.2.3Medical Supplies

Medical supplies are benefits of the Home Health Services Program if they meet the following criteria:

Unless otherwise noted in this handbook, the representative of the DME/medical supply provider and a physician who is familiar with the client must sign and date a completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form that prescribes the DME or supplies before requesting prior authorization for the DME or supplies. A current signature and date is valid for no more than 90 days prior to the date of the requested prior authorization or the initiation of service. The completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form must include the procedure codes and numerical quantities for the services requested.

The provider must contact TMHP within three business days of providing the supplies to the client and obtain prior authorization, if required.

The requesting provider and ordering physician must keep all Home Health Services (Title XIX) DME/Medical Supplies Physician Order Forms and Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Forms on file. The physician must maintain the original signed and dated Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form in their records.

Providers must retain individual delivery slips or invoices for each DOS that documents the date of delivery for all supplies provided to a client and must disclose them to HHSC or its designee upon request. Documentation of delivery must include one of the following:

Delivery slip or corresponding invoice signed and dated by client or caregiver, or

A dated carrier tracking document with shipping date and delivery date must be printed from the carrier’s website as confirmation that the supplies were shipped and delivered. The dated carrier tracking document must be attached to the delivery slip or corresponding invoice.

The dated delivery slip or invoice must include the client’s full name, the address to which supplies were delivered, and an itemized list of goods that includes the descriptions and numerical quantities of the supplies delivered to the client and the corresponding tracking number from the carrier. This document could also include prices, shipping weights, shipping charges, or other descriptions.

All claims submitted for medical supplies must include the same quantities or units that are documented on the delivery slip or corresponding invoice and on the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. They must reflect the number of units by which each product is measured. For example, diapers are measured as individual units. If one package of 300 diapers is delivered, the delivery slip or corresponding invoice and the claim must reflect that 300 diapers were delivered and not that one package was delivered. Diaper wipes are measured as boxes or packages. If one box of 200 wipes is delivered, the delivery slip or invoice and the claim must reflect that one box was delivered and not that 200 individual wipes were delivered. There must be one dated delivery slip or invoice for each claim submitted for each client. All claims submitted for medical supplies must reflect the same date as the delivery slip or corresponding invoice and the same timeframe covered by the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. The DME Certification and Receipt Form is still required for all equipment delivered.

Note:These records and claims must be retained for a minimum of five years from the DOS or until audit questions, appeals, hearings, investigations, or court cases are resolved. Use of these services is subject to retrospective review.

The requesting provider or ordering physician must document medical supplies as medically necessary in the client’s POC or on a completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form and Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

HHSC/TMHP reserves the right to request the signed and dated Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form or Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form at any time.

Note:Client eligibility can change monthly. Providers are responsible for verifying eligibility before providing supplies.

The DOS is the date on which supplies are delivered to the client or shipped by a carrier to the client as evidenced by the dated tracking document attached to the invoice for that date. The provider must maintain the signed and dated records supporting documentation that an item was not billed before delivery. These records are subject to retrospective review.

Refer to:  Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form on the TMHP website at www.tmhp.com.

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instruc­tions on the TMHP website at www.tmhp.com.

Subsection 2.7, “Durable Medical Equipment (DME) Supplier (CCP)” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for specific information about certain DME and medical supplies.

Subsection 2.2.1.1, “Client Eligibility” in this handbook.

2.2.3.1Supply Procedure Codes

When submitting supplies on the CMS-1500 claim form, itemize the supplies, including quantities, and also provide the Healthcare Common Procedure Coding System (HCPCS) national procedure codes.

Refer to:  Subsection 6.3.3, “Procedure Coding” in “Section 6: Claims Filing” (Vol. 1, General Infor­mation) for more information about HCPCS procedure codes.

2.2.3.2Prior Authorization

TMHP must prior authorize most medical supplies. They must be used for medical or therapeutic purposes, and supplied through an enrolled DME provider in compliance with the client’s POC.

Some medical supplies may be obtained without prior authorization; however, the provider must retain a copy of the completed POC or Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form in the client’s file. Unless otherwise noted in this handbook, a completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form for medical supplies not requiring prior authorization may be valid for a maximum of six months, unless the physician indicates the duration of need is less. If the physician indicates the duration of need is less than six months, then a new Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form is required at the end of the determined duration of need.

For a list of DME/medical supplies that do not require prior authorization, providers can refer to subsection 2.2.29, “Procedure Codes That Do Not Require Prior Authorization” in this handbook.

Clients with ongoing needs may receive up to six months of prior authorizations for some expendable medical supplies under Home Health Services when requested on a Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. Providers may deliver medical supplies as ordered on a Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form for up to six months from the date of the physician’s signature. In these instances, a review of the supplies requested by the physician familiar with the client’s condition, and a new Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form is required for each new prior authorization request. Requests for prior authorization can be made up to 60 days before the start of the new prior authori­zation period. Professional Home Health Services prior authorization requests require a review by the physician familiar with the client’s condition and a physician signature every 60 days when requested on a POC.

Note:These records and claims must be retained for a minimum of five years from the DOS or until audit questions, appeals, hearings, investigations, or court cases are resolved. Use of these services is subject to retrospective review.

2.2.3.3Cancelling a Prior Authorization

The client has the right to choose his DME/medical supply provider and change providers. If the client changes providers, TMHP must receive a change of provider letter with a new Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. The client must sign and date the letter, which must include the name of the previous provider and the effective date for the change. The client is responsible for notifying the original provider of the change and the effective date. Prior authorization for the new provider can only be issued up to three business days before the date TMHP receives the change of provider letter and the new Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

2.2.4Augmentative Communication Device (ACD) System

An ACD system, also known as an augmentative and alternative communication (AAC) device system, allows a client with an expressive speech language disorder to electronically represent vocabulary and express thoughts or ideas in order to meet the client’s functional speech needs.

Digitized speech devices and synthesized speech devices are benefits of Texas Medicaid Title XIX Home Health Services.

A digitized speech device, sometimes referred to as a “whole message” speech output device, uses words or phrases that have been recorded by someone other than the ACD system user for playback upon command by the ACD system user.

Providers must use procedure codes E2500, E2502, E2504, and E2506 when billing for a digitized speech device.

A synthesized speech device uses technology that translates a user’s input into device-generated speech using algorithms representing linguistic rules. Users of synthesized speech ACD systems are not limited to prerecorded messages, but can independently create messages as their communication needs dictate. Some synthesized speech devices require the user to make physical contact with a keyboard, touch screen, or other display containing letters.

Providers must use procedure code E2508 when billing for a synthesized speech device.

Other synthesized devices allow for multiple methods of message formulation and multiple methods of device access. Multiple methods of message formulation must include message selection by two or more of the following methods:

Letters

Words

Pictures

Symbols

Multiple methods of access must include the capability to access the device by direct physical contact with a keyboard or touch screen and one or more of the following indirect selection techniques:

Joystick/switches

Head mouse

Optical head pointer

Light pointer

Infrared pointer

Scanning device

Morse code

Note:ACD systems that do not meet the criteria through Title XIX Home Health Services may be considered for clients who are birth through 20 years of age under CCP.

Providers must use procedure code E2510 when billing for other synthesized speech devices.

Items included in the reimbursement for an ACD system and not reimbursed separately include, but are not limited to, the following:

ACD

Basic, essential software (except for software purchased specifically to enable a client-owned computer or personal digital assistant [PDA] to function as an ACD system)

Batteries

Battery charger

Power supplies

Interface cables

Interconnects

Sensors

Moisture guard

Alternating current (A/C) or other adapters

Adequate memory to allow for system expansion within a three-year timeframe

Access device, when necessary

Mounting device, when necessary

All basic operational training necessary to instruct the client and family/caregivers in the use of the ACD system

Manufacturer’s warranty

2.2.4.1ACD System Accessories

Accessories are a benefit of Texas Medicaid if the criteria for ACD system prior authorization are met and the medical necessity for each accessory is clearly documented in the speech language pathologist (SLP) evaluation.

All accessories necessary for proper use of an ACD system, including those necessary for the potential growth and expansion of the ACD system (such as a memory card), must be included in the initial prescription/Title XIX form. The following accessories for an ACD system may be covered:

Access devices for an ACD system include, but are not limited to, devices that enable selection of letters, words, or symbols by direct or indirect selection techniques such as optical head pointers, joysticks, and ACD scanning devices.

Gross motor access devices, such as switches and buttons, may be considered for clients with poor fine motor and head control.

Fine motor, head control access devices, such as laser or infrared pointers, may be considered for clients with poor hand control and good head control.

Mounting systems are devices necessary to place the ACD system, switches and other access devices within the reach of the client. Mounting devices may be considered for reimbursement when used to attach an ACD system or access device to a wheelchair or table.

A request for prior authorization of a wheelchair mounting device must include the manufacturer name, model, and purchase date of the wheelchair. One additional mounting device, separate from the one included in the system, may be considered for prior authorization for the same client.

Providers must use procedure codes E2512 and E2599 when billing for ACD system accessories.

2.2.4.1.1Carrying Case

Carrying cases may be considered for separate reimbursement with supporting documentation of medical necessity.

Providers must use procedure code E2599 and modifier U1 when billing for the carrying case. Carrying cases are limited to one every three years.

Carrying cases may be considered for prior authorization. The prior authorization request must include the make, model, and purchase date of the ACD system.

2.2.4.1.2Nonwarranty Repairs

Nonwarranty repairs of an ACD system may be considered for prior authorization using procedure code V5336 with documentation from the manufacturer explaining why the repair is not covered by the warranty.

2.2.4.1.3Trial Period

In order to ensure the client’s needs are met in the most cost effective manner and to ascertain the most appropriate system and access device for the client, the ACD system is prior authorized for purchase only after the client has completed a three-month trial period that includes experience with the requested system.

The ACD system for the trial period may be obtained through the rental, the school setting, or another setting determined by the licensed SLP.

In the situation where an ACD system is not available for rental and the client has recent documented experience with the requested ACD system, purchase can be considered.

A trial period is not required when replacing an existing ACD system, unless the client’s needs have changed and another ACD system or access device is being considered.

2.2.4.1.4Rental

Prior authorization may be provided for rental during this trial period. All components necessary for use of the device, such as access devices, mounting devices, and lap trays, must be evaluated during this trial period.

2.2.4.1.5Purchase

Purchase of an ACD system may be considered for prior authorization when all of the following ACD system criteria are met:

The evaluation/re-evaluation includes documentation that the client has had sufficient experience with the requested ACD system through trial, rental, school, or another setting. When the SLP has confirmed the appropriateness of a specific device for the client, the trial/rental period may be cancelled.

A Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form listing the prescribed ACD system, access device, and accessories (such as a mounting device) must be completed, signed by the physician, and dated.

ACD systems, equipment, and accessories that have been purchased are anticipated to last a minimum of three years.

2.2.4.1.6Replacement

Prior authorization for replacement may be considered within three years of purchase when one of the following occurs:

There has been a significant change in the client’s condition such that the current device no longer meets his or her communication needs.

The ACD system is no longer functional and either cannot be repaired or it is not cost effective to repair.

Three years have passed and the equipment is no longer repairable.

Note:Replacements for clients who are birth through 20 years of age that do not meet the criteria above may be considered through CCP.

2.2.4.1.7Software

Computer software that enables a client’s computer or PDA to function as an ACD system may be covered as an ACD system. Providers must use procedure code E2511 when billing for a speech gener­ating software. Requests for ACD software may be considered for prior authorization if the software is more cost effective than an ACD system.

If an ACD system is more cost effective than adapting the client’s computer or PDA, an ACD system may be prior authorized instead of the ACD software.

Laptop or desktop computers, PDAs, or other devices that are not dedicated ACD systems are not a benefit of Texas Medicaid, because they do not meet the definition of DME.

2.2.4.2Non-Covered ACD System Items

Noncovered items that are not necessary to operate the system and are unrelated to the ACD system or software components are not benefits of Texas Medicaid. These items include, but are not limited to:

Printer

Wireless Internet access devices

2.2.4.3Prior Authorization

Prior authorization is required for ACD systems provided through Home Health Services. The prior authorization also includes all related accessories and supplies. The physician must provide information supporting the medical necessity of the equipment or supplies requested, including:

Accurate diagnostic information pertaining to the underlying diagnosis or condition and any other medical diagnoses or conditions, including the client’s overall physical and cognitive limitations.

Diagnosis or condition causing the impairment of speech.

Prior authorization for an ACD system and accessories (rental or purchase) must be requested using the following information:

Medical diagnosis and how it relates to the client’s communication needs.

Any significant medical information pertinent to ACD system use.

Limitations of the client’s current communication abilities, systems, and devices.

Statement as to why the prescribed ACD system is the most effective, including a comparison of benefits using other alternatives.

Complete description of the ACD system with all accessories, components, mounting devices, or modifications necessary for client use (must include manufacturer’s name, model number, and retail price).

Documentation that the client is mentally, emotionally, and physically capable of operating the device.

An evaluation and assessment must be conducted by a licensed SLP in conjunction with other disci­plines, such as physical or occupational therapies. The prescribing physician must base the prescription on the professional evaluation and assessment.

The prior authorization request must include the specifications for the ACD system, all component accessories necessary for the proper use of the ACD, and all necessary therapies or training. It is recom­mended that the preliminary evaluation for an ACD system include the involvement of an occupational therapist or physical therapist to address the client’s seating/postural needs and the motor skills required to utilize the ACD system.

The prescribing physician familiar with the client must review the SLP evaluation of the client’s cognitive and language abilities and base the prescription and treatment plan on the SLP’s recommendations.

An evaluation and assessment by a licensed SLP must be signed and dated before the date on the physician’s prescription or the Title XIX form and include the following information:

Documentation of medical necessity for an ACD system, including a formal written evaluation performed by a licensed SLP.

Medical status or condition and medical diagnoses underlying the client’s expressive speech-language disorder that justifies the need for an ACD system.

Current expressive speech-language disorder, including the type, severity, anticipated course, and present language skills.

Description of the practical limitations of the client’s current aided and unaided modes of communication.

Other forms of therapy or intervention that have been considered and ruled out.

Rationale for the recommended ACD system and each accessory, including a statement as to why the recommended device is the most appropriate and least costly alternative for the client and how the recommended system will benefit the client.

Documentation that the client possesses the cognitive and physical abilities to use the recommended system.

Comprehensive description of how the ACD system will be integrated into the client’s everyday life, including home, school, or work.

Treatment plan that includes training in the basic operation of the recommended ACD system necessary to ensure optimal use by the client (if appropriate, the client’s caregiver) and a therapy schedule for the client to gain proficiency in using the ACD system.

Description of the client’s speech-language goals and how the recommended ACD system will assist the client in achieving these goals.

Description of the anticipated changes, modifications, or upgrades with projected time frames of the ACD system necessary to meet the client’s short- and long-term speech-language needs.

Identification of the assistance or support needed by, and available to, the client to use and maintain the ACD system.

Statement that the licensed SLP is financially independent of the ACD system manufacturer/vendor.

Speech- and language- skills assessment that includes the prognosis for speech or written communication.

Interactional/behavioral and social abilities.

Capabilities, including intellectual, postural, sensory (visual and auditory), and physical status.

Motivation to communicate.

Residential, vocational, and educational setting.

Alternative ACD system considered with comparison of capabilities.

Ability to meet projected communication needs, growth potential, and length of time it will meet the client’s needs.

2.2.5Bath and Bathroom Equipment

Bath and bathroom equipment is DME that is included in a treatment protocol, serves as a therapeutic agent for life and health maintenance, and is required to treat an identified medical condition. Bath and bathroom equipment may be considered for reimbursement for those clients who have physical limita­tions that do not allow for bathing, showering, or bathroom use without assistive equipment.

Bath seats are not considered for clients who are younger than one year of age or weighing less than 30 pounds.

Rental of equipment includes all necessary supplies, adjustments, repairs, and replacement parts.

2.2.5.1Hand-Held Shower Wand

A hand-held shower wand with attachments may be considered for prior authorization only if the client currently owns or meets the criteria for a bath or shower chair, tub stool or bench, or tub transfer bench. Prior authorization of a hand-held shower wand includes all attachments and accessories. Providers must use procedure code E1399 when billing for a hand-held shower wand. Hand-held shower wands with attachments are limited to one every five years.

2.2.5.2Bath Equipment

2.2.5.2.1Bath or Shower Chairs, Tub Stool or Bench, Tub Transfer Bench

A bath or shower chair is a stationary or mobile seat with or without upper body or head support used to support a client who is unable to stand or sit independently in the shower or tub.

Bath/shower chairs are grouped into three levels of design to assist the client based on their physical condition and mobility status:

Level 1- standard bath or shower chair is defined as stationary equipment.

Level 2 - intermediate bath or shower chair is defined as mobile equipment with or without a commode cut out.

Level 3 - complex bath or shower chair is defined as custom equipment (either stationary or mobile) with or without a commode cut out.

A tub stool or bench is a stationary seat or bench used to support a client who is unable to stand or sit independently in the shower or tub.

A tub transfer bench is a stationary bench that sits in the tub and extends outside the tub. It is used to support a client who is unable to stand or sit independently in the shower or tub and allows the client to scoot or slide over the side of the tub.

Bath or shower chairs, tub stools or benches, and tub transfers are limited to one every five years.

A custom bath or shower chair may be considered for prior authorization only if the client does not also have any type of commode chair.

Level 1 Group

A Level 1 device may be considered if the client:

Is either unable to stand independently or is unstable while standing, or

Is unable to independently enter or exit the shower or tub due to limited functional use of the upper or lower extremities, and

Maintains the ability to ambulate short distances (with or without assistive device), or

Has a condition that is defined as a short-term disability without a concomitant long-term disability (including, but not limited to postoperative status).

Providers must use procedure code E0240 without a modifier when billing for Level 1 group bath or shower chairs.

Level 2 Group

A Level 2 device may be considered if the client:

Has good upper body stability, and

Has impaired functional ambulation, including, but not limited to, lower body paralysis, osteoar­thritis, or

Is nonambulatory.

The client must have a shower that is adapted for rolling equipment; ramps will not be prior authorized for access to showers.

Providers must use procedure code E0240 and modifier TF (Intermediate Level) when billing for Level 2 group bath or shower chairs.

Level 3 Group

A Level 3 device may be considered if the client requires:

Trunk or head or neck support, or

Positioning to accommodate conditions, including, but not limited to, spasticity, or frequent and uncontrolled seizures.

Providers must use procedure code E0240 and modifier TG (Complex/high Level) when billing for Level 3 group bath/shower chairs.

A bath or shower chair may be prior authorized for clients who meet the Level 1, 2, or 3 criteria. A Level 3 custom bath or shower chair may be prior authorized only if the client does not also have any type of commode chair. A Level 3 mobile bath or shower chair may be considered for clients who have a shower that is adapted for rolling equipment; ramps will not be prior authorized for access to showers.

A tub stool or bench may be prior authorized for clients who meet the Level 1 criteria. Providers must use procedure code E0245 when billing for a tub stool or bench.

A tub transfer bench may be considered for clients who meet the Level 1 or 2 criteria. Providers must use procedure code E0247 when billing for a tub transfer bench.

A heavy duty tub transfer bench may be considered for clients who meet the Level 1 or 2 criteria and who weigh more than 200 pounds. Providers must use procedure code E0248 when billing for a heavy duty tub transfer bench.

2.2.5.3Bathroom Equipment

2.2.5.3.1Non-fixed Toilet Rail, Bathtub Rail Attachment, and Raised Toilet Seat

Nonfixed toilet rails are limited to two every five years. A bathtub rail is limited to one every five years.

Raised toilet seats are limited to one every five years. Nonfixed toilet rails and bathtub rail attachments may be considered for prior authorization for a client who has decreased functional mobility and is unable to safely self-toilet or self-bathe without assistive equipment. Raised toilet seats do not require prior authorization. Providers must use procedure code E0243 when billing for non-fixed toilet rails, procedure code E0244 when billing for raised toilet seats, and procedure code E0246 when billing for bathtub rails.

2.2.5.3.2Toilet Seat Lifts

A toilet seat lift mechanism is designed for the top of the toilet to assist lifting the body from a sitting position to a standing position.

A toilet seat lift mechanism must be prior authorized. To qualify for prior authorization, clients must meet all the following criteria:

The client must have severe arthritis of the hip or knee or have a severe neuromuscular disease.

The toilet seat lift mechanism must be a part of the physician’s course of treatment and be prescribed to correct or ameliorate the client’s condition.

Once standing, the client must have the ability to ambulate.

The client must be completely incapable of standing up from a regular armchair or any chair in the client’s home.

The client’s difficulty or incapability of getting up from a chair is not sufficient justification for a toilet seat lift mechanism. Almost all clients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.

Prior authorization will be given for either mechanical or powered toilet assist devices, not for both. If a client already owns one or more mechanical toilet-assist devices, a powered toilet seat lift mechanism will not be prior authorized unless there has been a documented change in the client’s condition such that the client can no longer use the mechanical equipment.

Toilet seat lift mechanisms are limited to those types that operate smoothly, can be controlled by the client, and effectively assist a client in standing up and sitting down without other assistance. A toilet seat lift operated by a spring release mechanism with a sudden, catapult-like motion that jolts the client from a seated to a standing position is not a benefit of Texas Medicaid.

Providers must use procedure code E0172 when billing for a toilet seat lift mechanism. A toilet seat lift mechanism is limited to one purchase very five years.

2.2.5.3.3Commode Chairs and Foot Rests

Commode chairs, foot rests, and replacement commode pails or pans may be considered as benefits, depending on the client’s level of need. The client must meet the criteria for the level of commode chair or foot rest requested.

A commode chair with or without a foot rest may be considered a benefit for the client who also has a stationary bath chair without a commode cutout.

Documentation must support medical necessity for a customized commode chair or the addition of attachments to a standard commode chair.

Level 1: Stationary Commode Chair

A Level 1 commode chair is defined as a stationary commode chair with fixed or removable attachments to support the arms.

A stationary commode chair with fixed or removable arms may be considered for prior authorization when the client has a medical condition that results in an inability to ambulate to the bathroom safely (with or without mobility aids).

Providers must use procedure code E0163 or E0165 when billing for a stationary and mobile commode chair.

Level 2: Mobile Commode Chair

A Level 2 commode chair is defined as a mobile commode chair with fixed or removable attachments to support the arms.

A mobile commode chair with fixed or removable arms may be considered for prior authorization when the following criteria are met:

In addition to meeting the criteria for a Level 1 commode chair, the client must be on a bowel program and require a combination commode or bath chair for performing the bowel program and bathing after.

A mobile commode chair will be considered for reimbursement with prior authorization only if the client does not also have any type of bath chair. If the client meets the criteria for a stationary bath chair, prior authorization of a stationary chair may be considered.

Level 3: Custom Commode Chair

A Level 3 commode chair is defined as a custom commode chair with all of the following characteristics:

Is stationary or mobile

Has fixed or removable attachments to support the arms, head, neck, or trunk.

A custom stationary or mobile commode chair with fixed or removable arms and head, neck, and/or trunk support attachments may be considered for prior authorization when the following criteria are met:

In addition to meeting the criteria for a Level 1 or 2 commode chair, the client must have a medical condition that results in an inability to support their head, neck, or trunk without assistance.

A mobile custom commode chair may be considered for reimbursement only if the client does not also have any type of bath chair.

Providers must use procedure code E0163 or E0165 with modifier TG when billing for a custom stationary or mobile commode chair.

Extra-wide and Heavy-Duty Commode Chair

An extra-wide, heavy-duty commode chair is defined as one with a width greater than or equal to 23 inches, and capable of supporting a client who weighs 300 pounds or more.

An extra-wide or heavy-duty commode chair may be considered for prior authorization when the client meets the criteria for a Level 1, 2, or 3 commode chair and weigh 300 pounds or more.

Providers must use procedure code E0168 and the appropriate modifiers when billing for an extra-wide or heavy-duty commode chair. Use modifier TF when billing for a mobile extra-wide, heavy-duty commode chair. Use modifier TG when billing for a custom extra-wide, heavy-duty commode chair.

Commode Chair With Integrated Seat Lift

A commode chair with integrated seat lift is designed to assist lifting the body from a sitting position to a standing position.

A commode chair with integrated seat lift mechanism for top of the commode must be prior authorized for clients who meet all the following criteria:

The client must have severe arthritis of the hip or knee or have a severe neuromuscular disease.

The client must be completely incapable of standing up from a regular toilet, commode, or any chair in their home.

The commode chair with integrated seat lift must be a part of the physician’s course of treatment and be prescribed to correct or ameliorate the client’s condition.

Once standing, the client must have the ability to ambulate independently for a short distance of no more than ten feet.

Note:The fact that a client has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all clients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.

Providers must use procedure code E0170 or E0171 when billing for a commode chair with integrated seat lift. The purchase of a commode chair with integrated seat lift is limited to one every five years.

Replacement Commode Pail or Pan

Replacement commode pails or pans are a benefit through Title XIX Home Health Services and are limited to one per year. Additional quantities may be considered for prior authorization with documen­tation of medical necessity.

Providers must use procedure code E0167 when billing for a commode pail or pan.

Foot Rest

A foot rest is used to support feet during use of the commode chair.

A foot rest may be considered for prior authorization if the client meets the criteria for a Level 1, 2, or 3 commode chair and the foot rest is necessary to support contractures of the lower extremities of clients who are paraplegic or quadriplegic.

Providers must use procedure code E0175 when billing for a foot rest.

2.2.5.3.4Portable Sitz Bath

Portable sitz baths that fit over commode seats are limited to two per year for clients requiring any of the following:

Cleaning, irrigation, or pain relief of a perianal wound.

Relief of pain associated with the pelvic area (hemorrhoids, bladder, vaginal infections, prostate infections, herpes, testicle disorders).

Muscle toning for bowel and bladder incontinence.

Providers must use procedure codes E0160 or E0161 when billing for portable sitz baths.

2.2.5.3.5Bath Lifts

The purchase of a bath lift is limited to one every five years. The rental of a bath lift is limited to one per month.

The two types of bath lifts that are considered for reimbursement include:

An outside the tub bath lift which is a portable transfer system used to move a nonambulatory client a short distance from bed or chair to bath and is designed to accommodate the smaller space. This type of lift is either hydraulic or electric and consists of a base with wheels or casters and a sling which can transfer the client in and out of the bath.

An inside the tub bath lift is a portable transfer system used to lower and raise a nonambulatory client into and out of the bath tub. This type of lift is either hydraulic or electric and consists of a base which adheres to the tub surface using suction cups and a seat that will lower and raise the client into and out of the tub.

Providers must use procedure code E0625 with the appropriate modifier (U1, U2, or U3) if necessary when billing for a bath lift.

The bath lift must be free standing, it cannot be attached to the floor, walls, or ceiling. Home adaptation for use of medical equipment is not a benefit of Home Health Services.

A hydraulic bath lift is for a client who is unable to assist in their own transfers and is operated by the weight or pressure of a liquid.

An electric bath lift is operated by electricity and may be considered when a hydraulic lift will not meet the client’s needs.

A bath lift is not a benefit for the convenience of a caregiver.

There are four levels of bath lifts:

Level 1 - an outside the tub bath lift (hydraulic or electric) and must accommodate a client weighing up to 300 pounds. Providers must use procedure code E0625 when billing for the purchase of a Level 1 bath lift.

Level 2 - an in-tub bath lift (hydraulic or electric) and must accommodate a client weighing up to 300 pounds. Providers must use procedure code E0625 and the U1 modifier when billing for the purchase of a Level 2 bath lift.

Level 3 - a bariatric lift (hydraulic or electric, out of tub type) designed to lift a client weighing greater than 300 pounds. Providers must use procedure code E0625 and the U2 modifier when billing for the purchase of a Level 3 bath lift.

Level 4 - a bariatric lift (hydraulic or electric, in tub type) designed to lift a client weighing greater than 300 pounds. Providers must use procedure code E0625 and the U3 modifier when billing for the purchase of a Level 4 bath lift.

A bath lift may be considered for prior authorization if the client:

Has an inability to transfer to the bathtub or shower independently using assistive devices (including, but not limited to, a cane, walker, bathtub rails).

Requires maximum assistance by the caregiver to transfer to the bathtub or shower.

Has bathroom and tub or shower that meets the manufacturer’s recommended depth, width, and height for safe bath lift installation and operation.

Providers must use procedure code E0621 when billing for a lift sling. The purchase of a lift sling is limited to one every five years.

The following are payable procedure codes for bath and bathroom equipment:

Procedure Code

Maximum Limitation

E0160

2 per year

E0161

2 per year

E0163

1 every 5 years

E0165

1 every 5 years

E0167

1 per year

E0168

1 every 5 years

E0170

1 every 5 years

E0171

1 every 5 years

E0172

1 every 5 years

E0175

1 every 5 years

E0240

1 every 5 years

E0243

2 every 5 years

E0244

1 every 5 years

E0245

1 every 5 years

E0246

1 every 5 years

E0247

1 every 5 years

E0248

1 every 5 years

E0621

1 per 5 years

E0625

1 purchase every 5 years; 1-month rental

E0630

1 purchase every 5 years; 1-month rental

E1399

1 every 5 years

2.2.5.4Prior Authorization

Except as otherwise indicated in this section, prior authorization is required for all bath and bathroom equipment and related supplies, including any accessories, modifications, adjustments, replacements and repairs to the equipment.

Bathroom and toilet lift rentals may be prior authorized during the period of repair up to a maximum of four months per lifetime per client.

Prior authorization will not be considered for modifications, adjustments, or repairs to bath or bathroom equipment delivered to a client’s home and then found to be inappropriate for the client’s condition within the first six months after delivery. This applies unless there is a significant change in the client’s condition that is documented by a physician familiar with the client.

2.2.5.5Documentation Requirements

2.2.5.5.1Bath and Bathroom Equipment

To request prior authorization for all bath or bathroom equipment, the following documentation must be provided:

Accurate diagnostic information pertaining to the underlying diagnosis or condition, including the client’s overall health status, any other medical needs, developmental level, and functional mobility skills and why regular bath or bathroom equipment will not meet the client’s needs.

The age, height, and weight of the client.

Assessment of the client’s home to ensure the requested equipment can be safely accommodated.

Anticipated changes in the client’s needs, including anticipated modifications or accessory needs and the growth potential of any custom shower and bath equipment.

2.2.5.5.2Toilet Seat Lifts

In addition to the above documentation, the submitted documentation for a toilet seat lift must include an assessment completed by a physician, physical therapist, or occupational therapist that includes all of the following:

A description of the client’s current level of function without the device

An explanation why a nonmechanical toilet elevation device, such as toilet rails or elevated toilet seat, will not meet the client’s needs

Documentation that identifies how the toilet seat lift mechanism will improve the client’s function

A list of the mobility related activities of daily living (MRADLs) the client will be able to perform with the toilet seat lift mechanism that the client is unable to perform without the toilet seat lift mechanism and how the device will increase the client’s independence

The client’s goals for use of the toilet seat lift mechanism

Supporting documentation must be kept in the client’s record that all appropriate therapeutic modalities (e.g., medication or physical therapy) have been tried and that they failed to enable the client to transfer from a chair to a standing position.

2.2.6Blood Pressure Devices (Manual and Automated)

Blood pressure devices are benefits in the home setting for self-monitoring when:

The devices are medically necessary and appropriate.

The devices are prescribed by a physician.

A manual blood pressure device requires manual cuff inflation with real-time visualization of the results displayed on the manometer and does not require prior authorization for purchase when provided for one of the diagnosis codes listed in the table below. Providers must use procedure code A4660 when billing for a manual blood pressure device.

An automated blood pressure device inflates the cuff manually or automatically, displays the blood pressure results on a small screen, and does not require prior authorization for purchase when provided for one of the diagnosis codes listed in the table below. Providers must use procedure code A4670 when billing for an automated blood pressure device.

Repair of equipment may be considered with documentation of why the equipment needs repair. Providers must use procedure code A4660 when billing for the replacement of other components or repair of equipment.

Finger cuff automated blood pressure devices and ambulatory blood pressure devices for diagnostic purposes are not a benefit of Texas Medicaid.

2.2.6.1Prior Authorization

Procedure codes A4660 and A4670 do not require prior authorization if they are billed with one of the following diagnosis codes:

Diagnosis Codes

I10

I110

I119

I120

I129

I130

I1310

I1311

I132

I150

I151

I152

I158

I159

I160

I161

I169

I219

I21A1

I21A9

I2601

I2602

I2609

I2690

I2692

I2699

I270

I271

I2720

I2721

I2722

I2723

I2724

I2729

I2781

I2782

I2783

I2789

I279

I340

I341

I342

I348

I349

I350

I351

I352

I358

I359

I360

I361

I362

I368

I369

I370

I371

I372

I378

I379

I421

I422

I424

I425

I428

I429

I43

I440

I441

I442

I4430

I4439

I444

I445

I4460

I4469

I447

I450

I4510

I4519

I452

I453

I454

I455

I456

I4581

I4589

I459

I471

I472

I479

I480

I481

I482

I483

I484

I4891

I4892

I495

I501

I5020

I5021

I5022

I5023

I5030

I5031

I5032

I5033

I5040

I5041

I5042

I5043

I50810

I50811

I50812

I50813

I50814

I5082

I5083

I5084

I5089

I509

I950

I951

I952

I953

I9581

I9589

I959

N010

N011

N012

N013

N014

N015

N016

N017

N018

N050

N051

N052

N053

N054

N055

N056

N057

N058

N059

N08

N130

N1330

N1339

N13721

N13722

N13729

N13731

N13732

N13739

N170

N171

N172

N178

N179

N181

N182

N183

N184

N185

N186

N189

N250

N2589

Q200

Q201

Q202

Q203

Q204

Q205

Q208

Q210

Q211

Q212

Q213

R001

T800XXA

T81718A

T8172XA

T82817A

T82818A

T82855A

T82855D

T82855S

T82856A

T82856D

T82856S

Manual and automated blood pressure devices should last at least one year and may be considered for replacement after one year has passed. If it is medically necessary to replace nonfunctional and irrepa­rable equipment before one year has passed, providers can submit prior authorization requests with documentation of medical necessity that explains the need for the replacement.

Prior authorization is required in the following situations:

Another blood pressure device is medically necessary within the same year. Replacement of equipment within the same year as the purchase requires prior authorization. If equipment must be replaced before the end of the anticipated lifespan, the provider must submit a copy of the police or fire report, when appropriate, and the measures that will be taken to prevent reoccurrence.

The diagnosis code is not in the table above. If the diagnosis code is not one of those listed in the table above, providers must submit a request for the prior authorization of the initial or replacement device and must include all of the documentation necessary to support the medical necessity of the blood pressure device.

2.2.6.2Hospital-Grade Blood Pressure Devices

Hospital-grade blood pressure devices and their components are benefits of CCP in the home setting for self-monitoring when the equipment is prescribed by a physician. A hospital-grade blood pressure device includes memory for continuous recording, has an alarm system to notify the caregiver of abnormal readings, and is capable of frequent or continuous automatic blood pressure and heart rate monitoring with correction of motion artifact.

Documentation that supports medical necessity of the requested equipment, including the diagnosis, must be maintained in the client's medical record and is subject to retrospective review.

Refer to:  Section 9.2.25.1, “Ambulatory Blood Pressure Monitoring” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for information about ambulatory blood pressure devices.

Providers must use procedure code A9279 with modifier U1 when billing for hospital-grade blood pressure devices.

Hospital-grade blood pressure devices that have been purchased are anticipated to last a minimum of three years and may be considered for replacement when three years have passed or when the equipment is not functional and not repairable.

For clients who are birth through 11 months of age, the rental or purchase of a hospital-grade blood pressure device is a benefit when documentation supports medical necessity and includes an explanation of why the client cannot use a standard automated blood pressure device.

For clients who are 12 months of age and older, the rental or purchase of a hospital-grade blood pressure device is a benefit on a case-by-case basis. Supporting documentation of medical necessity must be provided.

The following indications are recognized by Texas Medicaid for hospital-grade blood pressure devices:

Hypotension

Essential hypertension

Hypertensive heart disease

Hypertensive renal disease

Acute pulmonary heart disease

Chronic pulmonary heart disease

Cardiomyopathy

Conduction disorders

Cardiac dysrhythmias

Heart failure

Acute kidney failure

Chronic kidney disease

Hydronephrosis

Vesicoureteral reflux with neuropathy

Bulbus cordis anomalies and anomalies of cardiac septal closure

All rental costs of the hospital-grade blood pressure device apply toward the purchase price.

2.2.6.3Components, Replacements, and Repairs

The following may be considered for reimbursement of blood pressure device replacement and repairs with prior authorization:

Replacement of blood pressure cuffs (procedure code A4663)

Replacement of other components (procedure code A4660)

Repairs of the equipment (procedure code A4660)

2.2.6.4Prior Authorization

Prior authorization is required for the rental or purchase of a hospital-grade blood pressure device. A determination will be made by HHSC or its designee as to whether the equipment will be rented, purchased, repaired, or modified based on the client's needs, duration of use, and age of the equipment. Repairs and modifications can only be performed on purchased equipment.

Documentation of medical necessity for the hospital-grade blood pressure device must support the client's need for self-monitoring and address why an automated blood pressure device will not meet the client's needs. The documentation must include:

All pertinent diagnoses.

Initial evaluation.

Symptoms.

Duration of symptoms.

Any recent hospitalizations (within past 12 months).

Comorbid conditions.

How frequent or continuous self-monitoring will affect treatment.

All pertinent laboratory and radiology results.

Client's weight.

A family or caregiver(s) who has an understanding of cause and effect and object permanence and who has agreed to accept the responsibility to be trained to use the hospital-grade monitor.

Prior authorization may be granted for a six-month rental period when the request is submitted with documentation of medical necessity supporting the client's need for self-monitoring and addressing why an automated blood pressure device will not meet the client's needs.

Recertification for an additional six-month period may be considered when the physician provides current documentation that supports the ongoing medical necessity for self-monitoring and confirms the client or family is compliant with its use.

A hospital-grade blood pressure device will not be considered for prior authorization of purchase until the client has completed a six-month trial period.

Purchase of a hospital-grade blood pressure device may be prior authorized when all of the following criteria are met:

The client is 12 months of age or older.

Documentation of medical necessity supports the client's need for ongoing self-monitoring and addresses why an automated blood pressure device will not meet the client's needs.

2.2.6.4.1Components, Replacements, and Repairs

Replacement of blood pressure cuffs and other components may be considered for purchase with prior authorization and documentation of medical necessity that explains the need for the replacement.

Repair of equipment must be prior authorized when irreparable damage has occurred and documen­tation exists that supports the need for repair. Repair of equipment will be considered after the factory warranty has expired.

2.2.7Bone Growth Stimulators

Internal and external bone growth (osteogenic) stimulators are a benefit of Texas Medicaid. Bone growth stimulators are a benefit for skeletally-mature individuals only.

Electromagnetic bone growth stimulators promote healthy bone growth and repair by low intensity electrical stimulation. Electrical stimulation is provided by implanting low-voltage electrodes within the tissue surrounding the bone (internal) or by external placement of a device that transmits low-voltage currents through the soft tissue to the bone (external).

Ultrasonic bone growth stimulators promote healthy bone growth and repair through low-intensity, pulsed ultrasound waves.

A noninvasive electrical bone growth stimulator (procedure codes E0747 and E0748) and noninvasive ultrasound bone growth stimulator (procedure code E0760) are benefits of Texas Medicaid for DME providers when provided in the home setting. An invasive electrical bone growth stimulator (procedure code E0749) is a benefit of Texas Medicaid for freestanding and hospital-based ambulatory surgical centers when provided in the outpatient setting.

Electrical and ultrasonic bone growth stimulator devices for the treatment of orthopedic and neurosur­gical conditions are a benefit for Texas Medicaid clients when the client experiences nonunion of a fracture, requires an adjunct to spinal fusion surgery, or experiences congenital pseudarthrosis.

Nonunion is defined as a fractured bone that fails to heal completely. Diagnosis of nonunion is estab­lished when a minimum of six months has passed since the injury and the fracture site shows no progressive signs of healing for a minimum of three months and is not complicated by a synovial pseudoarthrosis. Serial radiographs must confirm that fracture healing has ceased for three months or longer before the client begins treatment with the bone growth stimulator.

2.2.7.1Professional Services

Procedure codes 20974, 20975, and 20979 are a benefit of Texas Medicaid and limited to one per six months. During the six-month limitation period, a subsequent fracture that meets the above criteria for a bone growth stimulator may be reimbursed after the submission of an appeal with documentation of medical necessity that demonstrates the criteria have been met.

2.2.7.2Prior Authorization Criteria and Documentation Requirements for Bone Growth Stimulators

Procedure codes E0747, E0748, E0749, and E0760 require prior authorization. Additional bone growth stimulators may be considered for prior authorization with documentation that supports treatment of a different fracture.

A completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form prescribing the DME or medical supplies must be signed and dated by the prescribing physician familiar with the client prior to requesting authorization. The completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept in the physician’s medical record for the client.

To avoid unnecessary authorization denials, the physician must provide correct and complete infor­mation, including documentation for medical necessity of the equipment or supplies requested. The requesting provider may be asked for additional information to clarify or complete a request for the bone growth stimulator.

Documentation that supports medical necessity for a bone growth stimulator must be maintained by the ordering physician and requesting provider in the client’s medical record and is subject to retrospective review.

2.2.7.2.1Documentation for Noninvasive Electrical Bone Growth Stimulator

Documentation of one of the following is required for prior authorization of the external, electromag­netic bone stimulator (procedure code E0747):

Nonunions, failed fusions, and congenital pseudarthrosis where there is no evidence of progression of healing for three or more months despite appropriate fracture care.

Delayed unions of fractures of failed arthrodesis at high risk sites (e.g., open or segmental tibial fractures, carpal navicular fractures).

Documentation must also indicate all of the following:

Serial radiographs have confirmed that no progressive signs of healing have occurred.

The fractured gap is 1 cm or less.

The individual can be adequately immobilized and is likely to comply with non-weight-bearing restrictions.

Documentation of one of the following is required for prior authorization of the external, electromag­netic bone stimulator for spinal application (procedure code E0748):

One or more failed fusions.

Grade II or worse spondylolisthesis.

A multiple-level fusion with extensive bone grafting is required.

Other risk factors for fusion failure are present, including gross obesity, degenerative osteoarthritis, severe spondylolisthesis, current smoking, previous fusion surgery, previous disc surgery, or gross instability.

2.2.7.2.2Documentation for Invasive Electrical Bone Growth Stimulators

Documentation of one of the following is required for prior authorization of the surgically implanted bone growth stimulator (procedure code E0749):

Nonunion of long bone fractures (i.e., clavicle, humerus, radius, ulna, femur, tibia, fibula, and metacarpal, metatarsal, carpal, and tarsal bones). Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for three or more months prior to starting treatment with the bone growth stimulator. Serial radiographs must include a minimum of two sets of radiographs separated by a minimum of 90 days. Each set of radio­graphs must include multiple views of the fracture site.

Failed fusion of a joint other than the spine when a minimum of three months has elapsed since the joint fusion was performed.

Congenital pseudoarthrosis.

An adjunct to spinal fusion surgery for patients at high risk for pseudoarthrosis due to previously failed spinal fusion at the same site.

An adjunct to multiple-level fusion, which involves three or more vertebrae (e.g., L3-L5, L4-S1, etc).

2.2.7.2.3Documentation for Ultrasound Bone Growth Stimulator

Documentation of the following is required for prior authorization of the external, low-intensity ultra­sound bone growth stimulator device (procedure code E0760):

Nonunion of a fracture, other than the skull or vertebrae, in a skeletally mature person, which is documented by a minimum of two sets of radiographs that were:

Obtained prior to starting treatment with the bone growth stimulator.

Separated by a minimum of 90 days.

Taken with multiple views of the fracture site.

Accompanied by a written interpretation by a physician who states that there has been no clini­cally significant evidence of fracture healing between the two set of radiographs.

Evidence of all of the following:

The fracture is not tumor-related.

The fracture is not fresh (less than seven days), closed or grade I open, tibial diaphyseal fractures, or    closed fractures of the distal radius (Colles fracture).

2.2.7.3Claims Reimbursement for Professional Services

Professional claims that are submitted for bone growth stimulation (procedure codes 20974, 20975, and 20979) may be reimbursed if the claim includes documentation of one of the following:

Documentation of medical necessity as outlined in subsection 2.2.7.2, “Prior Authorization Criteria and Documentation Requirements for Bone Growth Stimulators” in this handbook.

The corresponding bone growth stimulator device was submitted within 95 days of the date the bone growth stimulation procedure was performed.

The appropriate evaluation and management (E/M) procedure code must be billed for monitoring the effectiveness of bone growth stimulation treatment.

2.2.8Breast Feeding Support Services

Refer to:  Section 3, “Breastfeeding Support Services” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for information about breastfeeding support services.

2.2.9Cochlear Implants

Cochlear implant services (procedure codes L8499, L8615, L8616, L8617, L8618, L8619, L8623, and L8624) may be reimbursed in the home setting to DME providers.

Refer to:  Subsection 9.2.22, “Cochlear Implants” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about cochlear implant services.

2.2.10Continuous Passive Motion (CPM) Device

A CPM device is reimbursed on a daily basis and is limited to once per day. Reimbursement includes delivery, set-up and all supplies. Providers must use procedure code E0935 when billing for a CPM machine.

2.2.10.1Prior Authorization

A CPM device may be considered for prior authorization through Home Health Services. Reimbursement for a CPM device is considered after joint surgery, such as knee replacement, when prescribed by a physician and submitted with clinical documentation of medical necessity and appropriateness.

2.2.11Diabetic Equipment and Supplies

Diabetic equipment and supplies are a benefit through Title XIX Home Health Services and do not require prior authorization unless otherwise specified.

Diabetic equipment and supplies may be obtained through one of the following methods:

A Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form prescribing the DME or medical supplies. The Title XIX Form must be signed and dated by the prescribing physician who is familiar with the client prior to supplying any medical equipment or supplies.

A verbal or a detailed written order provided by a physician, physician assistant (PA), nurse practi­tioner (NP), clinical nurse specialist (CNS), or a certified nurse midwife (CNM).

2.2.11.1Obtaining Equipment and Supplies Through a Title XIX Form

The completed Title XIX Form must be maintained by the dispensing provider and the prescribing physician in the client’s medical record. The physician must maintain the original signed and dated copy of the Title XIX Form. The completed Title XIX Form is valid for a period up to six months from the physician’s signature date.

2.2.11.2Obtaining Equipment and Supplies Through a Verbal or Detailed Written Order

If the dispensing provider does not have a detailed written order then a verbal order is required to be on file until the written order is received from the prescribing provider and before providing diabetic equipment and supplies. The prescribing provider’s order may be a written, fax, electronic, or verbal order and must include:

A description of the item(s).

The client’s name.

The name of the physician or authorized prescribing provider.

The date of the order.

A detailed written order must be received by the DME supplier within 90 days from the date of the prescribing provider’s signature. The detailed written order for diabetic equipment and supplies is valid for six months from the date of the order or the date of the prescribing provider’s signature, whichever is earlier, for initial orders, and from the start date of renewal orders. In the absence of a start date, then the authorized prescribing signature date will be the beginning date of service.

A completed, detailed written order must be signed and dated by the authorized prescribing provider. The prescribing provider is required to retain a copy of the signed and dated detailed written order in the client’s medical record. The DME provider must retain the original, faxed, photocopied, or electronic, signed and dated detailed written order in the client’s medical record.

A completed detailed written order must contain all the following components:

The client’s name

The date of the verbal order if different from the date the authorized prescribing provider signed the written order

Description of item(s) to be provided

Quantity to dispense (quantity required per day or month)

Diagnosis code or description supporting the medical necessity

Before submitting a claim to Texas Medicaid, DME providers must have on file a detailed written order with the required information. No other documentation is required.

Prior Authorization

Prior authorization, when necessary, may be considered with documentation of medical necessity, which must include one of the following:

A completed Title XIX Form that has been signed and dated by the physician who is familiar with the client

Or all the following:

A completed and signed detailed written order.

A Title XIX Form with section A completed.

2.2.11.3Glucose Testing Equipment and Other Supplies

The prescribing provider must indicate on a completed, signed and dated Title XIX Form, or a signed and dated detailed written order how many times a day the client is required to test blood glucose or ketone levels when applicable (not all supplies are related to testing glucose or urine, e.g., batteries).

Glucose tablets or gel (procedure code A9150) may be considered with prior authorization when provided to a client with a diagnosis from the diagnosis code table below. Procedure code A9150 is limited to one per six months.

The procedure codes for the diabetic supplies listed in the following table do not require prior authori­zation, up to the quantities listed in the table, when provided to a client with a diagnosis from the diagnosis code table below. These limitations are not dependent on the client’s use of insulin:

Procedure Code

Limitation

A4233

1 per 6 months

A4234

1 per 6 months

A4235

1 per 6 months

A4236

1 per 6 months

A4252

10 strips per month

A4256

2 per year

A4258

2 per year

A9275

2 per month*

*Combined total with code A4253

Insulin-Dependent Clients

The following procedure codes for diabetic supplies do not require prior authorization up to the quantities listed when the supplies are provided to an insulin-dependent client with a valid diagnosis. If the client is insulin-dependent, providers must submit claims for these procedure codes with modifier U9:

Procedure Code

Limitation

A4253*

2 boxes per month

A4259

1 box per month

A9275*

2 per month

*A client may receive a combined total of two per calendar month of procedure codes A4253 and A9275, either two or one procedure code or one of each procedure code

Non-Insulin-Dependent Clients

The following procedure codes for diabetic supplies do not require prior authorization up to the quantities listed when they are provided to a non-insulin-dependent client with a valid diagnosis. If the client is not insulin-dependent, providers must submit claims for these procedure codes with no modifier:

Procedure Code

Limitation

A4253*

1 box per month

A4259

1 box every 2 months

A9275*

1 per month

*A client may receive only one per calendar month of either procedure code A4253 or A9275.

The following diagnosis codes apply to the tables listed above:

Diabetic Diagnosis Codes

E0800

E0801

E0810

E0811

E0821

E0822

E0829

E08311

E08319

E083211

E083212

E083213

E083219

E083291

E083292

E083293

E083299

E083311

E083312

E083313

E083319

E083391

E083392

E083393

E083399

E083411

E083412

E083413

E083419

E083491

E083492

E083493

E083499

E083511

E083512

E083513

E083519

E083521

E083522

E083523

E083529

E083531

E083532

E083533

E083539

E083541

E083542

E083543

E083549

E083551

E083552

E083553

E083559

E083591

E083592

E083593

E083599

E0836

E0837X1

E0837X2

E0837X3

E0837X9

E0839

E0840

E0841

E0842

E0843

E0844

E0849

E0851

E0852

E0859

E08610

E08618

E08620

E08621

E08622

E08628

E08630

E08638

E08641

E08649

E0865

E0869

E088

E089

E0900

E0901

E0910

E0911

E0921

E0922

E0929

E09311

E09319

E093211

E093212

E093213

E093219

E093291

E093292

E093293

E093299

E093311

E093312

E093313

E093319

E093391

E093392

E093393

E093399

E093411

E093412

E093413

E093419

E093491

E093492

E093493

E093499

E093511

E093512

E093513

E093519

E093521

E093522

E093523

E093529

E093531

E093532

E093533

E093539

E093541

E093542

E093543

E093549

E093551

E093552

E093553

E093559

E093591

E093592

E093593

E093599

E0936

E0937X1

E0937X2

E0937X3

E0937X9

E0939

E0940

E0941

E0942

E0943

E0944

E0949

E0951

E0959

E09610

E09618

E09620

E09621

E09622

E09628

E09630

E09638

E09641

E09649

E0965

E0969

E098

E099

E1010

E1011

E1021

E1022

E1029

E10311

E10319

E103211

E103212

E103213

E103219

E103291

E103292

E103293

E103299

E103311

E103312

E103313

E103319

E103391

E103392

E103393

E103399

E103411

E103412

E103413

E103419

E103491

E103492

E103493

E103499

E103511

E103512

E103513

E103519

E103521

E103522

E103523

E103529

E103531

E103532

E103533

E103539

E103541

E103542

E103543

E103549

E103551

E103552

E103553

E103559

E103591

E103592

E103593

E103599

E1036

E1037X1

E1037X2

E1037X3

E1037X9

E1039

E1040

E1041

E1042

E1043

E1044

E1049

E1051

E1052

E1059

E10610

E10618

E10620

E10621

E10622

E10628

E10630

E10638

E10641

E10649

E1065

E1069

E108

E109

E1100

E1101

E1110

E1121

E1122

E1129

E11311

E11319

E113211

E113212

E113213

E113219

E113291

E113292

E113293

E113299

E113311

E113312

E113313

E113319

E113391

E113392

E113393

E113399

E113411

E113412

E113413

E113419

E113491

E113492

E113493

E113499

E113511

E113512

E113513

E113519

E113521

E113522

E113523

E113529

E113531

E113532

E113533

E113539

E113541

E113542

E113543

E113549

E113551

E113552

E113553

E113559

E113591

E113592

E113593

E113599

E1136

E1137X1

E1137X2

E1137X3

E1137X9

E1139

E1140

E1141

E1142

E1143

E1144

E1149

E1151

E1152

E1159

E11610

E11618

E11620

E11621

E11622

E11628

E11630

E11638

E11641

E11649

E1165

E1169

E118

E119

E1300

E1301

E1310

E1311

E1321

E1322

E1329

E13311

E13319

E133211

E133212

E133213

E133219

E133291

E133292

E133293

E133299

E133311

E133312

E133313

E133319

E133391

E133392

E133393

E133399

E133411

E133412

E133413

E133419

E133491

E133492

E133493

E133499

E133511

E133512

E133513

E133519

E133521

E133522

E133523

E133529

E133531

E133532

E133533

E133539

E133541

E133542

E133543

E133549

E133551

E133552

E133553

E133559

E133591

E133592

E133593

E133599

E1336

E1337X1

E1337X2

E1337X3

E1337X9

E1339

E1340

E1341

E1342

E1343

E1344

E1349

E1351

E1352

E1359

E13610

E13620

E13621

E13622

E13628

E13638

E13641

E13649

E1365

E1369

E138

E139

O24011

O24012

O24013

O2402

O2403

O24414

O24415

O24424

O24425

O24434

O24435

O99810

O99814

O99815

P702

Non-diabetic Diagnosis Codes

Non-diabetic Diagnosis Codes

E161

E162

E71111

E71310

E71311

E71312

E71313

E71314

E71318

E7132

E7420

E7421

E7429

E8881

K911

R7303

R7309

R81

Note:THSteps-eligible clients who qualify for medically necessary services beyond the limits of this home health benefit will receive those services through CCP.

Alcohol wipes (procedure code A4245) and urine test or reagent strips or tablets (procedure code A4250) are a benefit of Texas Medicaid when they are necessary for the treatment of some diabetic conditions or other conditions and therefore are not limited to the diagnoses listed in the diagnosis code table above.

Procedure code A4245 is limited to four boxes per month and procedure code A4250 is limited to one box per six months. Prior authorization is not required for these procedure codes up to the quantities listed.

The quantity of glucose testing supplies billed for a one-month supply should relate to the number of tests ordered per day by the prescribing provider.

Glucose testing supplies may be reimbursed for the quantities prescribed or the quantity prior authorized.

Blood glucose test or reagent strips (procedure code A4253) and home glucose disposable monitors with test strips (procedure code A9275) are limited to a combined total of two per month.

2.2.11.3.1Prior Authorization

Glucose tablets or gel (procedure code A9150) requires prior authorization with documentation supporting medical necessity.

Glucose testing supplies for quantities beyond the limits listed in the procedure code table above or for diagnoses other than those listed in the diagnosis code table above in subsection 2.2.11.3, “Glucose Testing Equipment and Other Supplies” in this handbook may be considered for prior authorization with documentation of medical necessity. Quantities will be prior authorized based on the documen­tation of medical necessity related to the number of tests ordered per day by the physician.

2.2.11.4Blood Glucose Monitors

Blood glucose monitors with integrated voice synthesizers (procedure code E2100) and blood glucose monitors with integrated lancing blood sample (procedure code E2101) may be considered for prior authorization with documentation of medical necessity. Glucose monitors that have been purchased are anticipated to last a minimum of three years and may be considered for replacement when three years have passed or the equipment is no longer repairable.

Standard home glucose monitors (procedure code E0607) are not a benefit of Texas Medicaid.

Invasive continuous glucose monitoring (CGM) is used for diagnostic purposes to assist the clinician in establishing or modifying the client’s treatment plan. A CGM device is worn up to 72 hours for the diagnostic purpose of collecting continuous blood sugar readings. These are later analyzed by the clinician.

Refer to:  Subsection 9.2.23, “Continuous Glucose Monitoring (CGM)” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for additional information.

2.2.11.4.1Prior Authorization

Blood glucose monitors with special features (procedure code E2100 or E2101) may be considered for prior authorization with documentation supporting medical necessity for the special feature requested.

Purchase of a blood glucose monitor with integrated voice synthesizer (procedure code E2100) may be considered for prior authorization with documentation that includes a diagnosis of diabetes and signif­icant visual impairment.

Purchase of a blood glucose monitor with integrated lancing and blood sample (procedure code E2101) may be considered for prior authorization with documentation that includes a diagnosis of diabetes and significant manual dexterity impairment related but not limited to neuropathy, seizure activity, cerebral palsy, or Parkinson’s disease.

The invasive CGM device will not be prior authorized as it is considered part of the physician interpre­tation and report for CGM.

2.2.11.5External Insulin Pump and Supplies

An external insulin infusion pump is a programmable, battery-powered mechanical syringe or reservoir device controlled by a microcomputer to provide a basal continuous subcutaneous insulin infusion (CSII) and release a “bolus” dose at meals and at programmed intervals. The pump is connected to an infusion set with an attached small needle or cannula that is inserted into the subcutaneous tissue. The purpose of the insulin pump is to provide an accurate, continuous, controlled delivery of insulin which can be regulated by the user to achieve intensive glucose control and prevent the metabolic complica­tions of hypoglycemia, hyperglycemia and diabetic ketoacidosis. The typical external insulin pump capacity is two to three days of insulin.

Note:External insulin pumps that do not require tubing may be considered for clients who are birth through 20 years of age.

An external insulin pump must be ordered by, and the client’s follow-up care must be managed by, a prescribing provider with experience managing clients with insulin infusion pumps and who is knowl­edgeable in the use of insulin infusion pumps.

The external insulin pump (procedure code E0784) may be considered for prior authorization with documentation of medical necessity. Procedure code E0784 is limited to one purchase every three years, and one rental per month. External insulin pumps that have been purchased are anticipated to last a minimum of three years and may be considered for replacement when three years have passed or the equipment is no longer repairable.

The following procedure codes for external insulin pump supplies are a benefit through Title XIX Home Health Services and do not require prior authorization up the maximum quantities allowed. Additional quantities may be considered with documentation of medical necessity and prior authorization.

Procedure Code

Limitation

A4224

4 per month

A4225

15 per month

A4230

15 per month

A4231

15 per month

A4232

10 per month

A4601

1 per 6 months

A4602

1 per 6 months

A6257

15 per month

A6258

15 per month

A6259

15 per month

K0601

4 per 2 months

K0602

4 per 2 months

K0603

4 per 2 months

K0604

1 per 6 months

K0605

1 per 6 months

Providers must bill replacement batteries (procedure codes K0601 through K0605) with modifier U1.

When there is not an appropriate procedure code for supplies providers may request prior authorization using procedure code A9900.

The external insulin pump supplies (including batteries) are not included in the external insulin pump rental. Routine maintenance of rental equipment is the provider’s responsibility.

Infusion sets for the external insulin pump (procedure codes A4230 or A4231) are limited to clients with a previously billed external insulin pump device or supply. Infusion sets for clients who did not receive the external insulin pump through Texas Medicaid are considered for reimbursement on appeal with a physician’s statement documenting medical necessity.

An internal insulin pump will not be prior authorized as it is considered part of the surgery to place the pump.

2.2.11.5.1Prior Authorization

Prior authorization is required for an external insulin pump (procedure code E0784) with carrying cases.

Rental of External Insulin Pump

An external insulin pump may be considered for prior authorization of rental with submission of clinical documentation indicating one of the following:

A client who has a diagnosis of type 1 or 2 diabetes must meet at least two of the following criteria while on multiple daily injections of insulin:

Elevated glycosylated hemoglobin level (HbA1c) > 7.0 percent

History of dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl

History of severe glycemic excursions with wide fluctuations in blood glucose

History of recurring hypoglycemia (less than 60 mg/dL) with or without hypoglycemic unawareness

Anticipation of pregnancy within three months

A client with a diagnosis of gestational diabetes must meet at least one of the following criteria:

Erratic blood sugars in spite of maximal compliance and split dosing

Other evidence that adequate control is not being achieved by current methods

In addition to the clinical documentation the provider must submit the External Insulin Pump form indicating:

The client or caregiver possess the following competencies:

The cognitive and physical abilities to use the recommended insulin pump treatment regimen

An understanding of cause and effect

The willingness to support the use of the external insulin pump

The prescribing provider must attest that:

A training/education plan will be completed prior to initiation of pump therapy.

The client or caregiver will be given face-to-face education and instruction and will be able to demonstrate proficiency in integrating insulin pump therapy with their current treatment regimen for ambient glucose control.

Purchase of External Insulin Pump

An external insulin pump may be considered for prior authorization of purchase after it has been rented for a three-month trial and all of the following documentation is provided:

The training/education plan has been completed

The pump is the appropriate equipment for the specific client

The client is compliant with the use of the pump

2.2.11.6Tubeless External Insulin Infusion Pumps

The tubeless external insulin infusion pump and supplies are a benefit of Texas Medicaid for clients who are birth through 20 years of age.

The tubeless external insulin pump must be ordered by, and the client's follow-up care must be managed by, a prescribing provider who has experience managing clients with insulin infusion pumps and who is knowledgeable in the use of insulin infusion pumps.

Providers must use procedure code E0784 and modifier U1 for the rental or purchase of the tubeless external insulin pump and procedure code A9274 for the tubeless external insulin pump supplies.

Procedure code A9274 is limited to 15 per month.

A tubeless external insulin pump that has been purchased is expected to last a minimum of three years and may be considered for replacement when three years have passed or the equipment is no longer repairable. The replacement of the equipment may also be considered when it has been lost or irrepa­rably damaged. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent a reoccurrence must be submitted. Additional services may be considered based on documen­tation of medical necessity.

Routine maintenance of rental equipment is the provider's responsibility.

2.2.11.6.1Prior Authorization and Documentation Requirements

Prior authorization is required for the tubeless external insulin pump with carrying cases and related supplies and repairs. The tubeless external insulin pump supplies may be considered separately when a tubeless external insulin pump is rented.

The tubeless external insulin pump and supplies may be obtained through one of the following methods:

CCP Prior Authorization Request Form—the completed CCP Prior Authorization Request Form must be maintained by the dispensing provider and the prescribing physician in the client's medical record. The physician must maintain the original signed and dated copy of the CCP Prior Authori­zation Request Form. The completed CCP Prior Authorization Request Form is valid for a period up to six months from the physician's signature date.

Verbal or detailed written order—the verbal or detailed written order must be provided by a physician, PA, NP, CNS, or a CNM.

If the dispensing provider does not have a detailed written order, a verbal order is required to be on file until the written order is received from the prescribing provider and before providing diabetic equipment and supplies. The prescribing provider's order may be a written, fax, electronic, or verbal order and must include:

A description of the item(s).

The client's name.

The name of the physician or authorized prescribing provider.

The date of the order.

A detailed written order must be received by the DME supplier within 90 days from the date of the prescribing provider's signature. For initial orders, the detailed written order for diabetic equipment and supplies is valid for six months from the date of the order or the date of the prescribing provider's signature, whichever is earlier. For renewal orders the detailed written order is valid for six months from the start date, or in absence of a start date, the date of the authorized prescribing signature.

2.2.11.6.2Tubeless External Insulin Pump Rentals

Tubeless external insulin pump rentals may be considered for prior authorization with the submission of clinical documentation that indicates one of the following:

The client has a diagnosis of type 1 or type 2 diabetes and meets at least two of the following criteria while on multiple daily injections of insulin:

Elevated glycosylated hemoglobin level (HbA1c) > 7.0 percent.

A history of dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl.

A history of severe glycemic excursions with wide fluctuations in blood glucose.

A history of recurring hypoglycemia (less than 60 mg/dL) with or without hypoglycemic unawareness.

Expectation of becoming pregnant within three months.

The client has a diagnosis of gestational diabetes and meets at least one of the following criteria:

Erratic blood sugars in spite of maximal compliance and split dosing.

Other evidence that adequate control is not being achieved by current methods.

In addition to the clinical documentation, the provider must submit an External Insulin Pump form that indicates:

The client or caregiver possesses:

The cognitive and physical abilities to use the recommended insulin pump treatment regimen.

An understanding of cause and effect.

The willingness to support the use of the external insulin pump

The prescribing provider has attested that:

A training and education plan will be completed prior to initiation of pump therapy.

The client or caregiver will be given face-to-face education and instruction and will be able to demonstrate the necessary proficiency to integrate insulin pump therapy with their current treatment regimen for ambient glucose control.

2.2.11.6.3Purchase of Tubeless External Insulin Pump

The purchase of a tubeless external insulin pump may be considered for prior authorization after it has been rented for a three-month trial and all of the following documentation has been provided:

The training or education plan has been completed.

The pump is the appropriate equipment for the specific client.

The client is compliant with the use of the pump.

2.2.11.7Insulin and Insulin Syringes

Insulin and insulin syringes (0.5 and 1.0 cc sizes only) that are prescribed to fee-for-service clients are reimbursed through the Medicaid Vendor Drug Program and are not covered under Title XIX Home Health Services. The Medicaid Vendor Drug Program (VDP) only enrolls pharmacies.

Refer to:  “Appendix B: Vendor Drug Program” (Vol. 1, General Information) for more information about VDP.

2.2.12Donor Human Milk

Donor human milk is a benefit for clients who are birth through 11 months of age when documentation submitted clearly shows that it is medically necessary and will correct or ameliorate the client's disability or physical or mental illness or condition. Documentation must include all of the following:

The requesting physician has documented medical necessity and appropriateness.

The parent or guardian has signed and dated an informed consent form indicating that the risks and benefits of using banked donor human milk have been discussed with them.

The donor human milk bank adheres to quality guidelines consistent with the Human Milk Bank Association of North America or such other standards as may be adopted by HHSC.

Additional donor human milk benefits beyond the limitations listed in this handbook may be available to clients who are birth through 20 years of age with documentation of medical necessity.

Procedure code B9998 must be used when requesting or billing for donor human milk.

Donor human milk is reimbursed at a maximum fee determined by HHSC or manual pricing.

Donor human milk is only reimbursed to a Texas Medicaid-enrolled donor milk bank and only for children who are in the home setting.

The physician must address the benefits and risks of using donor human milk, such as HIV, freshness, effects of pasteurization, nutrients, and growth factors to the parent. The physician also must address donor screening, pasteurization, milk storage, and transport of the donor milk. The physician may obtain this information from the donor milk bank.

2.2.12.1Prior Authorization and Documentation Requirements

Donor human milk may be considered for a maximum of six months per authorization. The authori­zation may be extended with documentation of medical necessity.

Prior authorization is required for donor human milk provided through Texas Medicaid CCP Services.

To obtain prior authorization, providers must complete the CCP Prior Authorization Request Form and a Donor Human Milk Request Form every 180 days. Both the ordering physician and the providing milk bank must maintain copies of the form in the client's medical records.

The physician ordering the donor human milk must complete all of the fields in Part A of the original form, including the documentation of medical necessity. This information must be substantiated by written documentation in the clinical report. The physician must specify the quantity and the time frame in the Quantity Requested field (e.g., cubic centimeters per day or ounces per month). All of the fields in Part B of the form must be completed by the donor milk bank providing the donor human milk.

The documentation of medical necessity and appropriateness and the signed and dated written informed consent form must be maintained in the client's clinical records. The documentation of medical necessity must be completed by the physician ordering the donor human milk. The clinical records are subject to retrospective review. The documentation must address all of the following:

Medical necessity, including why the particular client cannot survive and gain weight on any appro­priate formula (e.g., elemental, special, or routine formula or food), or any enteral nutritional product other than donor human milk.

clinical feeding trial of an appropriate nutritional product has been considered with each authorization.

The informed consent provided to the parent or guardian details the risks and benefits of using banked donor human milk.

A copy of the CCP Prior Authorization Request Form and the Donor Human Milk Request Form.

Refer to:  Donor Human Milk Request Form on the TMHP website at www.tmhp.com.

CCP Prior Authorization Request Form on the TMHP website at www.tmhp.com.

2.2.12.2Donor Human Milk Services for Inpatient Clients

Donor human milk may be reimbursed to hospital providers for services rendered to inpatient clients. Hospital providers may receive reimbursement for the donor human milk service separate from the inpatient diagnosis-related group (DRG) payment.

The hospital may be reimbursed using the following revenue and procedure code combination as an outpatient hospital service using the CMS-1450 (UB-04) claim form with the most appropriate outpa­tient type of bill (TOB):

Revenue Code

Procedure Code

220 (special charges)

T2101

For proper reimbursement when billing procedure code T2101, the Units field on the claim form must indicate the number of ounces rendered to the client.

Procedure code T2101 may be reimbursed for donor human milk as medically necessary for clients who are 6 months of age and younger. Prior authorization is not required.

Hospitals must follow clinical recommendations for administering donor human milk to inpatient clients, and must maintain all applicable and appropriate medical necessity documentation in the client's medical record.

2.2.13Hospital Beds and Equipment

A hospital bed and related equipment are considered for reimbursement for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. A hospital bed is not one that is typically sold as home furniture.

The following items are a benefit of Home Health Services with prior authorization:

Hospital bed

Air-fluidized bed

Pressure pads or a nonpowered pressure-reducing mattress overlay

Nonpowered pressure-reducing mattress

Powered pressure-reducing mattress overlay system

Powered pressure-reducing mattress

Advanced nonpowered pressure-reducing mattress overlay

Powered pressure-reducing mattress overlay

Advanced nonpowered pressure-reducing mattress

Sheepskin and lamb’s wool pads

Decubitus care accessories

Side rails or mattresses may be considered for replacement only and may be considered if it is a client-owned hospital bed and the client’s condition requires a replacement of an innerspring mattress or side rails.

The following items may be considered for clients who are birth through 20 years of age when documen­tation submitted clearly shows that the equipment is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition:

Pediatric hospital cribs and beds

Enclosure frame, canopy, or bubble tops

Positioning pillows or cushions

Reflux wedges

Reflux slings

Hospital beds, cribs, and equipment are a benefit when all the following criteria are met:

FFP must be available.

The requested equipment or supplies must be safe for use in the home.

2.2.13.1Hospital Beds

A hospital bed is defined as a medical device with all of the following features:

An articulating frame that allows adjustment of the head and foot of the bed

A headboard

A foot board

A mattress

Side rails of any type (A side rail is defined as a hinged or removable rail, board, or panel of any height.)

Note:Without all the components listed above, Texas Medicaid will not consider a request for any hospital bed.

 

2.2.13.2Pediatric Hospital Bed

A pediatric hospital bed or pediatric crib is defined as a fully enclosed bed with all of the following features:

A bed that allows adjustment of the head and foot of the bed.

A manual pediatric hospital bed (procedure code E0328) or pediatric crib (procedure code E0300) allows manual adjustment to the head and leg elevation.

A semi-electric or fully electric hospital bed (procedure code E0329) allows manual or electric adjustments to height and electric adjustments to head and leg elevation.

A headboard

A footboard

A mattress

Side rails of any type (A side rail is defined as a hinged or removable rail, board, or panel.)

Pediatric hospital beds and pediatric cribs that do not have all of these features will not be considered for prior authorization.

A bed that has side rails that extend 24 inches or less above the mattress is considered a pediatric hospital bed (procedure code E0328 or E0329). A pediatric hospital bed may be fixed or variable height. Variable height beds may be adjusted manually or electrically as required for the client’s medical condition.

Procedure codes E0328 and E0329 are restricted to clients who are 20 years of age and younger.

A bed that has side rails that extend more than 24 inches above the mattress is considered a pediatric crib (procedure code E0300).

A pediatric hospital bed or pediatric crib of any width that has all of the features defined above may be considered for prior authorization using only procedure code E0300, E0328, or E0329.

Hospital beds that are not fully enclosed can be considered through Texas Medicaid home health services.

Note:Texas Medicaid defines fully enclosed as having 360-degree side enclosures.

The following procedure codes are used when billing for the rental or purchase of pediatric hospital beds, cribs, and equipment:

Procedure Codes

E0190*

E0300

E0316

E0328

E0329

E1399

K0739*

* Purchase only

Note:Procedure code E1399 may be used for reflux slings only.

The purchase of a safety enclosure frame, canopy, or bubble top (procedure code E0316) may be a benefit when the protective crib top or bubble top is for safety use. It is not considered a benefit when it is used as a restraint or for the convenience of family or caregivers.

Procedure code E0316 may be used in conjunction with procedure codes E0300, E0328, or E0329 to request a pediatric fully-enclosed bed with a canopy.

Enclosed bed systems that are not approved by the Food and Drug Administration (FDA) are not a covered benefit.

Reflux slings or wedges may be considered for clients who are birth through 11 months of age. Reflux slings or wedges may be used as positioning devices for infants who require elevation after feedings when prescribed by a physician as medically necessary and appropriate.

Procedure code E0190 with modifier UD must be used to bill the purchase of reflex wedges and positional devices (positioning pillows and cushions). This code and modifier will require manual pricing. Procedure code E0190 is limited to once per three years, per client, any provider.

Procedure code K0739 may be reimbursed for the repair of equipment.

2.2.13.3Prior Authorization

Hospital beds may be considered for prior authorization for clients who cannot safely utilize a regular bed.

2.2.13.3.1Fixed-Height Hospital Bed

A fixed-height bed (procedure code E0250), which allows for manual adjustment to the head and leg elevation but not height, may be considered for prior authorization if at least one of the following criteria exists:

The client’s medical condition requires positioning of the body in ways that are not feasible in an ordinary bed.

The client’s medical condition requires special positioning to alleviate pain.

It is necessary to elevate the head of the bed 30 or more degrees most of the time due to, but not limited to, congestive heart failure, chronic pulmonary disease, or problems with aspiration, and alternative measures such as wedges or pillows, have been attempted but have failed to manage the client’s medical condition.

Note:Texas Medicaid defines a failed measure as having no clinically significant improvement after being introduced.

The client requires traction equipment that can only be attached to a hospital bed.

2.2.13.3.2Variable-Height Hospital Bed

A variable-height hospital bed (procedure E0255), which allows manual adjustments to height as well as to head and leg elevations, may be considered for prior authorization if the client meets the criteria for a fixed -height hospital bed and requires a bed height that is different from a fixed-height hospital bed to permit transfers in and out of the bed to a chair, wheelchair, or to a standing position. Medical condi­tions that require a variable-height hospital bed include, but are not limited to, the following:

Severe arthritis and other injuries to lower extremities that require the variable height feature to assist in ambulation by enabling the client to place his or her feet on the floor while sitting on the edge of the bed.

Severe cardiac conditions, where the client is able to leave the bed, but must avoid the strain of “jumping” up and down.

Spinal cord injuries (including quadriplegia and paraplegia), multiple limb amputations, and stroke, where the client is able to transfer from a bed to a wheelchair with or without help.

Other severely debilitating diseases and conditions if the client requires a bed height different than a fixed-height hospital bed to permit transfers to a chair, wheelchair, or to a standing position.

2.2.13.3.3Semi-Electric Hospital Bed

A semi-electric hospital bed (procedure code E0260), which allows manual adjustments to height and electric adjustments to head and leg elevation, may be considered for prior authorization if the client meets the criteria for a fixed-height hospital bed and has a condition that requires frequent changes in body position or might require an immediate change in body position to avert a life-threatening situation.

2.2.13.3.4Fully-Electric Hospital Bed

A fully-electric bed (procedure code E0265), which allows electric adjustments to height and head and leg elevation, may be considered for prior authorization when all of the following criteria are met:

The client has paraplegia or hemiplegia.

The fully-electric hospital bed will allow the client to have functional independence with self-care.

Documentation must include an attestation statement from the client’s physician or physical or occupa­tional therapist that verifies a determination has been made that the fully-electric hospital bed will allow the client to independently meet their daily self-care needs.

The following hospital beds may be considered for prior authorization if the client meets the criteria for a hospital bed and the weight requirements for a bariatric bed as listed below:

Heavy-duty, extra-wide hospital bed (procedure code E0303) capable of supporting a client who weighs more than 350 pounds, but no more than 600 pounds

Extra heavy-duty, extra-wide hospital bed (procedure code E0304) capable of supporting a client who weighs more than 600 pounds

2.2.13.3.5Pediatric Hospital Beds and Safety Enclosure

Pediatric hospital beds and pediatric cribs (procedure codes E0300, E0316, E0328, and E0329) may be considered for prior authorization when the documentation submitted clearly shows that the requested bed or crib will correct or ameliorate the client’s condition. The documentation must meet at least one of the following criteria:

The client’s medical condition requires positioning of the body in ways that are not feasible in an ordinary bed, including, but not limited to, the need for positioning to alleviate pain.

The head of the bed must be elevated 30 or more degrees most of the time due to, but not limited to, congestive heart failure, chronic pulmonary disease, or problems with aspiration, and alternative measures, such as wedges or pillows, have been attempted but have failed to manage the client’s medical condition.

Note:Texas Medicaid defines a failed measure as having no clinically significant improvement after being introduced.

The client requires traction equipment that can only be attached to a hospital bed.

A semi-electric or fully electric hospital bed (procedure code E0329) may be considered for prior autho­rization when the submitted documentation shows that the client has a medical condition that requires frequent changes in body position or might require an immediate change in body position to avert a life- threatening situation.

The safety enclosure frame, canopy, or bubble top may be considered for prior authorization with documentation that the protective canopy top or bubble will provide for the client’s safety. Prior autho­rization will not be considered when it will be used as a restraint or for the convenience of family or caregivers.

Reflux slings or wedges may be considered for prior authorization for clients who are 11 months of age and younger. These may be used as positioning devices for infants who require the head of the bed or crib to be elevated greater than 30 degrees after feedings when prescribed by a physician as medically necessary and appropriate.

Positioning pillows and cushions may be considered for prior authorization with documentation of medical necessity that indicates the item will provide for or assist in the positioning needs of the client to maintain proper body alignment and skin integrity. Documentation must include what other devices have been used previously and why they proved to be ineffective.

Items used for PT or rehabilitation in the home are provided by the therapist. Requests for authorization for these purposes will not be considered.

2.2.13.4Documentation Requirements

To request prior authorization for a hospital bed, the following documentation must be submitted:

Accurate diagnostic information pertaining to the underlying medical diagnoses or conditions (e.g., gastrostomy feeding, suctioning, ventilator dependent, other respiratory equipment or ventilation assistance devices) to include the client’s overall health status

Client height and weight

Client functional mobility status

Client use of any pressure-reducing support surfaces, if applicable

The following documentation must be submitted for clients who are birth through 20 years of age:

The diagnosis, medical needs, treatments, developmental level, and functional skills of the child. A diagnosis alone is insufficient information to consider prior authorization of the requested equipment.

The age, length, and weight of the child.

Description of any other devices that have been used, the length of time used, and why they were ineffective.

How the requested equipment will correct or ameliorate the client's condition beyond that of a standard child's crib, regular bed, or standard hospital bed.

The name of the manufacturer and the manufacturer's suggested retail price (MSRP).

A determination will be made by HHSC or its designee whether the equipment will be rented, purchased, repaired, or modified based on the client’s needs, duration of use, and age of equipment. All modifications, adjustments, and repairs within the first six months after delivery are considered to be part of the purchase price.

2.2.13.5Mattresses and Support Surfaces

A pressure-reducing support surface includes three separate groups of mattress or mattress-like equipment designed to assist in the healing of wounds. These devices are used in conjunction with conventional wound care therapy to prevent the occurrence of said wounds in susceptible clients. Pressure-reducing support surfaces are designed to prevent skin breakdown or to promote the healing of pressure ulcers by reducing or eliminating tissue interface pressure. Most of these devices reduce interface pressure by conforming to the contours of the body so that pressure is distributed over a larger surface area rather than concentrated on a more circumscribed location.

For all types of pressure-reducing support surfaces, the support surface provided for the client should be one in which the client does not “bottom out.” The Centers for Medicare & Medicaid Services (CMS) define “bottoming out” as: when an outstretched hand, palm up, between the undersurface of the overlay or mattress and in an area under the bony prominence can readily palpate the bony prominence (coccyx or lateral trochanter). This “bottoming out” criterion should be tested with the client in the supine position with head flat, in the supine position with head slightly elevated (no more than 30 degrees), and in the side-lying position.

Pressure-reducing support surfaces containing multiple components are categorized according to the clinically predominant component (usually the top-most layer of a multi-layer product) and the presence and stage of pressure ulcers.

The staging of pressure ulcers is as follows:

Stage I: Observable pressure related alteration of intact skin whose indicators are as follows:

Compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), or sensation (pain, itching).

The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.

Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Stage III: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

2.2.13.5.1Documentation Requirements

A support surface that does not meet the characteristics specified in the criteria for grouping levels may be denied and considered to be not medically necessary.

To request prior authorization for a pressure-reducing support surface, the following documentation must be provided:

Client’s overall health status and all other medical diagnoses or conditions (e.g., history of decubitus)

Documentation of the client’s limited mobility or confinement to a bed

History of previous use and results of pressure-reducing support surfaces, (e.g., wound improvement, stasis, or degradation)

Current wound therapy, if any

2.2.13.5.2Group 1 Support Surfaces

A group 1 Support Surface may be considered for prior authorization with documentation of medical necessity if the client is completely immobile without assistance, or the client has limited mobility or existing pressure ulcer on the pelvis or trunk and at least one of the following conditions:

Impaired nutritional status

Fecal or urinary incontinence

Altered sensory perception

Compromised circulatory status

All of the support surfaces described below are considered a benefit of the Home Health Services Program when medical necessity criteria for Group 1 support surfaces are met.

Pressure pads or a nonpowered pressure-reducing mattress overlay for mattresses with the following features may be considered for reimbursement with documentation of medical necessity:

A gel or gel-like layer with a height of two inches or greater

An air mattress overlay with interconnected air cells that are inflated with an air pump and a cell height of three inches or greater

A water mattress overlay with a filled height of three inches or greater

A foam mattress overlay with all the following features:

Base thickness of two inches or greater and peak height of three inches or greater if it is a convo­luted overlay (e.g., eggcrate) or an overall height of at least three inches if it is a nonconvoluted overlay

Foam with a density and other qualities that provide adequate pressure reduction

Durable, waterproof cover

Nonpowered pressure-reducing mattresses, with the following features, may be considered for reimbursement with documentation supporting medical necessity:

A foam mattress with all the following features may be considered with documentation supporting medical necessity. Documentation must include all of the following features:

A foam height of five inches or greater

Foam with a density and other qualities that provide adequate pressure reduction

Durable, waterproof cover

Can be placed directly on a hospital bed frame

An air, water, or gel mattress with all the following features may be considered for reimbursement:

A height of five inches or greater

Durable, waterproof cover

A powered pressure reducing mattress overlay system, with all the following features, may be considered for reimbursement when documentation supports medical necessity:

The system includes an air pump or blower which provides either sequential inflation and deflation of air cells, or a low interface pressure throughout the overlay.

Inflated cell height of the air cells through which air is being circulated is 2.5 inches or greater.

Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure provide adequate client lift, reduces pressure, and prevents bottoming out.

2.2.13.5.3Group 2 Support Surfaces

A Group 2 support surface may be considered for prior authorization with documentation of medical necessity if the client has multiple stage II ulcers on the trunk or pelvis and has been on a comprehensive ulcer treatment program for at least the past month which has included the use of a Group 1 support surface.

The client must also have at least one of the following:

The ulcers have remained the same or worsened over the past month.

There are large or multiple stage III or IV pressure ulcers on the trunk or pelvis.

Received a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the last 60 days, and have been prescribed or placed on a Group 2 or 3 support surface immediately before discharge (within the last 30 days) from the hospital or a nursing facility

All of the support surfaces described below are considered a benefit of the Home Health Services Program when medical necessity criteria for Group 2 support surfaces are met.

The powered pressure reducing mattress (alternating pressure low air loss, or powered flotation without air loss) device with all the following features may be considered for reimbursement when documen­tation supports medical necessity:

The system includes an air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress.

Inflated cell height of the air cells through which air is being circulated is five inches or greater.

Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattress), and air pressure to provide adequate client lift, reduce pressure, and prevent bottoming out.

A surface designed to reduce friction and shear.

A semi-electric hospital bed with fully integrated powered pressure-reducing mattress that has all of the features described above may be considered for reimbursement when documentation supports medical necessity.

The advanced nonpowered pressure-reducing mattress overlay device with all the following features may be considered for reimbursement when documentation supports medical necessity:

Height and design of individual cells which provide significantly more pressure reduction than Group 1 overlay and prevent bottoming out

Total height of 3 inches or greater

A surface designed to reduce friction and shear

Manufacturer product information that substantiates the product is effective for the treatment of conditions described by the coverage criteria for Group 2 support surfaces

The powered pressure-reducing mattress overlay device with all the following features may be considered for reimbursement when documentation supports medical necessity:

The system includes an air pump or blower that provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the overlay.

Inflated cell height of the air cells through which air is being circulated is three and a half inches or greater.

Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure to provide adequate client lift, reduce pressure and prevent bottoming out.

The advanced nonpowered pressure-reducing mattress device with all the following features may be considered for reimbursement when documentation supports medical necessity:

Height and design of individual cells designed to provide significantly more pressure than a Group 1 mattress and prevent bottoming out

Total height of 5 inches or greater

A surface designed to reduce friction and shear

Documented evidence substantiates that the product is effective for the treatment of conditions described by the coverage criteria for Group 2 support surfaces

Sheepskin and lambs wool pads are considered a benefit of the Home Health Services Program under the same conditions as alternating pressure pads and mattresses (Group 2 pressure-reducing support surfaces) when prior authorized.

2.2.13.5.4Group 3 Support Surfaces

A Group 3 support surface may be considered for prior authorization with documentation of medical necessity when all the following criteria are met:

There is a presence of a stage III or IV ulcer.

Severely limited mobility rendering the client bed or chair bound.

Without an air-fluidized bed, the client would be institutionalized.

The client has been placed on a Group 2 support surface for at least a month before ordering the air-fluidized bed with the ulcers not improving or worsening.

There has been at least weekly assessment of the wound by the physician, a nurse or other licensed health-care professional and the treating physician has done a comprehensive evaluation of the client’s’s condition within the week before ordering the air-fluidized bed.

A trained adult caregiver is available to assist the client with activities of daily living, maintaining fluid balance, supplying dietary needs, aiding in repositioning and skin care, administering prescribed treatments, recognizing and managing altered mental status, and managing the air-fluidized bed system and its potential problems, such as leakage.

The physician continues to re-evaluate and direct the home treatment regimen monthly.

All other alternative equipment has been considered and ruled out.

The existence of any one of the following conditions may result in noncoverage of the air-fluidized bed:

Coexisting pulmonary disease (the lack of firm back support can render coughing ineffective and dry air inhalation thickens pulmonary secretions).

Wounds requiring moist wound dressings that are not protected with an impervious covering such as plastic wrap or other occlusive material (if wet-to-dry dressings are being utilized, dressing changes must be frequent enough to maintain their effectiveness).

For clients who are 21 years of age and older, the caregiver is unwilling or unable to provide the type of care required by the client who uses an air-fluidized bed.

The home’s structural support or electrical system cannot safely accommodate the air-fluidized bed.

Initial prior authorization for a Group 3 pressure-reducing support surface will be for no more than 30 days. Prior authorized extensions may be considered for reimbursement in increments of 30-day periods, up to a maximum of four months, when documentation supports continued significant improvement in wound healing. Coverage beyond four months will be on a case-by-case basis after review by the medical director or designee.

Air-fluidized beds may be considered for reimbursement when the medical necessity criteria for Group 3 support surfaces are met.

2.2.13.6Equipment and Other Accessories

The following equipment or accessories may be considered with documentation of medical necessity:

Positioning devices

Bed cradle (keeps bed covers from touching affected skin)

Trapeze bars

2.2.13.6.1Accessories

A mattress of any size with innerspring may be considered for prior authorization with procedure code E0271.

Replacement rails and hospital bed frame padding or covers may be considered for prior authorization as a hospital bed accessory (procedure code E0315) with documentation that the padding, covers or rails are required to prevent injury (for example, related to seizure activity) or to prevent entrapment.

2.2.13.6.2Prior Authorization

Heel or elbow protector (procedure code E0191) does not require prior authorization. Prior authori­zation is required for all other hospital beds, equipment, and services provided through Texas Medicaid Title XIX Home Health Services. Prior authorization also includes any accessories, modifications, adjustments, and repairs of the equipment. Positioning cushions or pillows (procedure code E0190) may be considered with documentation of medical necessity that the item will provide pressure relief and positioning in the treatment of decubiti, burns, or musculoskeletal injuries. Documentation must include a listing of other devices that have been used and why the devices proved ineffective.

A trapeze bar attached to a bed (procedure code E0910 or E0911) may be considered if the client requires this device to sit up, to change body position, to get in or out of bed, or for other medical reasons with documentation of medical necessity.

“Free-standing” trapeze equipment (procedure code E0940 or E0912) may be considered if the client does not have an eligible hospital bed, but the client needs this device to sit up, to change body position, to get in or out of bed, or for other medical reasons with documentation of medical necessity.

An over-bed table (procedure code E0315) may be considered if the client is bed-bound and needs the over-bed table for treatments.

2.2.13.7Decubitus Care Accessories

For prior authorization of decubitus care accessories, the following documentation must be provided:

Wound measurements including location, length, width, and depth

Any undermining or tunneling

Odor, if applicable

2.2.13.8Replacement

Beds rails and frames that have been purchased are anticipated to last a minimum of five years.

2.2.13.8.1Prior Authorization

Prior authorization for replacement may be considered within five years of purchase when one of the following occurs:

There has been a significant change in the client’s condition, such that the current equipment no longer meets the client’s needs.

The equipment is no longer functional and cannot be repaired or it is not cost effective to repair.

Replacement of equipment may be considered when loss or irreparable damage has occurred. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent reoccurrence must be submitted.

In situations where the equipment has been abused or neglected by the client, the client’s family, or the caregiver, a referral to the Department of State Health Services (DSHS) Health Screening and Case Management unit will be made by the Home Health Services prior authorization unit for clients who are 20 years of age and younger. Providers will be notified that the state will be monitoring this client’s services to evaluate the safety of the environment for both the client and equipment.

Repairs require replacement of components that are no longer functional. Technician fees are considered to be part of the cost of the repair.

Repairs to client-owned equipment may be considered with documentation of medical necessity.

Providers are responsible for maintaining documentation in the client’s medical record specifying the repairs and supporting medical necessity.

Rental equipment may be considered during the period of repair. Routine maintenance of rented equipment is the provider’s responsibility.

Pediatric hospital cribs and beds, enclosed beds, and safety enclosure frames, canopies, or bubble tops that have been purchased are anticipated to last a minimum of five years.

2.2.13.9Non-covered Items

A safety enclosure (procedure code E0316) used to prevent a client from leaving the bed is not a benefit of Home Health Services. A safety enclosure may be considered through CCP.

Traction equipment (procedure codes E0890, E0947, and E0948) is not a benefit of Home Health Services.

The following types of beds will not be considered for prior authorization, because they are not considered medically necessary or are inappropriate for use in the home setting:

Institutional type beds (procedure code E0270)

An ordinary or standard bed typically sold as furniture (may consist of a frame, box spring, and mattress, and is of fixed height with no head or leg elevation adjustments). These types of beds are not primarily medical in nature, not primarily used in the treatment of disease of injury, and are normally of use in the absence of illness or injury. They are not considered durable medical equipment (DME) by Texas Medicaid.

All non-hospital adjustable beds available to the general public as furniture. These types of beds are not primarily medical in nature, not primarily used in the treatment of disease or injury, and are normally of use in the absence of illness or injury. They are a comfort and convenience item and are not considered DME by Texas Medicaid.

Hospital beds without rails. Texas Medicaid considers side rails an integral part of medically necessary bed.

Beds with rails of any height that do not allow head and foot elevation (e.g., platform beds with rails), and are primarily used to prevent clients from leaving the bed. This types of beds are not primarily medical in nature.

2.2.13.10Hospital Beds and Equipment Procedure Code Table

Procedure Code

Maximum Limitation

E0184

1 purchase every 5 years; 1-month rental

E0185

1 purchase every 5 years; 1-month rental

E0186

1 purchase every 5 years; 1-month rental

E0187

1 purchase every 5 years; 1-month rental

E0188

1 every year

E0189

1 every year

E0193

1 per month

E0194

1 per month

E0196

1 per month

E0197

1 per month

E0198

1 purchase every 5 years; 1-month rental

E0199

1 every 5 years

E0250

1 purchase every 5 years; 1-month rental

E0255

1 purchase every 5 years; 1-month rental

E0260

1 purchase every 5 years; 1-month rental

E0265

1 purchase every 5 years; 1-month rental

E0271

1 every 5 years

E0277

1 per month

E0280

1 purchase every 5 years; 1-month rental

E0303

1 purchase every 5 years; 1-month rental

E0304

1 purchase every 5 years; 1-month rental

E0305

1 every 5 years

E0310

1 every 5 years

E0315

1 every 5 years

E0371

1 purchase every 5 years; 1-month rental

E0372

1 purchase every 5 years; 1-month rental

E0373

1 purchase every 5 years; 1-month rental

E0910

1 purchase every 5 years; 1-month rental

E0911

1 purchase every 5 years; 1-month rental

E0912

1 purchase every 5 years; 1-month rental

E0940

1 purchase every 5 years; 1-month rental

2.2.14Incontinence Supplies

Incontinence supplies, such as diapers, briefs, pull-ons, liners, wipes, and underpads, may be considered for reimbursement through CCP for those clients who are birth through 3 years of age with a medical condition resulting in an increased urine or stool output beyond the typical output for this age group, such as celiac disease, short bowel syndrome, Crohn’s disease, thymic hypoplasia, Acquired Immunode­ficiency Syndrome (AIDS), congenital adrenal hyperplasia, diabetes insipidus, Hirschsprung’s disease, or radiation enteritis.

For clients who are 4 years of age and older, incontinence supplies may be considered through Title XIX Home Health Services when their medical condition results in an impairment of urination and/or stool. For clients who do not meet criteria through Title XIX Home Health Services, incontinence supplies may be considered through CCP with documentation of medical necessity.

Lack of bladder or bowel control is considered normal development for clients who are 4 years of age or younger.

Reusable diapers, briefs, pull-ons, liners, wipes, and underpads are not a benefit of CCP. Gloves used to change diapers, briefs, and pull-ons are not considered medically necessary unless the client has skin breakdown or a documented disease that may be transmitted through the urine.

Incontinence supplies billed for a one-month period must be based on the frequency or quantity ordered by the physician on the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

2.2.14.1Skin Sealants, Protectants, Moisturizers, and Ointments for Incontinence-Associated Dermatitis

Incontinence-associated dermatitis is classified by category:

Category 1—Small area of skin breakdown (<20 cm2) with mild redness (blotchy and non-uniform) and mild erosion involving the epidermis only.

Category 2—Moderate area of skin breakdown (20-50 cm2) with moderate redness (severe in spots, but not uniform in appearance) and moderate erosion involving epidermis and dermis with no or little exudate.

Category 3—Large area of skin breakdown (>50 cm2) with severe redness (uniformly severe in appearance) and severe erosion of epidermis with moderate involvement of the dermis and no or small volume of exudate.

Category 4—Large area of skin breakdown (>50 cm2) with severe redness (uniformly severe in appearance) and extreme erosion of epidermis and dermis with moderate volume of persistent exudate.

Skin sealants, protectants, moisturizers, and ointments (procedure code A6250) may be considered for clients who are 4 years of age or older and have documented incontinence-associated dermatitis.

For clients who have Category 1 or Category 2 incontinence-associated dermatitis, prior authorization is not required for a maximum quantity of 2 containers (no less than 4 ounces per container) per month and 12 containers per year of skin sealants, protectants, moisturizers, and ointments. Providers must use procedure code A6250 with modifier UA to bill for these products.

For clients who have Category 3 or Category 4 incontinence-associated dermatitis, prior authorization and documentation of medical necessity is required for skin sealants, protectants, moisturizers, and ointments that are not used for Category 1 or Category 2 incontinence-associated dermatitis. Providers must use procedure code A6250 without a modifier to bill for these products.

Providers must use procedure code A6250 instead of procedure code A5120 when billing for skin sealants, protectants, moisturizers, and ointments.

Note:Skin sealants, protectants, moisturizers, ointments for diagnoses other than incontinence related dermatitis (i.e., wounds, decubitus ulcers, periwound skin complications, peristomal skin complications) may be considered for reimbursement with prior authorization.

2.2.14.2Diapers, Briefs, Pull-ons, and Liners

Diapers and briefs are defined as incontinence items attached with tabs. Pull-ons are defined as incon­tinence items that do not attach with tabs and are slip-on items, such as “pull-ups.” Liners are intended to be worn inside diapers, briefs, and pull-ons to increase absorbency. Reusable diapers or briefs are not a benefit of Home Health Services.

For clients who are 4 years of age and older and have a medical condition that results in chronic incon­tinence, up to a maximum total combination of 240 per month of diapers, briefs, or liners may be considered without prior authorization. Quantities in excess of 240 per month may be considered with documentation of medical necessity and prior authorization.

The following procedure codes must be used when billing for diapers, briefs, and liners and are limited to a combined total of 240 per month:

Procedure Codes

T4521

T4522

T4523

T4524

T4525

T4526

T4527

T4528

T4529

T4530

T4531

T4532

T4533

T4534

T4535

T4543

T4544

Note:Gloves used to change diapers and briefs are not considered medically necessary unless the client has skin breakdown or a documented disease that may be transmitted through the urine or stool.

2.2.14.3Diaper Wipes

For clients who are 4 years of age and older and are receiving diapers/briefs/pull-ons, up to 2 boxes of diaper wipes do not require prior authorization. Exceptions will not be considered through Title XIX Home Health Services. Quantities in excess of 2 boxes per month may be considered through CCP for clients who are 20 years of age and younger with documentation of medical necessity and prior authorization.

Providers must use procedure code A4335 with modifier U9 instead of procedure code A5120 when billing for diaper wipes.

If there is not an appropriate procedure code for supplies, providers may request prior authorization using procedure code A4335.

Diaper wipes may be considered for clients who are receiving diapers, briefs, or pull-ons through CCP.

2.2.14.4Underpads

For clients who are 4 years of age and older and are receiving diapers/briefs/pull-ons/liners/urine collection devices/bowel management supplies, up to a maximum of 120 underpads per month may be considered without prior authorization. Quantities in excess of 120 per month may be considered with documentation of medical necessity and prior authorization.

Reusable underpads are not a benefit of Home Health Services.

Underpads may be considered for clients who are receiving diapers, briefs, or pull-ons through CCP.

Providers must use procedure code A4554 when billing for underpads. Procedure code A4554 is limited to 120 per month.

Note:The Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form for the supplies listed above must reflect no more than a one-month’s supply of the incontinence product. The Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form must not reflect more than the maximum allowed quantity per month without requesting prior authorization.

2.2.14.5Ostomy Supplies

The physician must specify the type of ostomy device or system to be used and how often it is to be changed on the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. The quantity of ostomy supplies billed for a one-month period must relate to the number of changes per month based on the frequency ordered by the physician.

Ostomy supplies may be considered for reimbursement without prior authorization.

2.2.14.6Indwelling or Intermittent Urine Collection Devices

The home setting is considered a clean environment, not a sterile one. Sterile incontinence supplies, (including the supplies in procedure codes A4311, A4312, A4313, A4314, A4315, A4316, and A4353) are a benefit in the home setting when requested for the following:

Indwelling urinary catheters

Intermittent catheters for clients who:

Are immunosuppressed

Have radiologically documented vesico-ureteral reflux

Are pregnant and have a neurogenic bladder due to spinal cord injury

Have a history of distinct, recurrent urinary tract infections, defined as a minimum of two within the prior 12-month period, while on a program of clean intermittent catheterization

Nonsterile or sterile gloves for use by a health-care provider in the home setting, such as a registered nurse (RN), licensed vocational nurse (LVN), or attendant, are not a benefit of Home Health Services.

2.2.14.6.1Indwelling Catheters and Related Insertion Supplies

Indwelling catheters and related supplies may be considered without prior authorization up to a maximum of 2 per month for clients who have a medical condition that results in an impairment of urination. Quantities in excess of 2 per month may be considered with documentation of medical necessity and prior authorization.

2.2.14.6.2Intermittent Catheters and Related Insertion Supplies

Intermittent catheters and related supplies, up to a maximum of 150 per month, may be considered without prior authorization for clients who have a medical condition that results in an impairment of urination. Quantities in excess of 150 per month may be considered with documentation of medical necessity and prior authorization.

Procedure code A4351 denotes catheters used for intermittent catheterizations. Procedure code A4351 must be accompanied with modifier SC when a hydrophilic catheter is used.

A completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form may be valid for up to 12 months for intermittent catheters and related insertion supplies for quantities within the stated benefit limits for clients who have one of the following chronic conditions:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)

G35

G8221

G8222

G8250

G8253

G8254

G834

N310

N311

N312

N319

Q054

Q057

Q058

Q0701

Q0702

Q0703

Q6410

Q6412

Q6419

Q760

Q794

Note:The diagnosis codes R32 and R339 are not specific enough to allow for the extension of the prior authorization to 12 months.

For clients who have a diagnoses other than those listed in the above table, the completed Title XIX Form may be valid for up to six months for intermittent catheters and related insertion supplies for quantities within the stated benefit limits.

For quantities greater than the stated benefit limits, prior authorization will be required and may be granted for up to six months regardless of diagnosis.

Nonsterile gloves are a benefit with prior authorization when a family member or friend is performing the catheterization.

Providers must use procedure codes A4351 or A4352 when billing for intermittent catheters. Providers must use procedure code A4353 when billing for intermittent catheters with insertion supplies. For hydrophilic catheters, procedure code A4351 must be accompanied with modifier SC.

2.2.14.6.3External Urinary Collection Devices

For clients who are 4 years of age and older and have a medical condition that results in a permanent impairment of urination, external urinary collection devices, including, but not limited to, male external catheters, female collection devices, and related supplies may be considered without prior authorization. Male external catheters are limited to 31 per month. Female collection devices are limited to 4 per month. Male external catheters in excess of 31 per month and female collection devices in excess of 4 per month may be considered with documentation of medical necessity and prior authorization.

External urinary collection devices, including, but not limited to, male external catheters, female collection devices, and related supplies may be considered with a documented medical condition resulting in an increased urine or stool output beyond the typical output.

The following procedure codes must be used when billing for external urinary collection devices:

Procedure Code

Maximum Limitation

A4326

31 per month

A4327

4 per month

A4328

4 per month

A4349

31 per month

2.2.14.6.4Urinals and Bed Pans

Urinals and bed pans may be considered without prior authorization for clients who have a medical condition that results in an inability to ambulate to the bathroom safely (with or without mobility aids) up to a limit of 2 per year. Quantities in excess of 2 per year may be considered with documentation of medical necessity and prior authorization.

Urinals and bed pans are purchase only.

2.2.14.7Prior Authorization

Prior authorization is required for incontinence supplies if amounts greater than the maximum limits are medically necessary.

Prior authorization is required for incontinence supplies through CCP.

A determination is made by HHSC or its designee as to the number of incontinence supplies prior authorized based on the client’s medical needs.

Additional quantities may be considered with documentation of medical necessity.

The quantity of incontinence supplies billed for a one-month period must be consistent with the number of times per day the physician has ordered the supply be used on the CCP Prior Authorization Request Form.

To request prior authorization for incontinence supplies, the following documentation must be provided for the items requested:

Accurate diagnostic information pertaining to the underlying diagnosis or condition as well as any other medical diagnoses or conditions, to include the client’s overall health status

Diagnosis or condition causing increased urination or stooling

Client’s height, weight, and waist size

Number of times per day the physician has ordered the supply be used

Quantity of disposable supplies requested per month

Additional information may be requested to clarify or complete a request for the supplies and equipment.

2.2.14.8Documentation Requirements

To request prior authorization for incontinence supplies and equipment, the following documentation must be provided:

Diagnostic information pertaining to the underlying diagnosis or condition, the diagnosis causing incontinence, and any other medical diagnoses or conditions, including the client’s overall health status

Weight and height or waist size, when applicable

Number of times per day the physician has ordered the supply be used

Quantity of disposable supplies requested per month by the physician

Additional information may be requested to clarify or complete a request for the supplies.

2.2.14.9Incontinence Procedure Codes with Limitations

Any service or combination of services, except diaper wipes, requires prior authorization if the maximum limitation is exceeded. Requests for prior authorization of diaper wipes that exceed more than two boxes per month will not be considered through Home Health Services.

Procedure Code

Maximum Limitation

A4310

2 per month

A4311

2 per month

A4312

2 per month

A4313

2 per month

A4314

2 per month

A4315

2 per month

A4316

2 per month

A4320

2 per month

A4322

4 per month

A4326

31 per month

A4327

4 per month

A4328

4 per month

A4330

As needed

A4331

2 per month

A4332

50 per month

A4333

2 per month

A4334

2 per month

A4335

2 per month

A4338

2 per month

A4340

2 per month

A4344

2 per month

A4346

2 per month

A4349

31 per month

A4351

150 per month

A4352

150 per month

A4353

150 per month

A4354

2 per month

A4355

2 per month

A4356

2 per month

A4357

2 per month

A4358

2 per month

A4360

31 per month

A4361

As needed

A4362

As needed

A4363

As needed

A4364

As needed

A4366

As needed

A4367

As needed

A4368

As needed

A4369

As needed

A4371

As needed

A4372

As needed

A4373

As needed

A4375

As needed

A4376

As needed

A4377

As needed

A4378

As needed

A4379

As needed

A4380

As needed

A4381

As needed

A4382

As needed

A4383

As needed

A4384

As needed

A4385

As needed

A4387

As needed

A4388

As needed

A4389

As needed

A4390

As needed

A4391

As needed

A4392

As needed

A4393

As needed

A4394

As needed

A4395

As needed

A4396

1 per month

A4397

As needed

A4398

As needed

A4399

1 per month

A4400

As needed

A4402

4 per month

A4404

As needed

A4405

As needed

A4406

As needed

A4407

As needed

A4408

As needed

A4409

As needed

A4410

As needed

A4411

As needed

A4412

As needed

A4413

As needed

A4414

As needed

A4415

As needed

A4416

As needed

A4417

As needed

A4418

As needed

A4419

As needed

A4420

As needed

A4421

As needed

A4422

As needed

A4423

As needed

A4424

As needed

A4425

As needed

A4426

As needed

A4427

As needed

A4428

As needed

A4429

As needed

A4430

As needed

A4431

As needed

A4432

As needed

A4433

As needed

A4434

As needed

A4435

As needed

A4455

4 per month

A4456

50 per month

A4554

120 per month

A4927

1 per month

A5051

As needed

A5052

As needed

A5053

As needed

A5054

As needed

A5055

As needed

A5056

As needed

A5057

As needed

A5061

As needed

A5062

As needed

A5063

As needed

A5071

As needed

A5072

As needed

A5073

As needed

A5081

As needed

A5082

As needed

A5083

As needed

A5093

As needed

A5102

2 per month

A5105

4 per year

A5112

2 per month

A5113

2 per month

A5114

2 per month

A5120

50 per month

A5121

As needed

A5122

As needed

A5126

As needed

A5131

1 per month

A5200

2 per month

T4521

*240 per month

T4522

*240 per month

T4523

*240 per month

T4524

*240 per month

T4525

*240 per month

T4526

*240 per month

T4527

*240 per month

T4528

*240 per month

T4529

*240 per month

T4530

*240 per month

T4531

*240 per month

T4532

*240 per month

T4533

*240 per month

T4534

*240 per month

T4535

*240 per month

T4543

*240 per month

T4544

*240 per month

E0275

2 per year

E0276

2 per year

E0325

2 per year

E0326

2 per year

 

Note:Providers must include modifier U1 with procedure code T4528 when submitting claims for bariatric adult size products.

Refer to:  Subsection 2.2.14.2, “Diapers, Briefs, Pull-ons, and Liners” in this handbook for an expla­nation of the item limitations identified with an asterisk (*).

The following procedure codes always require prior authorization even if the maximum benefit limitation allowed has not been exceeded:

Procedure Code

Maximum Limitation

A4927

1 per month

A6250

2 per month

2.2.15Intravenous (IV) Therapy Equipment and Supplies

The following equipment and supplies are used in the delivery of IV therapy and are a benefit of Home Health Services. Additional supply procedure codes may be considered with documentation of medical necessity:

Procedure Code

A4206

A4207

A4208

A4209

A4212

A4222

A4245

A4247

A4248

A4300

A4305

A4306

A4450

A4452

A4602

A4930

A6206

A6207

A6257

A6258

A6402

A9900

E0776

E0779

E0780

E0781

E0791

K0455

K0552

K0601

K0602

K0603

K0604

K0605

S1015

Types of IV access devices include but are not limited to:

Peripheral IV lines.

Central IV lines, including but not limited to, peripherally-inserted central catheters, subclavian catheters, and vena cava catheters.

Central venous lines, including but not limited to, tunneled and peripherally inserted central venous catheters.

Implantable ports, including but not limited to, access devices with subcutaneous ports.

Stopcocks increase the risk of infection and should not be routinely used for infusion administration. Routine use of in-line filters is not recommended for infection control.

Note:Nonsterile or sterile gloves for use by a health-care provider in the home setting, such as an RN, LVN, or attendant, are not a benefit of Home Health Services.

Stationary infusion pumps may be a benefit when the infusion rate must be more consistent and cannot be obtained with gravity drainage. Ambulatory infusion pumps may be a benefit when the length of infusion is greater than two hours, the client must be involved in activities away from home, and when the infusion rate must be more consistent and cannot be obtained with gravity drainage. Elastomeric infusion pumps may be a benefit for short-term use when the caregiver cannot administer the infusion by pump. Dial flow regulators are a benefit and are incorporated into IV extension sets or IV tubing. Elastomeric devices may be reimbursed using procedure codes A4305 and A 4306.

Rental of an infusion pump may be prior authorized on a monthly basis for a maximum of four months per lifetime. Purchase of an infusion pump (ambulatory or stationary) may be prior authorized with documentation of medical necessity that supports repeated IV administration for a chronic condition.

For clients who require cardiovascular medications, infusion pumps will be rented, but not purchased.

Repairs to client-owned equipment may be prior authorized as needed with documentation of medical necessity. Technician fees are considered part of the cost of the repair. Providers are responsible for maintaining documentation in the client’s medical record that specifies the repairs and supports medical necessity. All repairs and replacement parts within the first six months after delivery are considered part of the purchase price. Batteries for client-owned equipment require prior authorization. Additional documentation, such as the purchase date, serial number, and manufacturer’s information, may be required.

IV therapy, supplies, and equipment are not considered a benefit when the infusion or medication being administered:

Is not considered medically necessary to the treatment of the client’s illness.

Exceeds the frequency or duration ordered by the physician.

Is a chemotherapeutic agent.

Is not FDA-approved, unless the physician documents why the off-label use is medically appro­priate and not likely to result in an adverse reaction. In order to consider coverage of an off-label (non-FDA approved) use of a drug, documentation must include why a drug usually indicated for the specific diagnosis or condition has not been effective for the client.

Routine maintenance of rental equipment is included in the rental price.

Repairs or replacement parts may be reimbursed with documentation of a client-owned device.

Replacement batteries (procedure codes K0601, K0602, K0603, K0604, and K0605) for client-owned pumps are limited to one battery per 180 days.

2.2.15.1Prior Authorization

Additional replacement batteries for client-owned pumps (procedure codes K0601, K0602, K0603, K0604, and K0605) beyond the limit of 1 per 180 days may be considered for prior authorization with documentation of medical necessity.

All IV equipment and supplies, with the exception of implantable access catheter (A4300) require prior authorization. Prior authorization of IV equipment and supplies may be considered when adminis­tration of the drug in the home is medically necessary and is appropriate in the home setting. IV equipment may be prior authorized for rental or purchase depending on the clinician’s predicted length of treatment.

The following standards are used when considering prior authorization of IV supplies:

The aseptic technique is acceptable for IV catheter insertion and site care; the sterile technique is not required:

Nonsterile gloves are acceptable for the insertion of a peripheral IV catheter and for changing any IV site dressing.

The sterile technique may be medically necessary. Examples of medical necessity include, but are not limited to, a client who is immuno-compromised.

A peripheral IV site is rotated no more frequently than every 72 hours, but it is rotated at least weekly.

The IV administration set (with or without dial flow regulator), extension set (with or without dial flow regulator), and any add-on devices are changed every 72 hours.

One IV access catheter is used per insertion.

Saline or heparin-locked catheters:

Use one syringe to flush the catheter before administration of an intermittent infusion to assess.

Use two syringes to flush the catheter after the intermittent infusion—one to clear the medication and one to infuse the anticoagulant or other medication used to maintain IV patency between doses, including, but not limited to, heparin.

An injection port is cleaned before administering an intermittent infusion and capped after the infusion.

IV catheter site care:

Disinfect the site with an appropriate antiseptic (including but not limited to 2 percent chlorhex­idine-based preparation, tincture of iodine, or 70 percent alcohol).

Cover with sterile gauze, transparent dressing, or semi-permeable dressing.

Replace the dressing if it becomes damp, loosened, or visibly soiled.

Elastomeric devices and dial flow regulators are specialized infusion devices that may be considered for prior authorization when the device:

Will be used for short-term medication administration (less than two weeks duration).

Is expected to increase client compliance.

Will better facilitate drug administration.

Costs less than the cost of pump rental or tubing.

The caregiver can not administer the infusion by pump.

The following criteria must be met for prior authorization of a stationary infusion pump:

An infusion pump is required to safely administer the drug.

The standard method of administration of the drug is through prolonged infusion or intermittent infusion, and the infusion rate must be more consistent than can be obtained with gravity drainage.

The drug being administered requires IV infusion (i.e., the drug cannot be administered orally, intramuscularly, or by push technique).

The following criteria must be met for prior authorization of an ambulatory infusion pump:

An infusion pump is required to safely administer the drug.

The standard method of administration of the drug is through prolonged infusion or intermittent infusion and the infusion rate must be more consistent than can be obtained with gravity drainage.

The drug being administered requires IV infusion (i.e., the drug cannot be administered orally, intramuscularly, or by push technique).

The infusion administration is more than two hours and the client is involved in activities away from home, including but not limited to, physician visits.

2.2.15.2Documentation Requirements

To request prior authorization for IV supplies and equipment, the following documentation must be provided:

Diagnostic information pertaining to the underlying diagnosis or condition

A physician’s order and documentation supporting medical necessity

The medication and dose being administered, the duration of drug therapy, and the frequency of administration

If additional supplies are needed beyond the standards listed, prior authorization may be considered with documentation supporting medical necessity.

For additional IV access catheters, supporting documentation must have evidence that includes, but is not limited to, the following:

Dehydration

Vein scarring

Fragile veins, including but not limited to, clients who are infants or elderly

For more frequent IV site changes, supporting documentation must have evidence that includes, but is not limited to, the following:

Phlebitis

Infiltration

Extravasation

For more frequent IV tubing or add-on changes, supporting documentation must have evidence that includes, but is not limited to, the following:

Phlebitis

IV catheter-related infection

The administered infusion requires more frequent tubing changes

2.2.16Mobility Aids

Mobility aids and related supplies, including, but not limited to canes, crutches, walkers, wheelchairs, and ramps are a benefit through Title XIX Home Health Services to assist clients to move about in their environment.

Mobility aids and related supplies, including, but not limited to, strollers, special-needs car seats, travel safety restraints, and thoracic-hip-knee-ankle orthoses (THKAO)/parapodiums are a benefit to assist clients to move about in their environment when medically necessary and Federal Financial Partici­pation is available.

Mobility aids and related supplies may be considered for reimbursement through CCP for clients who are 20 years of age or younger who are CCP-eligible when documentation submitted clearly shows that the equipment is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition. Documentation must include the following:

The client’s mobility status would be compromised without the requested equipment.

The requested equipment or supplies are safe for use in the home.

Mobility aids may be considered through CCP if the requested equipment is not available through Title XIX Home Health Services or the client does not meet criteria through Title XIX Home Health Services

Note:A mobility aid for a client who is birth through 20 years of age is medically necessary when it is required to correct or ameliorate a disability or physical illness or condition.

2.2.16.1Canes, Crutches, and Walkers

Canes, crutches, and walkers are a benefit through Title XIX Home Health Services when medically necessary to assist clients to move about in their environment. Walkers require prior authorization. Prior authorization is not required for canes, crutches, or walker accessories. Documentation of medical necessity must be provided by a physician familiar with the client and must include information on the client’s impaired mobility.

2.2.16.2Wheeled Mobility Systems

A wheeled mobility system is a manual or power wheelchair, or scooter that is a customized power or manual mobility device, or a feature or component of the mobility device, including, but not limited to, the following:

Seated positioning components

Manual seating options

Adjustable frame

Other complex or specialized components

A stroller (a multipositional client transfer system with integrated seat, operated by caregiver) for medical needs may be considered for clients who are CCP-eligible when documentation submitted clearly shows that the equipment is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition. Documentation must include the following:

The client does not own another seating system, including, but not limited to, a wheelchair

The client’s condition does not require another type of seating system, including, but not limited to, a wheelchair

If the client does not meet criteria for a stroller, a wheelchair may be considered through Texas Medicaid (Title XIX) Home Health Services.

Scooters may be considered for reimbursement through Texas Medicaid (Title XIX) Home Health Services.

A wheelchair is a non-customized chair mounted on four wheels that incorporates a non-adjustable frame, a sling or solid back and seat, and arm rests. Optional items included in this definition include, but are not limited, to the following:

Handles at the back

Foot rest

Seat belt or safety restraint

A wheelchair includes all of the following:

Standard (manual) wheelchairs

Standard hemi (manual) wheelchairs

Standard reclining (manual) wheelchairs

Lightweight (manual) wheelchairs

High strength lightweight (manual) wheelchairs

2.2.16.2.1Prior Authorization

A wheelchair may be prior authorized for short-term rental or for purchase with documentation supporting medical necessity and an assessment of the accessibility of the client’s residence to ensure that the wheelchair is usable in the home (i.e., doors and halls wide enough, no obstructions). The wheel­chair must be able to accommodate a 20 percent change in the client’s height or weight.

2.2.16.2.2Documentation Requirements

Documentation by a physician familiar with the client must include information on the client’s impaired mobility and physical requirements. In addition, the following information must be submitted with documentation of medical necessity:

Why the client is unable to ambulate a minimum of 10 feet due to their condition (including, but not limited to, AIDS, sickle cell anemia, fractures, a chronic diagnosis, or chemotherapy)

If the client is able to ambulate further than 10 feet, why a wheelchair is required to meet the client’s needs

2.2.16.3Manual Wheelchairs-Standard, Standard Hemi, and Standard Reclining

A standard manual wheelchair is defined as a manual wheelchair that:

Weighs more than 36 pounds.

Does not have features to appropriately accept specialized seating or positioning.

Has a weight capacity of 250 pounds or less.

Has a seat depth of between 15 and 19 inches.

Has a seat width of between 15 and 19 inches.

Has a seat height of 19 inches or greater.

Is fixed height only, fixed, swing away, or detachable armrest.

Is fixed, swing away, or detachable footrest.

A standard hemi (low seat) wheelchair is defined as a manual wheelchair that:

Has the same features as a standard manual wheelchair.

Has a seat to floor height of less than 19 inches.

A standard reclining wheelchair is defined as a manual wheelchair that:

Has the same features as a standard or standard hemi manual wheelchair.

Has the ability to allow the back of the wheelchair to move independently of the seat to provide a change in orientation by opening the seat-to-back angle and, in combination with leg rests, open the knee angle.

2.2.16.3.1Prior Authorization

A standard manual wheelchair may be considered for prior authorization for short-term rental or purchase when all the following criteria are met:

The client has impaired mobility and is unable to ambulate more than 10 feet.

The client does not require specialty seating components.

The client is not expected to need powered mobility within the next 5-year period.

A standard hemi wheelchair may be considered for prior authorization for short-term rental or purchase when the client meets criteria for a standard manual wheelchair and the following criteria is met:

The client requires a low seat-to-floor height.

The client must use their feet to propel the wheelchair.

A standard reclining wheelchair may be considered for prior authorization for short-term rental or purchase when the client meets criteria for a standard manual wheelchair and one or more of the following criteria are met:

The client develops fatigue with longer periods of sitting upright.

The client is at increased risk of pressure sores with prolonged upright position.

The client requires assistance with respirations in a reclining position.

The client needs to perform mobility related activities of daily living (MRADLs) in a reclining position.

The client needs to improve venous return from lower extremity in a reclining position.

The client has severe spasticity.

The client has excess extensor tone of the trunk muscles.

The client has quadriplegia.

The client has a fixed hip angle.

The client must rest in a reclining position two or more times per day.

The client has the inability or has great difficulty transferring from wheelchair to bed.

The client has trunk or lower extremity casts or braces that require the reclining feature for positioning.

2.2.16.4Manual Wheelchairs-Lightweight and High-Strength Lightweight

A lightweight manual wheelchair is defined as a manual wheelchair that:

Has the same features as a standard or hemi manual wheelchair.

Weighs 34 to 36 pounds.

Has available arm styles that are height adjustable.

A high-strength lightweight wheelchair is defined as a manual wheelchair that:

Has the same features as a lightweight manual wheelchair.

Weighs 30 to 34 pounds.

Has a lifetime warranty on side frames and cross braces.

2.2.16.4.1Prior Authorization

A lightweight manual wheelchair may be considered for prior authorization for rental or purchase when all the following criteria are met:

The client is unable to propel a standard manual wheelchair at home.

The client is capable of independently propelling a lightweight wheelchair to meet their MRADLs at home.

A high-strength lightweight wheelchair may be considered for prior authorization for rental or purchase when the client meets all of the criteria for a lightweight manual wheelchair and meets one or more of the following criteria:

The high-strength lightweight wheelchair will allow the client to self-propel while engaging in frequently performed activities that cannot otherwise be completed in a standard or lightweight wheelchair.

The client requires frame dimensions (seat width, depth, or height) that cannot be accommodated in a standard, lightweight, or hemi wheelchair and the wheelchair is used at least 2 hours a day.

2.2.16.5Manual Wheelchairs-Heavy-Duty and Extra Heavy Duty

A heavy duty wheelchair is defined as a manual wheelchair that:

Meets the standard manual wheelchair definition.

Has a weight capacity greater than 250 pounds.

An extra heavy duty wheelchair is defined as a manual wheelchair that:

Meets the standard manual wheelchair definition.

Has a weight capacity greater than 300 pounds.

2.2.16.5.1Prior Authorization

A heavy-duty wheelchair may be considered for prior authorization for short-term rental or purchase when the client has severe spasticity or all the following criteria are met:

The client meets criteria for a standard manual wheelchair.

The client weighs between 250 and 300 pounds.

An extra heavy duty wheelchair may be considered for prior authorization for short-term rental or purchase when all the following criteria are met:

The client meets criteria for a standard manual wheelchair.

The client weighs more than 300 pounds.

2.2.16.6Wheeled Mobility Systems

A wheeled mobility system is a manual or power wheelchair, or scooter that is a customized power or manual mobility device, or a feature or component of the mobility device, including but not limited to, the following:

Seated positioning components

Powered or manual seating options

Specialty driving controls for powered chairs

Adjustable frame

Other complex or specialized components

A wheeled mobility system includes all of the following:

Tilt-in-space (manual) wheelchairs

Pediatric size (manual) wheelchairs and strollers

Custom ultra lightweight (manual) wheelchairs

All power wheelchairs

All scooters

2.2.16.6.1Definitions and Responsibilities

The following definitions and responsibilities apply to the provision of wheeled mobility systems.

Adjustments—The adjustment of a component or feature of a wheeled mobility system.

Adjustments require labor only and do not include the addition, modification, or replacement of components or supplies needed to complete the adjustment.

Texas Medicaid will consider adjustments only to client-owned equipment that is considered a benefit of Texas Medicaid.

Major Modification—The addition of a custom or specialized feature or component of a wheeled mobility system that did not previously exist on the system due to changes in the client’s needs, including, but not limited to, the items listed in this paragraph. This definition also includes the modifi­cation of a custom or specialized feature or component due to a change in the client’s needs, including, but not limited to, the following:

Seated positioning components, including, but not limited to, specialized seating or positioning components

Powered or manual seating options, including, but not limited to, power tilt or recline seating systems and seat elevation systems

Specialty driving controls, including, but not limited to, non-standard alternative power drive control systems

Adjustable frame, including, but not limited to, non-standard seat frame dimensions

Other complex or specialized components, including, but not limited to, power elevating leg rests and specialized electronic interfaces

The replacement of a previously existing custom or specialized feature or component with an identical or comparable component is considered a repair and not a major modification.

Texas Medicaid will consider major modifications only to client-owned equipment that is considered a benefit of Texas Medicaid.

Minor Modification—The addition or modification of non-custom or non-specialized features or components due to changes in the client’s needs, including but not limited to, the following:

Armpads/armrests

Legrests/Leg extensions

Modification of seating and positioning components to accommodate for a change in the client’s size.

The replacement of a previously existing non-custom or non-specialized feature or component with an identical or comparable component is considered a repair and not a minor modification.

Texas Medicaid will consider minor modifications only to client-owned equipment that is considered a benefit of Texas Medicaid.

Mobility Related Activity to Daily Living (MRADL)—An activity of daily living requiring the use of mobility aids (i.e., toileting, feeding, dressing, grooming, and bathing).

Occupational Therapist—A person who is currently licensed by the Executive Council of Physical Therapy & Occupational Therapy Examiners to practice occupational therapy.

Physical Therapist—A person who is currently licensed by the Executive Council of Physical Therapy & Occupational Therapy Examiners to practice physical therapy.

Note:A physical or occupational therapist is responsible for completing the seating assessment of a client required for obtaining a wheeled mobility system.

Qualified Rehabilitation Professional (QRP)—A person who meets one or more of the following criteria:

Holds a certification as an Assistive Technology Professional (ATP) or a Rehabilitation Engineering Technologist (RET) issued by, and in good standing with, the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).

Holds a certification as a Seating and Mobility Specialist (SMS) issued by, and in good standing with, RESNA.

Holds a certification as a Certified Rehabilitation Technology Supplier (CRTS) issued by, and in good standing with, the National Registry of Rehabilitation Technology Suppliers (NRRTS).

The QRP is responsible for:

Being present at and involved in the seating assessment of the client for the rental or purchase of a wheeled mobility system.

Being present at the time of delivery of the wheeled mobility system to direct the fitting of the system to ensure that the system functions correctly relative to the client.

Repairs—The replacement of a component or feature of a wheeled mobility system that is no longer functioning as designed, with an identical or comparable component that does not change the size or function of the system.

Texas Medicaid will consider repairs only to client-owned equipment that is considered a benefit of Texas Medicaid.

Additional Benefit Information

The initial purchase of all manual wheelchairs and wheeled mobility systems must include the wheel­chair base or frame, and the following standard components, which will not be prior authorized separately:

Complete set of standard propulsion and caster wheels, including all of the following:

Propulsion or caster tires of any size, made of solid rubber or plastic

Standard hand rims

Complete wheel lock assembly

Bearings

Standard footrest assembly (fixed, detachable, or swing away), including standard footplates, calf rests/pads, and ratchet assembly

Standard armrests (fixed non-adjustable or detachable non-adjustable), including standard foam or plastic arm pads

Standard seat and back upholstery

Medically necessary non-standard components may be considered for prior authorization with documentation of medical necessity for the requested component. Such components include, but are not limited to, the following:

Flat-free inserts

Foam filled propulsion or caster tires

Pneumatic propulsion or caster tires

Non-standard hand rims (including ergonomic and contoured)

Non-standard length footrests

Custom footrests

Elevating footrests

Angle adjustable footplates

Adjustable height fixed armrests

Adjustable height detachable armrests

Custom size arm pads

Gel arm pads

Arm troughs

Elevating leg rests

Claims for wheelchairs, components, and accessories must be submitted using the most appropriate procedure code that describes the item.

2.2.16.6.2Prior Authorization

A wheeled mobility system may be prior authorized for short-term rental or for purchase with documentation supporting medical necessity and an assessment of the accessibility of the client’s residence to ensure that the wheelchair is usable in the home (i.e., doors and halls wide enough, no obstructions). The wheelchair must be able to accommodate a 20 percent change in the client’s height or weight.

2.2.16.6.3Documentation Requirements

Documentation by a physician familiar with the client must include information on the client’s impaired mobility and physical requirements. In addition, the following information must be submitted with documentation of medical necessity:

Why the client is unable to ambulate a minimum of 10 feet due to their condition (including, but not limited to, AIDS, sickle cell anemia, fractures, a chronic diagnosis, or chemotherapy), or

If the client is able to ambulate further than 10 feet, why a wheelchair is required to meet the client’s needs.

A completed Wheelchair/Scooter/Stroller Seating Assessment Form with seating measurements that includes documentation supporting medical necessity

An itemized component list for custom manual or power wheeled mobility systems.

When medically necessary, prior authorization may also be considered for the rental or purchase of an alternative wheelchair on a case-by-case basis, as follows:

A manual wheelchair will be considered for a client who owns or is requesting a power wheeled mobility system with no custom features.

A manual wheelchair or a manual wheeled mobility system will be considered for a client who owns or is requesting a power wheeled mobility system with custom features.

2.2.16.7Manual Wheeled Mobility System - Tilt-in-Space

A tilt-in-space manual wheeled mobility system is defined as a manual wheelchair that meets the following requirements:

Has the ability to tilt the frame of the wheelchair greater than or equal to 45 degrees from horizontal while maintaining a constant back to seat angle to provide a change of orientation and redistribute pressure from one area (such as the buttocks and the thighs) to another area (such as the trunk and the head)

Adult size has a weight capacity of at least 250 pounds

Pediatric size has a seat width or depth of less than 15 inches

2.2.16.7.1Prior Authorization

A tilt-in-space wheeled mobility system may be considered for prior authorization for short-term rental or purchase when all the following criteria are met:

The client meets criteria for a standard manual wheelchair.

The client has a condition that meets criteria for a tilt-in-space feature, including but not limited to:

Severe spasticity

Hemodynamic problems

Quadriplegia

Excess extensor tone

Range of motion limitations prohibit a reclining system, such as hip flexors, hamstrings, or even heterotopic ossification

The need to rest in a recumbent position two or more times per day and the client has an inability to transfer between bed and wheelchair without assistance

Documented weak upper extremity strength or a disease that will lead to weak upper extremities

At risk for skin break down because of inability to reposition body in a chair to relieve pressure areas

2.2.16.8Manual Wheeled Mobility System- Pediatric Size

A pediatric sized wheeled mobility system is defined as a manual standard/custom wheelchair (including those optimally configured for propulsion or custom seating) that has a seat width or depth of less than 15 inches.

2.2.16.9Manual Wheeled Mobility System -Custom (Includes Custom Ultra-Lightweight)

Custom manual wheeled mobility systems may be considered for a client who meets criteria for a manual wheelchair, has a condition that requires specialized seating, and cannot safely utilize a standard manual wheelchair.

A custom ultra lightweight wheeled mobility system is defined as an optimally configured wheelchair for independent propulsion which cannot be achieved in a standard, lightweight, or high-strength light­weight wheelchair that:

Meets the high-strength lightweight definition and weighs less than 30 pounds.

Has one or more of the following features to appropriately accept specialized seating or positioning:

Adjustable seat-to-back angle

Adjustable seat depth

Independently adjustable front and rear seat-to-floor dimensions

Adjustable caster stem hardware

Adjustable rear axle

Adjustable wheel camber

Adjustable center of gravity

Has a lifetime warranty on side frames and cross braces

2.2.16.9.1Prior Authorization

A custom ultra-lightweight wheeled mobility system may be considered for prior authorization for rental or purchase when the client meets all the criteria for a lightweight manual wheelchair and one or more of the following criteria:

The client is able to self-propel, will have independent mobility with the use of an optimally configured chair, and meets all of the following criteria:

The client uses the wheelchair for a significant portion of their day to complete MRADLs.

The client uses the wheelchair in the community to complete MRADLs.

Powered mobility is not anticipated within the next 5-year period.

The client is able to self-propel, will have independent mobility with the use of an optimally configured chair, has a medical condition that cannot be accommodated by the seating available on a standard, lightweight, or high-strength lightweight wheelchair and one or more of the following features needed by the client to ensure optimal independence with MRADLs:

Adjustable seat to back angle.

Adjustable seat depth.

Independently adjustable front and rear seat-to-floor dimensions.

Adjustable caster stem hardware.

Adjustable rear axle (adjustable center of gravity).

Powered mobility is not anticipated within the next 5-year period.

The client meets all of the following criteria:

The client is unable to self-propel.

The client has a documented condition that requires custom seating, including, but not limited to:

Poor trunk control.

Contractures of elbow or shoulders.

Muscle spasticity.

Tone imbalance through shoulders or back.

Kyphosis or Lordosis.

Lack of flexibility in pelvis or spine.

The client requires custom seating that cannot be accommodated on a standard, lightweight, or hemi-wheelchair.

Prior authorization for labor to create a custom molded seating system is limited to a maximum of 15 hours.

A medical stroller does not have the capacity to accommodate the client’s growth. Strollers for medical use may be considered for prior authorization when all of the following criteria are met:

The client weighs 30 pounds or more.

The client does not already own another seating system, including, but not limited to, a standard or custom wheelchair.

The stroller must have a firm back and seat, or insert.

The client is expected to be ambulatory within one year of the request date or is not expected to need a wheelchair within two years of the request date.

To request prior authorization for the purchase of procedure code E1035, the criteria must be met for the level of stroller requested:

Level One, Basic Stroller—The client meets the criteria for a stroller. Providers must use procedure code E1035.

Level Two, Stroller with Tray for Oxygen or Ventilator—The client meets the criteria for a level-one stroller and is oxygen- or ventilator-dependent. Providers must use procedure code E1035 with modifier TF.

Level Three, Stroller with Positioning Inserts—The client meets the criteria for a level-one or level-two stroller and requires additional positioning support. Providers must use procedure code E1035 with modifier TG.

The following supporting documentation must be submitted:

A completed Wheelchair/Stroller Seating Assessment Form that includes documentation supporting medical necessity. This documentation must address why the client is unable to ambulate a minimum of 10 feet due to his or her condition (including, but not limited to, AIDS, sickle cell anemia, fractures, a chronic diagnosis, or chemotherapy), or if able to ambulate further, why a stroller is required to meet the client’s needs.

If the client is three years of age or older, documentation must support that the client’s condition, stature, weight, and positioning needs allow adequate support from a stroller.

Note:A stroller may be considered on a case-by-case basis with documentation of medical necessity for a client who does not meet the criteria listed above.

A seating assessment must be completed by a physician or licensed occupational therapist or physical therapist, who is not employed by the equipment supplier, before requesting prior authorization.

2.2.16.10Seating Assessment for Manual and Power Custom Wheelchairs

A seating assessment is required for:

The rental or purchase of any device meeting the definition of a wheeled mobility system as defined in subsection 2.2.16.6, “Wheeled Mobility Systems” in this handbook.

The purchase of any device meeting the definition of a wheelchair as defined under subsection 2.2.16.2, “Wheeled Mobility Systems” in this handbook for a client with a congenital or neurological condition, myopathy, or skeletal deformity, which requires the use of a wheelchair.

A seating assessment is required for the rental or purchase of any device meeting the definition of a wheeled mobility system or purchase of any device meeting the definition of a wheelchair for a client with a congenital or neurological condition, myopathy, or skeletal deformity that requires the use of a wheelchair as defined under subsection 2.6.9.1.2, “Wheeled Mobility Systems” in this handbook.

A seating assessment with measurements, including specifications for exact mobility/seating equipment and all necessary accessories, must be completed by a physician, licensed occupational therapist, or licensed physical therapist.

A QRP directly employed or contracted by the DME provider must be present at and participate in all seating assessments, including those provided by a physician.

Upon completion of the seating assessment, the QRP must attest to his or her participation in the assessment by signing the Wheelchair/Scooter/Stroller Seating Assessment Form. This form must be submitted with all requests for wheeled mobility systems.

When the practitioner completing the seating assessment is an occupational or physical therapist, the occupational or physical therapist may perform the seating assessment as the therapist, or as the QRP, but may not perform in both roles at the same time. If the occupational or physical therapist is attending the seating assessment as the QRP, the occupational or physical therapist must meet the credentialing requirements and be enrolled in Texas Medicaid as a QRP.

If the practitioner completing the seating assessment is a physician, the seating assessment is considered part of the evaluation and management service provided.

If the seating assessment is completed by a physician, reimbursement is considered part of the physician’s office visit and will not be reimbursed separately.

2.2.16.10.1Prior Authorization

A seating assessment performed by an occupational therapist, physical therapist, or a physician, with the participation of a QRP, does not require prior authorization. A seating assessment performed by a physician is considered part of the physician evaluation and management service.

The QRP’s participation in the seating assessment requires authorization before the service can be reimbursed. Authorization must be requested at the same time and on the same prior authorization request form as the prior authorization request for the QRP fitting and the wheeled mobility system or major modification to the wheeled mobility system.

Prior authorization requests for the QRP’s participation in the seating assessment will be returned to the provider if the seating assessment is requested separately from the prior authorization for the QRP fitting and the wheeled mobility system or major modification to the wheeled mobility system.

The QRP participating in the seating assessment must be directly employed by or contracted with the DME provider requesting the wheeled mobility system or major modification to a wheeled mobility system.

An authorization for the QRP’s participation in the seating assessment for a wheeled mobility system or major modification to a wheeled mobility system may be issued to the QRP in 15-minute increments, for a time period of up to one hour (4 units).

If the seating assessment is completed by a physician, reimbursement is considered part of the physician office visit and will not be reimbursed separately.

If the seating assessment is completed by a physician, reimbursement is considered part of the physician office visit and will not be reimbursed separately.

The physical therapist completing the seating assessment must submit procedure code 97542 with the GP and UC modifiers to bill for the seating assessment.

The occupational therapist completing the seating assessment must submit procedure code 97542 with the GO and UC modifiers to bill for the seating assessment.

Services for the QRP’s participation in the seating assessment must be submitted for reimbursement by the DME provider billing for the wheeled mobility system using procedure code 97542 with modifier U1. The DME provider must include the QRP specialty as the performing provider on the claim for all components of the wheeled mobility system, including the QRP’s participation in the seating assessment.

Seating assessments are reimbursed in 15-minute increments (units) and are limited to four units (one hour).

2.2.16.10.2Documentation Requirements

The seating assessment must clearly show that the equipment is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition.

Documentation must include the following:

Explain how the client or family will be trained in the use of the equipment.

Anticipate changes in the client’s needs and include anticipated modifications or accessory needs, as well as the growth potential of the wheelchair. A wheelchair must have growth potential that will accommodate a 20 percent change in the client’s height and/or weight.

Include significant medical information pertinent to the client’s mobility and how the requested equipment will accommodate these needs, including intellectual, postural, physical, sensory (visual and auditory), and physical status.

Address trunk and head control, balance, arm and hand function, existence and severity of ortho­pedic deformities, as well as any recent changes in the client’s physical and/or functional status, and any expected or potential surgeries that will improve or further limit mobility.

Include information on the client’s current mobility/seating equipment, how long the client has been in the current equipment and why it no longer meets the client’s needs.

Include the client’s height, weight, and a description of where the equipment is to be used.

Include seating measurements.

Include the accessibility of client’s residence.

Include manufacturer’s information, including the description of the specific base, any attached seating system components, and any attached accessories, as well as the manufacturer’s retail pricing information and itemized pricing for manually priced components.

Include documentation supporting medical necessity for all accessories.

Be documented on the Wheelchair/Scooter/Stroller Seating Assessment Form, which must be signed and dated by the qualified practitioner completing the assessment (occupational therapist, physical therapist, or physician), and the QRP who was present and participated in the assessment. All signatures and dates must be current, unaltered, original, and handwritten. Computerized or stamped signatures and dates will not be accepted.

Be submitted with the prior authorization request for the wheeled mobility system. The Form must be completed, signed and dated as outlined above.

2.2.16.11Fitting of Custom Wheeled Mobility Systems

The fitting of a wheeled mobility system is defined as the time the QRP spends with the client fitting the various systems and components of the system to the client. It may also include time spent training the client or caregiver in the use of the wheeled mobility system. Time spent setting up the system, or travel time without the client present, is not included.

A fitting is required for any device meeting the definition of a wheeled mobility system as defined under subsection 2.2.16.6, “Wheeled Mobility Systems” in this handbook.

The fitting of a wheeled mobility system must be:

Performed by the same QRP that was present for, and participated in, the seating assessment of the client.

Completed prior to submitting a claim for reimbursement of a wheeled mobility system.

The QRP performing the fitting will:

Verify the wheeled mobility system has been properly fitted to the client.

Verify that the wheeled mobility system will meet the client’s functional needs for seating, positioning, and mobility.

Verify that the client, parent, guardian of the client, and/or caregiver of the client has received training and instruction regarding the wheeled mobility system’s proper use and maintenance.

The QRP must complete and sign the DME Certification and Receipt form after the wheeled mobility system has been delivered and fitted to the client. Completion of this form by the QRP signifies that all components of the fitting as outlined above have been satisfied. The form must be completed prior to submission of a claim for a wheeled mobility system, and submitted to HHSC’s designee according to instructions on the form to allow for proper claims processing.

Services for fitting of a wheeled mobility system by the QRP must be submitted for reimbursement by the DME provider of the wheeled mobility system using procedure code 97542 with modifier U2. The DME provider must list the QRP who participated in the seating assessment as the performing provider on the claim for all components of the wheeled mobility system, including the fitting performed by the QRP.

All adjustments and modifications to the wheeled mobility system, as well as the associated services by the QRP for the seating assessment and fitting, within the first six months after delivery are considered part of the purchase price and will not be separately reimbursed.

Procedure code 97542 with modifier U2 must be billed on the same claim as the procedure code(s) for the wheeled mobility system in order for both services to be reimbursed.

2.2.16.11.1Prior Authorization

Prior authorization is required for the QRP performing the fitting of a wheeled mobility system, and must be included with the request for the wheeled mobility system.

The QRP must be directly employed by or contracted with the DME company providing the system, and must be the same QRP who was present at and participated in the client’s seating assessment.

A prior authorization may be issued to the QRP in 15-minute increments, for a time period of up to two hours (8 units), for the fitting of any manual or power wheeled mobility system. Up to one additional hour (4 units) may be authorized to the QRP with documentation of medical necessity demonstrating that fitting of three or more major systems is required, or that additional client training is required for such systems. Major systems can include, but are not limited to, the following:

Complete complex seating system (planar system with trunk supports and hip supports or abductor or custom contoured seating system such as a molded system) Off-the-shelf seat and back cushions do not constitute a complex seating system.

Alternative drive controls (such as a head array, mini-proportional system, etc.).

Additional specialty control features (such as infrared access).

Power positioning features (such as power tilt, power recline).

Specific purpose specialty features (such as power seat elevation systems, power elevating leg rests).

2.2.16.11.2Documentation Requirements

When the QRP that participated in the assessment of the client is not available to conduct the fitting of the wheeled mobility system, the DME provider must update the prior authorization for the wheeled mobility system and fitting by submitting all of the following information:

A letter written on the DME provider’s letterhead, signed and dated by a representative of the DME provider other than the new QRP.

Documentation explaining why the original QRP could not conduct the fitting. Examples may include, but are not limited to, documentation that the QRP:

Is no longer associated with the DME provider requesting the wheeled mobility system.

Is on an extended leave from the DME provider requesting the wheeled mobility system.

Note:For purposes of this policy, an extended leave is any leave of more than 30 consecutive calendar days.

The name, TPI, and NPI of the original QRP who performed the initial assessment, and the date the assessment was completed.

The name, TPI, and NPI of the QRP who will be performing the fitting.

A copy of the original, physician-signed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

A copy of this documentation must be maintained by the provider in the client’s medical record and be available upon request by HHSC or its designee.

2.2.16.12Power Wheeled Mobility Systems- Group 1 through Group 5

A power wheeled mobility system or powered mobility device (PMD) is a professionally manufactured device that provides motorized wheeled mobility and body support specifically for individuals with impaired mobility. PMDs are four- or six-wheeled motorized vehicles whose steering is operated by an electronic device or joystick to control direction, turning, and alternative electronic functions, such as seat controls.

Each PMD must include all of the following basic components that may not be billed separately:

Lap belt or safety belt (This does not include multiple-attachment-point positioning belts or padded belts.)

Battery charger, single mode

Batteries (initial)

Complete set of tires and casters, any type

Leg rests

Foot rests or foot platform

Arm rests

Any weight-specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by client weight capacity

Controller and input device

The following definitions apply to PMDs:

No-Power Option - A category of PMDs that cannot accommodate a power tilt, recline, or seat elevation system. A PMD that can accept only power-elevating leg rests is considered to be a no-power option chair.

Single-Power Option - A category of PMDs that can accept and operate a power tilt, power recline, or a power seat elevation system, but not a combination power tilt and recline seating system. A single-power option PMD might be able to accommodate power elevating leg rests, or seat elevator, in combination with a power tilt or power recline. A PMD does not have to be able to accommodate all features to meet this definition.

Multiple-Power Option - A category of PMDs that can accept and operate a combination power tilt and recline seating system. A multiple-power option PMD might also be able to accommodate power elevating leg rests, or a power seat elevator. A PMD does not have to accommodate all features to qualify to meet this definition.

2.2.16.12.1Prior Authorization

Prior authorization for a power wheeled mobility system/PMD requires the following documentation in addition to all documentation required for a custom manual wheelchair:

The client’s physical and mental ability to receive and follow instructions related to responsibilities of using equipment. The client must be able to operate a PMD independently. The therapist must provide written documentation that the client is physically and cognitively capable of managing a PMD.

How the PMD will be operated (i.e., joystick, head pointer, puff-and-go).

The capability of the client to understand how the PMD operates.

The capability of the caregiver or client to care for the PMD and accessories.

2.2.16.12.2Group 1 PMDs

All Group 1 PMDs must have all the specified basic components and meet all the following requirements:

Standard integrated or remote proportional joystick

Nonexpandable controller

Incapable of upgrade to expandable controller

Incapable of upgrade to alternative control devices

May have cross brace construction

Accommodates nonpowered options and seating systems (e.g., recline-only backs, manually elevating leg rests [except captains chairs])

Length - less than or equal to 40 inches

Width - less than or equal to 24 inches

Minimum top end speed - 3 mph

Minimum range - 5 miles

Minimum obstacle climb - 20 mm

Dynamic stability incline - 6 degrees

Prior Authorization Requirements

A Group 1 PMD may be considered for prior authorization for rental or purchase when all the following criteria are met:

The client will use the PMD for less than 2 hours per day.

The client will use the PMD indoors on smooth, hard surfaces.

The client will not encounter obstacles in excess of 0.75 inch.

2.2.16.12.3Group 2 PMDs

All Group 2 PMDs must have all the specified basic components and meet all the following requirements:

Standard integrated or remote proportional joystick

May have cross brace construction

Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medical thigh supports [except captains chairs])

Length - less than or equal to 48 inches

Width - less than or equal to 34 inches

Minimum top end speed - 3 mph

Minimum range - 7 miles

Minimum obstacle climb - 40 mm

Dynamic stability incline - 6 degrees

Prior Authorization Requirements

A Group 2 PMD may be considered for prior authorization for rental or purchase when the following criteria are met:

The client will use the PMD for 2 or more hours per day.

The client will not routinely use the PMD for MRADLs outside the home.

The client will not encounter obstacles in excess of 1.5 inches.

2.2.16.12.4Group 3 PMDs

All Group 3 PMDs must have all the specified basic components and meet all the following requirements:

Standard integrated or remote proportional joystick

Nonexpandable controller

Capable of upgrade to expandable controller

Capable of upgrade to alternative control devices

May not have cross brace construction

Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports [except captains chairs])

Drive wheel suspension to reduce vibration

Length - less than or equal to 48 inches

Width - less than or equal to 34 inches

Minimum top end speed - 4.5 mph

Minimum range - 12 miles

Minimum obstacle climb - 60 mm

Dynamic stability incline - 7.5 degrees

Prior Authorization Requirements

A Group 3 PMD may be considered for prior authorization for rental or purchase when the following criteria are met:

The client’s mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.

The client may routinely use the PMD for MRADLs outside of the home.

The client will use the PMD primarily on smooth or paved surfaces.

The client will not encounter obstacles in excess of 2.5 inches.

2.2.16.12.5Group 4 PMDs

All Group 4 PMDs must have all the specified basic components and meet all the following requirements:

Standard integrated or remote proportional joystick

Nonexpandable controller

Capable of upgrade to expandable controller

Capable of upgrade to alternative control devices

May not have cross brace construction

Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports [except captains chairs])

Drive wheel suspension to reduce vibration

Length - less than or equal to 48 inches

Width - less than or equal to 34 inches

Minimum top end speed - 6 mph

Minimum range - 16 miles

Minimum obstacle climb - 75 mm

Dynamic stability incline - 9 degrees

Prior Authorization Requirements

A Group 4 PMD may be considered for prior authorization for rental or purchase when all the following criteria are met:

In addition to using the PMD in the home, the client will routinely use the PMD for MRADLs outside the home.

The client will routinely use the PMD on rough, unpaved or uneven surfaces.

The client will encounter obstacles in excess of 2.25 inches.

The client has a documented medical need for a feature that is not available on a lower level PMD.

Documentation Requirements

The submitted documentation for a Group 4 PMD must include a completed assessment that is signed and dated by a physician or a licensed occupational or physical therapist and includes the following:

A description of the environment where the PMD will be used in the routine performance of MRADLs.

A listing of the MRADLs that would be possible with the use of a Group 4 PMD that would not be possible without the Group 4 PMD.

The distance the client is expected to routinely travel on a daily basis with the Group 4 PMD.

Note:The enhanced features found on a Group 4 PMD must be medically necessary to meet the client’s routine MRADL and will not be approved for leisure or recreational activities.

In addition to meeting criteria for Group 2 through Group 4 PMDs, the submitted documentation of medical necessity must demonstrate that the client requires the requested power option (e.g., the need for a power recline or tilt in space, or a combination power tilt and power recline), the no-power option, single-power option, or multiple-power option as defined in subsection 2.2.16.12, “Power Wheeled Mobility Systems- Group 1 through Group 5” in this handbook.

2.2.16.12.6Additional Requirements - Group 2 through Group 4 No-Power Option

Group 2 through Group 4 no-power option PMDs must have all the specified basic components and meet all the following requirements:

Nonexpandable controller

Incapable of upgrade to expandable controller

Incapable of upgrade to alternative control devices

Meets the definition of no-power option

Accommodates nonpowered options and seating systems (e.g., recline-only backs, manually elevating leg rests [except captains chairs])

2.2.16.12.7Group 2 through Group 4 Single-Power Option

Group 2 through Group 4 single-power option PMDs must have all the specified basic components and meet all the following requirements:

Nonexpandable controller

Capable of upgrade to expandable controller

Capable of upgrade to alternative control devices

Meets the definition of single-power option

2.2.16.12.8Group 2 through Group 4 Multiple-Power Option

Group 2 through Group 4 multiple-power option PMDs must have all the specified basic components and meet all the following requirements:

Nonexpandable controller

Capable of upgrade to expandable controller

Meets the definition of multiple-power option

Accommodates a ventilator

2.2.16.12.9Group 5 PMDs

All Group 5 PMDs must have all the specified basic components and meet all the following requirements:

Standard integrated or remote joystick

Nonexpandable controller

Capable of upgrade to expandable controller

Seat width - minimum of 5 one-inch options

Seat depth - minimum of 3 one-inch options

Seat height - adjustment requirements = 3 inches

Back height - adjustment requirements minimum of 3 options

Seat-to-back angle range of adjustment - minimum of 12 degrees

Accommodates nonpowered options and seating systems

Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports)

Adjustability for growth (minimum of 3 inches for width, depth, and back height adjustment)

Special developmental capability (i.e., seat to floor, standing, etc.)

Drive wheel suspension to reduce vibration

Length - less than or equal to 48 inches

Width - less than or equal to 34 inches

Minimum top end speed - 4 mph

Minimum range - 12 miles

Minimum obstacle climb - 60 mm

Dynamic stability incline - 9 degrees

Passed crash test

Prior Authorization Requirements

A Group 5 pediatric PMD may be considered for prior authorization for rental or purchase when all the following criteria are met:

The client weighs less than 125 pounds.

The client is expected to grow in height.

The client may require growth of up to 5 inches in width.

The client may require a change in seat to floor height up to 3 inches.

The client may require a seat to back angle range of adjustment in excess of 12 degrees.

The client requires special developmental capability (i.e., seat to floor, standing, etc.).

2.2.16.12.10Group 5 Single-PMDs

A group 5 single-power option PMD must have all the specified basic components and have the capability to accept and operate a power tilt or recline or seat elevation system, but not a combination power tilt and recline seating system, and may be able to accommodate power elevating leg rests, or seat elevator, in combination with a power tilt or power recline.

Prior Authorization Requirements

A Group 5 pediatric PMD with single power option may be considered for prior authorization for rental or purchase when all the following criteria are met:

The client meets criteria for a Group 5 PMD.

The client requires a drive control interface other than a hand or chin-operated standard propor­tional joystick (examples include but are not limited to head control, sip and puff, or switch control).

2.2.16.12.11Group 5 Multiple-PMDs

Group 5 multiple-power option PMD must have all the specified basic components and meet all the following requirements:

Has the capability to accept and operate a combination power tilt and recline seating system, and may also be able to accommodate power elevating leg rests, or a power seat elevator.

Accommodates a ventilator.

Prior Authorization Requirements

A Group 5 pediatric PMD with multiple power option may be considered for prior authorization for rental or purchase when the following criteria are met:

The client meets criteria for a Group 5 PMD.

The client requires a drive control interface other than a hand or chin-operated standard propor­tional joystick (examples include but are not limited to head control, sip and puff, switch control).

The client has a documented medical need for a power tilt and recline seating system and the system is being used on the wheelchair or the client uses a ventilator which is mounted on the wheelchair.

2.2.16.13Wheelchair Ramp-Portable and Threshold

Portable and threshold ramps are a benefit of Texas Medicaid.

A portable ramp is defined as a unit that is able to be carried as needed to access a home, weighs no more than 90 pounds, or measures no more than 10 feet in length. A threshold ramp is defined as a unit that provides access over elevated thresholds.

Portable ramps exceeding the above criteria may be considered on a case-by-case basis with documen­tation of medical necessity and a statement that the requested equipment is safe for use.

One portable ramp and one threshold ramp for wheelchair or stroller access may be considered for prior authorization when documentation supports medical necessity. The following documentation supporting medical necessity is required:

The date of purchase and serial number of the client’s wheelchair or documentation of a wheelchair request being reviewed for purchase

Diagnosis with duration of expected need

A diagram of the house showing the access points with the ground-to-floor elevation and any obstacles

Providers must use procedure code E1399 for the purchase of portable and threshold stroller ramps.

A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply.

Note:Permanent ramps, vehicle ramps, and home modifications are not a benefit of Texas Medicaid.

Ramps may be considered for rental for short term disabilities and for purchase for long term disabil­ities. Mobility aid lifts for vehicles and vehicle modifications are not a benefit of Texas Medicaid.

2.2.16.14Power Elevating Leg Lifts

A power elevation feature involves a dedicated motor and related electronics with or without variable speed programmability, which allows the leg rest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s).

2.2.16.14.1Prior Authorization

Power elevating leg lifts may be prior authorized for clients who have compromised upper extremity function that limits the client’s ability to use manual elevating leg rests. The client must meet criteria for a PMD with a reclining back and at least one of the following:

The client has a musculoskeletal condition such as flexion contractures of the knees and legs, or the placement of a brace that prevents 90-degree flexion at the knee.

The client has significant edema of the lower extremities that requires elevating the client’s legs.

The client experiences hypotensive episodes that require frequent positioning changes.

The client needs power tilt-and-recline and is required to maintain anatomically correct positioning and reduce exposure to skin shear.

2.2.16.14.2Documentation Requirements

The submitted documentation must include an assessment completed, signed, and dated by a physician or a licensed occupational or physical therapist that includes the following:

A description of the client’s current level of function without the device

Documentation that identifies how the power elevating leg lifts will improve the client’s function

A list of MRADLs the client will be able to perform with the power elevating leg lifts that the client is unable to perform without the power elevating leg lifts and how the device will increase independence

The duration of time the client is alone during the day without assistance

The client’s goals for use of the power elevating leg lifts

2.2.16.15Power Seat Elevation System

A power seat elevation system is used to raise and lower the client in their seated position without changing the seat angles to provide varying amounts of added vertical access.

The use of a power seat elevation system will:

Facilitate independent transfers, particularly uphill transfers, to and from the wheelchair, and

Augment the client’s reach to facilitate independent performance of MRADLs in the home.

2.2.16.15.1Prior Authorization

A power seat elevation system may be prior authorized to promote independence in a client who meets all of the following criteria:

The client does not have the ability to stand or pivot transfer independently.

The client requires assistance only with transfers across unequal seat heights, and as a result of having the power seat elevation system, the client will be able to transfer across unequal seat heights unassisted.

The client has limited reach and range of motion in the shoulder or hand that prohibits independent performance of MRADLs (such as, dressing, feeding, grooming, hygiene, meal preparation, and toileting).

2.2.16.15.2Documentation Requirements

The submitted documentation must include an assessment completed, signed, and dated by a physician or a licensed occupational or physical therapist that includes the following:

A description of the client’s current level of function without the device

Documentation that identifies how the power seat elevation system will improve the client’s function

A list of MRADLs the client will be able to perform with the power seat elevation system that the client is unable to perform without the power seat elevation system and how the device will increase independence

The duration of time the client is alone during the day without assistance

The client’s goals for use of the power seat elevation system

Note:A power seat elevation system option will not be authorized for the convenience of a caregiver, or if the device will not allow the client to become independent with MRADLs and transfers.

2.2.16.16Seat Lift Mechanisms

A medically necessary seat lift mechanism is one that operates smoothly, can be controlled by the client, and effectively assists the client in standing up and sitting down without other assistance.

The payment for a recliner or chair with the incorporated seat lift mechanism is limited to the amount of the seat lift mechanism.

2.2.16.16.1Prior Authorization

A seat lift mechanism may be prior authorized for clients who meet all the following criteria:

The client must have severe arthritis of the hip or knee or have a severe neuromuscular disease.

The seat lift mechanism must be a part of the physician’s course of treatment and be prescribed to correct or ameliorate the client’s condition.

Once standing, the client must have the ability to ambulate.

The client must be completely incapable of standing up from a regular armchair or any chair in their home.

Note:The fact that a client has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all clients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.

Seat lift mechanisms are limited to those types that operate smoothly, can be controlled by the client, and can effectively assist a client in standing up and sitting down without other assistance. A seat lift operated by a spring release mechanism with a sudden, catapult-like motion and jolts the client from a seated to a standing position is not a benefit of Texas Medicaid.

2.2.16.16.2Documentation Requirements

The submitted documentation must include an assessment completed, signed, and dated by a physician or a licensed occupational or physical therapist that includes the following:

A description of the client’s current level of function without the device

Documentation that identifies how the seat lift mechanism will improve the client’s function

A list of MRADLs the client will be able to perform with the seat lift mechanism that the client is unable to perform without the seat lift mechanism and how the device will increase independence

The duration of time the client is alone during the day without assistance

The client’s goals for use of the seat lift mechanism

Supporting documentation must be kept in the client’s record that shows that all appropriate therapeutic modalities (such as medication, physical therapy) have been tried and that they failed to enable the client to transfer from a chair to a standing position.

2.2.16.17Batteries and Battery Charger

A battery charger and initial batteries are included as part of the purchase of a PMD. Replacement batteries or a replacement battery charger may be considered for reimbursement if they are no longer under warranty.

A maximum of one hour of labor may be considered to install new batteries. Labor is not reimbursed with the purchase of a new PMD or with replacement battery chargers.

2.2.16.17.1Prior Authorization

Batteries and battery chargers will not be prior authorized for replacement within six months of delivery. Batteries and battery chargers within the first six months after delivery are considered part of the purchase price.

A maximum of one hour of labor may be prior authorized to install new batteries. Labor will not be prior authorized for a new power wheelchair or for replacement battery chargers.

2.2.16.17.2Documentation Requirements

To request prior authorization for replacement batteries or a replacement battery charger, the provider must document the date of purchase and serial number of the currently owned wheelchair as well as the reason for the replacement batteries or battery charger.

Documentation required supporting the need to replace the batteries or battery charger must include:

Why the batteries are no longer meeting the client’s needs, or

Why the battery charger is no longer meeting the client’s needs

2.2.16.18Power Wheeled Mobility Systems- Scooter

A scooter is a professionally manufactured three- or four-wheeled motorized base operated by a tiller with a professionally manufactured basic seating system for clients who have little or no positioning needs.

A scooter must meet all the following requirements:

Length- less than or equal to 48 inches

Width- less than or equal to 28 inches

Minimum top end speed- 3 mph

Minimum range- 5 miles

Minimum obstacle climb- 20 mm

Radius pivot turn of less than or equal to 54 inches

Dynamic stability incline- 6 degrees

Custom seating for scooters is not a benefit of Texas Medicaid Title XIX Home Health Services. Repairs to scooters will be considered only for a scooter purchased by the Texas Medicaid.

2.2.16.18.1Prior Authorization

A scooter may be prior authorized for ambulatory-impaired clients with good head, trunk, and arm/hand control, without a diagnosis of progressive illness (including, but not limited to, progressive neuromuscular diseases such as amyotrophic lateral sclerosis [ALS]).

To request prior authorization for a scooter, the client must not own, or be expected to require, a power wheelchair within five years of the purchase of a scooter.

A scooter may be prior authorized for a short-term rental or an initial three-month trial rental period based on documentation supporting the medical necessity and appropriateness of the device.

Assessment of the accessibility of the client’s residence must be completed and included in the prior authorization documentation to ensure that the scooter is usable in the home (i.e., doors and halls wide enough, no obstructions).

A scooter must be able to accommodate a 20 percent change in the client’s height and/or weight.

2.2.16.18.2Documentation Requirements

Prior authorization for a scooter requires all the documentation required for a standard power wheel­chair and meets all the following criteria:

The client’s physical and cognitive ability to receive and follow instructions related to the responsi­bilities of using the equipment.

The ability of the client to physically and cognitively operate the scooter independently.

The capability of the client to care for the scooter and understand how it operates.

2.2.16.19Client Lift

A lift is a portable transfer system used to move a nonambulatory client over a short distance from bed to chair and chair to bed.

A client lift for the convenience of a caregiver is not a benefit of Texas Medicaid.

A hydraulic lift is for a client who is unable to assist in their own transfers and is operated by the weight or pressure of a liquid.

An electric lift is operated by electricity and may be considered when a hydraulic lift will not meet the client’s needs.

2.2.16.19.1Prior Authorization

A client lift will not be prior authorized for the convenience of a caregiver.

A client limit must be able to accommodate a 20 percent change in the client’s height and/or weight.

 

2.2.16.20Portable Client Lifts for Outside the Home Setting

Portable client lifts are a benefit for clients who are 21 years of age and younger. Providers must use procedure code E0635 with modifier TG for the purchase of the portable client lift and is limited to once per lifetime, any provider. Portable electric lifts are a benefit of Texas Medicaid if they can fold-up for transport and can be used outside the home setting if the client must attend health- related services that require an overnight stay in a noninstitutional setting.

2.2.16.20.1Prior Authorization

Prior authorization is required and will be considered on a case-by-case basis for portable client electric lifts that can fold-up for transport and that are necessary for use outside the home setting.

The provider must submit a prior authorization request with the following documentation for consid­eration of medical necessity:

An explanation of why a home-based portable lift will not meet the client’s needs.

A description of the circumstances, including duration of need, when the client is required to attend health-related services requiring an overnight stay in a non-institutional setting.

The family member or caregiver(s) supporting the client in the use of the portable client lift when required to travel outside the home setting for health related visits.

2.2.16.21Electric Lift

Prior authorization for an electric lift may be considered when the client meets criteria for a hydraulic lift and additional documentation explains why a hydraulic lift will not meet the client’s needs.

2.2.16.22Hydraulic Lift

Hydraulic lifts require prior authorization.

2.2.16.22.1Documentation Requirements

Prior authorization for a hydraulic lift may be considered with the following documentation:

The inability of the client to assist in their own transfers

The weight of the client and the weight capacity of the requested lift

The availability of a caregiver to operate the lift

Training by the provider to the client and the caregiver on the safe use of the lift

2.2.16.23Standers

A stander is a device used by a client with neuromuscular conditions who is unable to stand alone. Standers and standing programs can improve digestion, increase muscle strength, decrease contrac­tures, increase bone density, and minimize decalcification (this list is not all inclusive).

2.2.16.23.1Prior Authorization

Standers, including all accessories, require prior authorization. Standers and gait trainers will not be prior authorized for a client within one year of each other.

2.2.16.23.2Documentation Requirements

Prior authorization may be considered for the standers with the following documentation:

Diagnoses relevant to the requested equipment, including functioning level and ambulatory status

Anticipated benefits of the equipment

Frequency and duration of the client’s standing program

Anticipated length of time the client will require this equipment

Client’s height, weight, and age

Anticipated changes in the client’s needs, anticipated modifications, or accessory needs, as well as the growth potential of the stander

2.2.16.24Gait Trainers

Gait trainers are devices with wheels used to train clients with ambulatory potential. They provide the same benefits as the stander, in addition to assisting with gait training.

2.2.16.24.1Prior Authorization

Prior authorization for a gait trainer may be considered with documentation supporting medical necessity and an assessment of the accessibility of the client’s residence to ensure that the gait trainer is usable in the home (i.e., doors and halls are wide enough and have no obstructions), when a physician familiar with the client documents that the client has ambulatory potential and will benefit from a gait training program, and when the client meets the criteria for a stander.

2.2.16.25Feeder Seats, Floor sitters, Corner Chairs, and Travel Chairs

Feeder seats, floor sitters, corner chairs, and travel chairs are not considered medically necessary and are not a benefit of CCP. If a client requires seating support and meets the criteria for a seating system, a stroller may be considered for reimbursement with prior authorization through CCP, or a wheelchair may be considered through Texas Medicaid (Title XIX) Home Health Services.

2.2.16.26Accessories, Modifications, Adjustments and Repairs

Accessories, modifications, adjustments, and repairs are benefits of Texas Medicaid as outlined below.

All major and minor modifications, adjustments, and repairs to standard mobility aid equipment within the first six months after delivery are considered part of the purchase price.

All modifications and adjustments to a wheeled mobility system, as well as the associated services by the QRP for the seating assessment and fitting, within the first six months after delivery are considered part of the purchase price.

Mobility aids that have been purchased are anticipated to last a minimum of five years.

A major modification to a wheeled mobility system requires the completion of a new seating assessment by a qualified practitioner (physician, occupational therapist, or physical therapist), with the partici­pation of a QRP.

Prior authorization for equipment replacement is considered within five years of equipment purchase when one of the following occurs:

There has been a significant change in the client’s condition such that the current equipment no longer meets the client’s needs.

The equipment is no longer functional and either cannot be repaired or it is not cost-effective to repair.

A wheeled mobility system that has been fitted and delivered to the client’s home by a QRP and then found to be inappropriate for the client’s condition will not be eligible for an upgrade, replacement, or major modification within the first six months following purchase unless there has been a significant change in the client’s condition. The significant change in the client’s condition must be documented by a physician familiar with the client.

2.2.16.26.1Prior Authorization

Modifications

Modifications to custom equipment after the first six months from fitting and delivery may be considered for prior authorization if a change occurs in the client’s needs, capabilities or physical/mental capability, that cannot be anticipated.

Documentation supporting the medical necessity of the requested modification must include the following:

Description of the change in the client’s condition that requires accommodation by different seating, drive controls, electronics, or other mobility base components.

All projected changes in the client’s mobility needs.

The date of purchase, the serial number of the current equipment, and the cost of purchasing new equipment versus modifying current equipment.

Major modifications to a wheeled mobility system also require that a new seating assessment be completed by a qualified practitioner (physician, physical therapist, or occupational therapist) and submitted with the prior authorization request. A request for authorization of the QRP’s participation in the seating assessment for the major modification must be included with the prior authorization request for the major modification.

Minor modifications to a wheeled mobility system do not require the completion of a new seating assessment.

Requests for equipment submitted as a minor modification or a repair to a wheeled mobility system must be submitted with modifier RB.

Adjustments

Adjustments within the first six months after delivery, including adjustments to a wheeled mobility system within the first six months after fitting and delivery by a QRP will not be prior authorized.

A seating or positioning component alteration that does not require replacement components to accom­modate a change in the client’s size (height or weight) is considered an adjustment and not a major modification.

A maximum of one hour of labor for adjustments may be prior authorized as needed after the first six months from delivery.

Documentation must include the date of purchase, the serial number of the current equipment, and the reason for adjustments.

Repairs

Repairs to client-owned equipment may be considered for prior authorization as needed with documen­tation of medical necessity. Technician fees are considered part of the cost of the repair.

HHSC or its designee reserves the right to request additional documentation about the need for repairs when there is evidence of abuse or neglect to equipment by the client, client’s family, or caregiver. Requests for repairs when there is documented proof of abuse or neglect will not be authorized.

Requests for equipment submitted as a repair to a wheeled mobility system must be submitted with modifier RB.

Providers are responsible for maintaining documentation in the client’s medical record specifying the repairs and supporting medical necessity.

Documentation must include the date of purchase and serial number of the current equipment, the cause of the damage or need for repairs, the steps the client or caregiver will take to prevent further damage if repairs are due to an accident, and when requested, the cost of purchasing new equipment as opposed to repairing current equipment.

2.2.16.27Replacement

Replacement of equipment is also considered when loss or irreparable damage has occurred. The following must be submitted with the prior authorization request:

A copy of the police or fire report, when appropriate.

A statement about the measures to be taken in order to prevent reoccurrence.

Replacement equipment for clients who are birth through 20 years of age and do not meet the criteria in this handbook may be considered for prior authorization through CCP.

2.2.16.28Procedure Codes and Limitations for Mobility Aids

Procedure Code

Maximum Limit

Canes

E0100

1 per 5 years

E0105

1 per 5 years

Crutches

A4635

As needed

E0110

1 purchase every 5 years

E0111

1 purchase every 5 years; 1-month rental

E0112

1 purchase every 5 years; 1-month rental

E0113

1 purchase every 5 years; 1-month rental

E0114

1 purchase every 5 years; 1-month rental

E0116

1 purchase every 5 years; 1-month rental

E0153

1 purchase every 5 years

Walkers

A4636

1 per month

A4637

As needed

E0130

1 purchase every 5 years; 1-month rental

E0135

1 purchase every 5 years; 1-month rental

E0141

1 purchase every 5 years; 1-month rental

E0143

1 purchase every 5 years; 1-month rental

E0144

1 purchase every 5 years; 1-month rental

E0147

1 purchase every 5 years; 1-month rental

E0148

1 purchase every 5 years; 1-month rental

E0149

1 purchase every 5 years; 1-month rental

E0154

1 per 5 years

E0155

1 per 5 years

E0157

1 per 5 years

E0158

1 per 5 years

E0159

1 per 5 years

Gait Trainers

E8001

1 purchase every 5 years

Wheelchairs

E1050

1 per month

E1060

1 per month

E1070

1 per month

E1100

1 per month

E1110

1 per month

E1161

1 purchase every 5 years; 1-month rental

E1220

1 per 5 years

E1229

1 per 5 years

E1231

1 purchase every 5 years; 1-month rental

E1232

1 purchase every 5 years; 1-month rental

E1233

1 purchase every 5 years; 1-month rental

E1234

1 purchase every 5 years; 1-month rental

E1235

1 purchase every 5 years; 1-month rental

E1236

1 purchase every 5 years; 1-month rental

E1237

1 purchase every 5 years; 1-month rental

E1238

1 purchase every 5 years; 1-month rental

E1239

1 per 5 years

Power Wheelchairs

K0001

1 purchase every 5 years; 1-month rental

K0002

1 purchase every 5 years; 1-month rental

K0003

1 purchase every 5 years; 1-month rental

K0004

1 purchase every 5 years; 1-month rental

K0005

1 purchase every 5 years; 1-month rental

K0006

1 purchase every 5 years; 1-month rental

K0007

1 purchase every 5 years; 1-month rental

K0008

1 purchase every 5 years; 1-month rental

K0009

1 purchase every 5 years; 1-month rental

K0010

1 per 5 years

K0011

1 per 5 years

K0012

1 per 5 years

K0013

1 purchase every 5 years; 1-month rental

K0015

As needed

K0017

As needed

K0018

As needed

K0019

As needed

K0020

As needed

K0037

As needed

K0038

As needed

K0039

As needed

K0040

As needed

K0041

As needed

K0042

As needed

K0043

As needed

K0044

As needed

K0045

As needed

K0046

As needed; 1 per month

K0047

As needed; 1 per month

K0050

As needed

K0051

As needed

K0052

As needed

K0053

As needed; 1 per month

K0056

As needed

K0065

As needed

K0069

As needed; 1 per month

K0070

As needed

K0071

As needed

K0072

As needed

K0073

As needed

K0077

As needed

K0098

As needed

K0105

As needed; 1 per month

K0195

As needed; 1 per month

K0669

As needed

K0813

1 purchase every 5 years; 1-month rental

K0814

1 purchase every 5 years; 1-month rental

K0815

1 purchase every 5 years; 1-month rental

K0816

1 purchase every 5 years; 1-month rental

K0820

1 purchase every 5 years; 1-month rental

K0821

1 purchase every 5 years; 1-month rental

K0822

1 purchase every 5 years; 1-month rental

K0823

1 purchase every 5 years; 1-month rental

K0824

1 purchase every 5 years; 1-month rental

K0825

1 purchase every 5 years; 1-month rental

K0826

1 purchase every 5 years; 1-month rental

K0827

1 purchase every 5 years; 1-month rental

K0828

1 purchase every 5 years; 1-month rental

K0829

1 purchase every 5 years; 1-month rental

K0835

1 purchase every 5 years; 1-month rental

K0836

1 purchase every 5 years; 1-month rental

K0837

1 purchase every 5 years; 1-month rental

K0838

1 purchase every 5 years; 1-month rental

K0839

1 purchase every 5 years; 1-month rental

K0840

1 purchase every 5 years; 1-month rental

K0841

1 purchase every 5 years; 1-month rental

K0842

1 purchase every 5 years; 1-month rental

K0843

1 purchase every 5 years; 1-month rental

K0848

1 purchase every 5 years; 1-month rental

K0849

1 purchase every 5 years; 1-month rental

K0850

1 purchase every 5 years; 1-month rental

K0851

1 purchase every 5 years; 1-month rental

K0852

1 purchase every 5 years; 1-month rental

K0853

1 purchase every 5 years; 1-month rental

K0854

1 purchase every 5 years; 1-month rental

K0855

1 purchase every 5 years; 1-month rental

K0856

1 purchase every 5 years; 1-month rental

K0857

1 purchase every 5 years; 1-month rental

K0858

1 purchase every 5 years; 1-month rental

K0859

1 purchase every 5 years; 1-month rental

K0860

1 purchase every 5 years; 1-month rental

K0861

1 purchase every 5 years; 1-month rental

K0862

1 purchase every 5 years; 1-month rental

K0863

1 purchase every 5 years; 1-month rental

K0864

1 purchase every 5 years; 1-month rental

K0868

1 purchase every 5 years; 1-month rental

K0869

1 purchase every 5 years; 1-month rental

K0870

1 purchase every 5 years; 1-month rental

K0871

1 purchase every 5 years; 1-month rental

K0877

1 purchase every 5 years; 1-month rental

K0878

1 purchase every 5 years; 1-month rental

K0879

1 purchase every 5 years; 1-month rental

K0880

1 purchase every 5 years; 1-month rental

K0884

1 purchase every 5 years; 1-month rental

K0885

1 purchase every 5 years; 1-month rental

K0886

1 purchase every 5 years; 1-month rental

K0890

1 purchase every 5 years; 1-month rental

K0891

1 purchase every 5 years; 1-month rental

K0898

1 purchase every 5 years; 1-month rental

K0899

1 purchase every 5 years; 1-month rental

K0900

1 purchase every 5 years; 1-month rental

Scooters

E1230

1 per 5 years

K0800

1 per 5 years

K0801

1 per 5 years

K0802

1 per 5 years

Wheelchair Parts

E0942

1 per year

E0944

2 per year

E0945

2 per year

E0950

1 per year

E0951

2 per year

E0952

2 per year

E0955

As needed

E0956

As needed

E0957

As needed

E0958

1 per year

E0959

As needed; 1 per month

E0960

As needed

E0961

2 per year

E0967

As needed; 1 per month

E0969

1 per 5 years

E0970

1 pair per year

E0971

2 per year

E0973

2 per year

E0974

2 per year

E0978

1 per year

E0980

1 per year

E0981

As needed

E0982

As needed

E0990

2 per year; 1 per month

E0992

1 per year

E0994

2 per year

E0995

2 per year

E1002

1 per 5 years

E1003

1 per 5 years

E1004

1 per 5 years

E1005

1 per 5 years

E1006

1 per 5 years

E1007

1 per 5 years

E1008

1 per 5 years

E1009

1 per 5 years

E1010

1 per 5 years

E1011

As needed

E1014

1 per 5 years

E1015

2 per year

E1016

2 per year

E1017

2 per year

E1018

2 per year

E1020

1 per 5 years

E1028

1 per 5 years

E1029

1 per 5 years

E1225

As needed; 1 per month

E1226

As needed; 1 per month

E2201

1 per 5 years

E2202

1 per 5 years

E2203

1 per 5 years

E2204

1 per 5 years

E2205

1 per 5 years

E2206

1 per 5 years

E2207

1 purchase every 5 years

E2208

1 purchase every 5 years

E2209

1 purchase every 5 years

E2210

4 per year

E2211

2 per year

E2212

2 per year

E2213

2 per year

E2214

2 per year

E2215

2 per year

E2216

2 per year

E2217

2 per year

E2218

2 per year

E2219

2 per year

E2220

2 per year

E2221

2 per year

E2222

2 per year

E2224

2 per year

E2225

2 per year

E2226

2 per year

E2227

1 per 5 years

E2228

1 per 5 years

E2291

1 per 5 years

E2292

1 per 5 years

E2293

1 per 5 years

E2294

1 per 5 years

E2300

1 per 5 years

E2310

1 per 5 years

E2311

1 per 5 years

E2312

1 purchase every 5 years; 1-month rental

E2313

1 per 5 years

E2321

1 per 5 years

E2323

1 per 5 years

E2324

1 per 5 years

E2325

1 per 5 years

E2326

1 per 5 years

E2327

1 per 5 years

E2328

1 per 5 years

E2329

1 per 5 years

E2330

1 per 5 years

E2340

1 per 5 years

E2341

1 per 5 years

E2342

1 per 5 years

E2343

1 per 5 years

E2351

1 per 5 years

E2359

1 per 5 years

E2368

1 per 5 years

E2369

1 per 5 years

E2370

1 per 5 years

E2373

1 per 5 years

E2374

1 per 5 years

E2375

1 per 5 years

E2376

1 per 5 years

E2377

1 per 5 years

E2378

1 per 5 years

E2381

2 per year

E2382

2 per year

E2383

2 per year

E2384

2 per year

E2385

2 per year

E2386

2 per year

E2387

2 per year

E2388

2 per year

E2389

2 per year

E2390

2 per year

E2391

2 per year

E2392

2 per year

E2394

1 per 5 years

E2395

1 per 5 years

E2396

1 per 5 years

Wheelchair/Pressure/Positioning Cushions

E0190

1 per 3 years

E2601

1 per year

E2602

1 per year

E2603

1 per year

E2604

1 per year

E2605

1 per year

E2606

1 per year

E2607

1 per year

E2608

1 per year

E2609

1 per year

E2611

1 per year

E2612

1 per year

E2613

1 per year

E2614

1 per year

E2615

1 per year

E2616

1 per year

E2617

1 per year

E2619

1 per year

E2620

1 per year

E2621

1 per year

E2622

1 per year

E2623

1 per year

E2624

1 per year

E2625

1 per year

Batteries

E2361

1 per 5 years

E2363

1 per 5 years

E2366

1 per 5 years

E2371

1 per 5 years

K0733

2 per year

Safety Equipment

E0700

2 per year

E0705

1 per 5 years

Lifts

E0627

1 per 5 years

E0629

1 per 5 years

E0630

1 per 5 years

E0635

1 per 5 years

E0638

1 per 5 years

E0641

1 per 5 years

Miscellaneous

A9900

As needed

E1399

As needed

K0108

As needed

K0739

As needed

The following mobility aids are not a benefit of Home Health Services:

Feeder seats, floor sitters, corner chairs, and travel chairs are not considered medically necessary devices

Items including but not limited to tire pumps, a color for a wheelchair, gloves, back packs, and flags are not considered medically necessary

Mobile standers, power standing system on a wheeled mobility device

Vehicle lifts and modifications

Permanent ramps, vehicle ramps, and home modifications

Stairwell lifts of any type

Elevators or platform lifts of any type

Patient lifts requiring attachment to walls, ceilings, or floors

Chairs with incorporated seat lifts

An attendant control, for safety, all power chairs are to include a stop switch

Powered mobility device for use only outside the home

Texas Medicaid does not reimburse separately for associated DME charges, including battery disposal fees or state taxes. Reimbursement for associated charges is included in the reimbursement for the specific piece of equipment. White canes for the blind are considered self help adaptive aids and are not a benefit of Home Health Services.

2.2.17Nutritional (Enteral) Products, Supplies, and Equipment

Medical nutritional products including enteral formulas and food thickener, may be approved for clients who have specialized nutritional requirements.

Medical nutritional products must be prescribed by a physician and be medically necessary.

Enteral nutritional products are those food products that are included in an enteral treatment protocol. They serve as a therapeutic agent for health maintenance and are required to treat an identified medical condition. Nutritional products, supplies, and equipment may be a benefit when provided in the home under Home Health Services.

2.2.17.1Enteral Nutritional Products, Feeding Pumps, and Feeding Supplies

Enteral nutritional products and related feeding supplies and equipment are a benefit through Home Health Services for clients who are 21 years of age and older and require tube feeding as their primary source of nutrition. The enteral product, supply, or equipment must be part of the medical POC outlined and maintained by the treating physician.

Enteral nutritional products may be reimbursed with the following procedure codes:

Procedure Codes

B4100

B4103

B4104

B4149

B4150

B4152

B4153

B4154

B4155

B4157

B4158

B4159

B4160

B4161

B4162

Enteral formulas consisting of semi-synthetic intact protein or protein isolates (procedure codes B4150 and B4152) are appropriate for the majority of clients requiring enteral nutrition.

Special enteral formulas or additives (procedure code B4104) may be considered for prior authorization with supporting documentation submitted by the client’s physician indicating the client’s medical needs for these special enteral formulas.

Special enteral formula may be reimbursed with the following procedure codes:

Procedure Codes

B4149

B4153

B4154

B4155

B4157

B4161

B4162

Pediatric nutritional products (procedure codes B4103, B4158, B4159, B4160, B4161, and B4162) are restricted to clients who are 20 years of age and younger.

Food thickener may be considered for clients with a swallowing disorder.

Enteral nutritional supplies and equipment may be reimbursed with the following procedure codes and limitations:

Procedure Codes

Limitations

A4322

4 per month

A5200

2 per month

B4034

Up to 31 per month

B4035

Up to 31 per month

B4036

Up to 31 per month

B4081

As needed

B4082

As needed

B4083

As needed

B4087

2 per rolling year

B4088

2 per rolling year

B9002

1 purchase every 5 years; 1 rental per month

B9998*

As needed*

B9998 with modifier U1

4 per month

B9998 with modifier U2

2 per rolling year

B9998 with modifier U3

4 per month

B9998 with modifier U4

2 per rolling year

B9998 with modifier U5

4 per month

T1999*

As needed*
If procedure code T1999 is used for a needleless syringe, the allowed amount is 8 per month.

* Appropriate limitations for miscellaneous procedure codes B9998 and T1999 are determined on a case-by-case basis through prior authorization. Specific items may be requested using procedure code B9998 using the modifiers outlined in the table above.

2.2.17.2Prior Authorization Requirements

Prior authorization is required for most enteral products, supplies, and equipment provided through Home Health Services. Requests are reviewed for medically necessary amounts based on caloric needs as indicated by the client’s physician.

2.2.17.2.1Clients who are 21 years of age and older

Enteral nutrition and related supplies and equipment may be considered for prior authorization for clients who are 21 years of age and older when all or part of the client’s nutritional intake is received through a feeding tube, and the enteral formula is:

The client’s sole source of nutrition

The client’s primary source of nutrition

An enteral tube feeding is considered the primary source of nutrition when it comprises more than 70 percent of the caloric intake needed to maintain the client’s weight.

The percent of calories provided by an enteral formula may be calculated by dividing the client’s daily calories supplied by the enteral formula by the daily caloric intake ordered by the physician to maintain the client’s weight. The result is multiplied by 100 to determine the percentage of calories provided by the enteral formula.

Related supplies and equipment may be considered for prior authorization when criteria for nutritional products are met, and medical necessity is included for each item requested.

Renewal of the prior authorization will be considered based on medical necessity.

Prior authorization may be given for up to 6 months. Prior authorization may be recertified with documentation supporting ongoing medical necessity for the nutritional products requested.

2.2.17.2.2Clients who are 20 years of age and younger

Prior authorization for nutritional products is not required for a client who is 20 years of age and younger and who meets at least one of the following criteria:

Client receives all or part of their nutritional intake through a tube.

Client has a metabolic disorder that has been documented with one of the following diagnosis codes:

Diagnosis Codes

C880

C965

C966

D472

D800

D801

D802

D803

D804

D805

D806

D807

D808

D809

D810

D811

D812

D814

D816

D817

D8189

D819

D820

D821

D822

D823

D824

D828

D829

D830

D831

D832

D838

D839

D840

D841

D848

D849

D890

D891

D893

D8982

D8989

D899

E201

E670

E671

E672

E673

E678

E68

E700

E701

E7020

E7021

E7029

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E70311

E70318

E70319

E70320

E70321

E70328

E70329

E70330

E70331

E70338

E70339

E7039

E7040

E7041

E7049

E705

E708

E709

E710

E71110

E71111

E71118

E71120

E71121

E71128

E7119

E712

E7130

E71310

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E7132

E7139

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E71440

E71448

E7150

E71510

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E71518

E71520

E71521

E71522

E71528

E71529

E7153

E71540

E71541

E71542

E71548

E7200

E7201

E7202

E7203

E7204

E7209

E7210

E7211

E7212

E7219

E7220

E7221

E7222

E7223

E7229

E723

E724

E7250

E7251

E7252

E7253

E7259

E728

E729

E730

E738

E739

E7400

E7401

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E7403

E7404

E7409

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E7439

E744

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E7529

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E754

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E756

E7601

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E761

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E7622

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E769

E770

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E778

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E781

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E7870

E7879

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E7889

E789

E791

E792

E798

E799

E800

E801

E8020

E8021

E8029

E803

E804

E805

E806

E807

E8300

E8301

E8309

E8310

E8319

E8330

E8331

E8332

E8339

E8340

E8341

E8342

E8349

E8350

E8351

E8352

E8359

E8381

E8389

E839

E840

E8411

E8419

E848

E849

E850

E851

E852

E853

E854

E8581

E8589

E859

E860

E861

E869

E870

E871

E872

E873

E874

E875

E876

E8770

E8779

E878

E8801

E8809

E881

E882

E8840

E8841

E8842

E8849

E8881

E8889

E889

H49811

H49812

H49813

M1000

M10011

M10012

M10019

M10021

M10022

M10029

M10031

M10032

M10039

M10041

M10042

M10049

M10051

M10052

M10059

M10061

M10062

M10069

M10071

M10072

M10079

M1008

M1009

M10111

M10112

M10121

M10122

M10131

M10132

M10141

M10142

M10151

M10152

M10161

M10162

M10171

M10172

M10211

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M10221

M10222

M10231

M10232

M10241

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M10252

M10261

M10262

M10271

M10272

M1030

M10311

M10312

M10319

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M10322

M10329

M10331

M10332

M10339

M10341

M10342

M10349

M10351

M10352

M10359

M10361

M10362

M10369

M10371

M10372

M10379

M1038

M1039

M1040

M10411

M10412

M10419

M10421

M10422

M10429

M10431

M10432

M10439

M10441

M10442

M10449

M10451

M10452

M10459

M10461

M10462

M10469

M10471

M10472

M10479

M1048

M1049

M109

M1A00X0

M1A00X1

M1A0110

M1A0111

M1A0120

M1A0121

M1A0190

M1A0191

M1A0210

M1A0211

M1A0220

M1A0221

M1A0290

M1A0291

M1A0310

M1A0311

M1A0320

M1A0321

M1A0390

M1A0391

M1A0410

M1A0411

M1A0420

M1A0421

M1A0490

M1A0491

M1A0510

M1A0511

M1A0520

M1A0521

M1A0590

M1A0591

M1A0610

M1A0611

M1A0620

M1A0621

M1A0690

M1A0691

M1A0710

M1A0711

M1A0720

M1A0721

M1A0790

M1A0791

M1A08X0

M1A08X1

M1A09X0

M1A09X1

M1A20X0

M1A20X1

M1A2110

M1A2111

M1A2120

M1A2121

M1A2190

M1A2191

M1A2210

M1A2211

M1A2220

M1A2221

M1A2290

M1A2291

M1A2310

M1A2311

M1A2320

M1A2321

M1A2390

M1A2391

M1A2410

M1A2411

M1A2420

M1A2421

M1A2490

M1A2491

M1A2510

M1A2511

M1A2520

M1A2521

M1A2590

M1A2591

M1A2610

M1A2620

M1A2621

M1A2690

M1A2691

M1A2710

M1A2711

M1A2720

M1A2721

M1A2790

M1A2791

M1A28X0

M1A28X1

M1A29X0

M1A29X1

M1A30X0

M1A30X1

M1A3110

M1A3111

M1A3120

M1A3121

M1A3190

M1A3191

M1A3210

M1A3211

M1A3220

M1A3221

M1A3290

M1A3291

M1A3310

M1A3311

M1A3320

M1A3321

M1A3390

M1A3391

M1A3410

M1A3411

M1A3420

M1A3421

M1A3490

M1A3491

M1A3510

M1A3511

M1A3520

M1A3521

M1A3590

M1A3591

M1A3610

M1A3611

M1A3620

M1A3621

M1A3690

M1A3691

M1A3710

M1A3711

M1A3720

M1A3721

M1A3790

M1A3791

M1A38X0

M1A38X1

M1A39X0

M1A39X1

M1A40X0

M1A40X1

M1A4110

M1A4111

M1A4120

M1A4121

M1A4190

M1A4191

M1A4210

M1A4211

M1A4220

M1A4221

M1A4290

M1A4291

M1A4310

M1A4311

M1A4320

M1A4321

M1A4390

M1A4391

M1A4410

M1A4411

M1A4420

M1A4421

M1A4490

M1A4491

M1A4510

M1A4511

M1A4520

M1A4521

M1A4590

M1A4591

M1A4610

M1A4611

M1A4620

M1A4621

M1A4690

M1A4691

M1A4710

M1A4711

M1A4720

M1A4721

M1A4790

M1A4791

M1A48X0

M1A48X1

M1A49X0

M1A49X1

M1A9XX0

M1A9XX1

M359

N200

Z431

Z87738

Z931

Z934

Prior authorization is required for nutritional products that are provided through CCP to clients who do not meet the criteria above.

A completed CCP Prior Authorization Request Form that prescribes the nutritional product and/or related services must be signed and dated by a prescribing physician who was familiar with the client before requesting prior authorization. The completed CCP Prior Authorization Request Form must include the procedure codes and numerical quantities for the services requested. A copy of the completed, signed, and dated CCP Prior Authorization Form must be maintained by the provider in the client’s medical record. The completed CCP Prior Authorization Request Form with the original dated signature must be maintained by the prescribing physician in the client’s medical record.

Requests for prior authorization must include the following documentation:

Accurate diagnostic information pertaining to the underlying diagnosis or condition that resulted in the requirement for a nutritional product, as well as any other medical diagnoses or conditions, including:

The client’s overall health status.

Height and weight.

Growth history and growth charts.

Why the client cannot be maintained on an age-appropriate diet.

Other formulas tried and why they did not meet the client’s needs.

Diagnosis or condition.

The goals and timelines on the medical plan of care.

Total caloric intake prescribed by the physician.

Acknowledgement that the client has a feeding tube in place.

Related supplies and equipment for clients who require nutritional products may be considered for prior authorization when the criteria for nutritional products are met and medical necessity is included for each item requested.

Prior authorization may be given for up to 12 months. Prior authorization may be recertified with documentation that supports the ongoing medical necessity of the requested nutritional products.

A retrospective review may be performed to ensure that the documentation included in the client’s medical record supports the medical necessity of the requested service.

Requests for prior authorization, when required, must include the necessary product information.

Prior authorization of nutritional pudding products may be considered for children who have a documented oropharyngeal motor dysfunction and receive greater than 50 percent of their daily caloric intake from a nutritional pudding product.

Requests for electrolyte replacement products, such as Pedialyte or Oralyte, require documentation of medical necessity, including:

The underlying acute or chronic medical diagnoses or conditions that indicate the need to replace fluid and electrolyte losses.

The presence of mild to moderate dehydration due to the persistent mild to moderate diarrhea or vomiting.

Electrolyte replacement products are not indicated for clients with:

Intractable vomiting

Adynamic ileus

Intestinal obstruction or perforated bowel

Anuria, oliguria, or impaired homeostatic mechanism

Severe, continuing diarrhea, when intended for use as the sole therapy

2.2.17.2.3Enteral Formulas

Enteral formulas require prior authorization. Requests for prior authorization must include the necessary product information.

2.2.17.2.4Nasogastric, Gastrostomy, or Jejunostomy Feeding Tubes

Feeding tubes require prior authorization.

Additional feeding tubes may be prior authorized if documentation submitted supports medical necessity, such as infection at gastrostomy site, leakage, or occlusion.

2.2.17.2.5Enteral Feeding Pumps

Enteral feeding pumps, with and without alarms, require prior authorization.

Enteral feeding pumps may be considered for prior authorization for lease or purchase with documen­tation of medical necessity indicating that the client meets the following criteria:

Gravity or syringe feedings are not medically indicated

The client requires an administration rate of less than 100 ml/hr

The client requires night-time feedings

The client has one of the following medical conditions (this list is not all-inclusive):

Reflux or aspiration

Severe diarrhea

Dumping syndrome

Blood glucose fluctuations

Circulatory overload

2.2.17.2.6Enteral Supplies

Enteral supplies require prior authorization, with the exception of irrigation syringes (procedure code A4322) and percutaneous catheter or tube anchoring devices (procedure code A4520) within the allowable limits.

Procedure code B4034 will not be prior authorized for use in place of procedure code A4322 for irrigation syringes when they are not part of a bolus administration kit.

Gravity bags and pump nutritional containers are included in the feeding supply kits and will not be prior authorized separately.

Specific items may be considered for prior authorization using miscellaneous procedure code B9998 and modifiers U1, U2, U3, or U5.

Requests for a backpack or carrying case for a portable enteral feeding pump may be considered for prior authorization for purchase only, under miscellaneous code B9998, for clients who meet all of the following medical necessity criteria:

The client requires enteral feedings lasting greater than eight hours continuously, or feeding intervals exceed the time that the client must be away from home to:

Attend school or work.

Participate in extensive, physician-ordered outpatient therapies.

Attend frequent, multiple medical appointments.

The client is ambulatory, or uses a wheelchair which will not support the use of a portable pump by other means, such as an IV pole.

The portable enteral feeding pump is client owned.

2.2.17.3Documentation Requirements

To request prior authorization for nutritional formula, supplies, or equipment, the following documen­tation must be provided:

Accurate diagnostic information pertaining to the underlying diagnosis or condition as well as any other medical diagnoses or conditions, to include the client’s overall health status

Diagnosis or condition (including the appropriate International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] code)

A statement from the ordering physician noting that enteral nutritional products for tube feedings are the client’s sole or primary source of nutrition

The goals and timelines on the medical POC

Total caloric intake prescribed by the physician

Acknowledgement that the client has a feeding tube in place

2.2.17.4Nutritional Counseling

Clients for whom nutritional products are being requested may benefit from nutritional counseling. Nutritional counseling is a benefit of CCP if it is provided to treat, prevent, or minimize the effects of illness, injury, or other impairment.

Refer to:  Subsection 2.10, “Medical Nutrition Counseling Services (CCP)” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for information about nutritional counseling.

2.2.17.5Women, Infants, and Children Program (WIC)

Generic nutritional products that have been approved by the United States Department of Agriculture (USDA) for use in the Women, Infants, and Children Program (WIC) may be approved for use by CCP clients.

While CCP does not require that a client access WIC, it is only recommended as another source of services for clients who are 4 years of age and younger, or clients who are pregnant or breast feeding. Nutritional products are not provided to infants who are 11 months of age and younger unless medical necessity is documented.

2.2.17.6Managed Care Clients

Nutritional products that are provided to WIC clients are carved-out of the Medicaid Managed Care Program and must be billed to TMHP for payment consideration. Carved-out services are those that are rendered to Medicaid Managed Care clients but are administered by TMHP and not the client’s managed care organization (MCO).

Nutrition products that are provided to other Medicaid Managed Care Program clients (other than WIC clients) are not carved out and must be submitted to the managed care organization that administers the client’s Medicaid managed care benefits.

2.2.17.7Noncovered Services

CCP will not cover the following:

Nutritional products that are traditionally used for infant feeding.

Nutritional products for the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth. The underlying cause of failure to thrive, gain weight, and lack of growth is required.

Nutritional bars.

Nutritional products for clients who could be sustained on an age-appropriate diet.

2.2.18Orthotic Services (CCP)

Orthoses, including orthopedic shoes, wedges, and lifts, are a benefit of Texas Medicaid when provided by a licensed orthotist or a licensed prosthetist/orthotist through CCP for clients who are birth through 20 years of age.

The following orthoses and related services may be reimbursed when medical necessity criteria are met:

Spinal orthoses and additions to spinal orthoses, including those for scoliosis

Lower-limb orthoses and additions to lower-limb orthoses, including fracture orthoses

Foot orthoses, including inserts, orthopedic shoes, surgical boots, heel lifts, and wedges

Upper-limb orthoses and additions to upper-limb orthoses, including fracture orthoses

Other orthopedic devices, including protective helmets and dynamic splints

Repairs, replacements, and modifications

Orthotic device training

Note:Training in the use of an orthotic device for a client who has not worn one previously, has not worn one for a prolonged period, or is receiving a different type is a benefit when the training is provided by a physical or occupational therapist.

Refer to:  The Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (Vol. 2, Provider Handbooks) for additional information about physical and occupational therapy services.

As defined by the Texas State Board of Orthotics and Prosthetics the following definitions are used by Texas Medicaid:

An orthosis is defined as: A custom-fabricated or custom-fitted medical device designed to provide for the support, alignment, prevention or correction of neuromuscular or musculoskeletal disease, injury, or deformity. The term does not include a fabric or elastic support, corset, arch support, low temperature plastic splint, a truss, elastic hose, cane, crutch, soft cervical collar, orthosis for diagnostic or evaluation purposes, dental appliance, or other similar device carried in stock and sold by a drugstore, department store or corset shop.

A brace is defined as: An orthosis or orthopedic appliance that supports or holds in correct position any movable part of the body, and that allows for motion of that part. It must be a rigid or semirigid device used for the purpose of supporting a weak or deformed body part or restricting or eliminating motion in a diseased or injured body part.

To be considered for reimbursement, orthoses must be dispensed, fabricated, or modified by a licensed orthotist or licensed prosthetist/orthotist enrolled with Medicare and CCP. The following applies:

Upper extremity customized splints made with low-temperature materials and inhibitive casting may be provided by occupational or physical therapists.

Other orthopedic devices addressed in the orthotic section may be provided by a Medicaid-enrolled DME vendor.

Orthopedic shoes must be provided by a shoe vendor enrolled as a DME provider.

The date of service for a custom-made or custom-fitted orthosis is the date the supplier places an order for the equipment and incurs liability for the equipment. The custom-made or custom-fitted orthosis will be eligible for reimbursement as long as the service is provided during a month the client is eligible for Medicaid.

The following items and services are included in the reimbursement for an orthotic device and not reimbursed separately:

Client evaluation, measurement, casting, or fitting of the orthosis.

Repairs due to normal wear and tear during the 90 days following delivery.

Adjustments or modifications of the orthotic device made when fitting the orthosis and for 90 days from the date of delivery (adjustments and modifications during the first 90 days are considered part of the purchase of the initial device).

Orthopedic shoes that are attached to a brace must be billed by the vendor that bills for the brace.

Reimbursement for lifts and wedges may include the cost of the prescription shoe.

2.2.18.1Noncovered Orthotic Services

The following circumstances are not a benefit of Texas Medicaid:

Orthoses whose sole purpose is for restraint

Orthoses provided solely for use during sports-related activities in the absence of an acute injury or other indicated medical condition

Orthotic devices prescribed by a chiropractor

Diagnoses that are not considered medically necessary include, but are not limited to, the following:

Tired feet

Fatigued feet

Nonsevere bow legs

Valgus deformity of the foot, except as outlined in the orthotic section

Pes planus (flat feet), except when there is a coexisting medical condition as outlined in the orthotic section

Orthopedic shoes with deluxe features, such as special colors, special leathers, and special styles, are not considered medically necessary, and the features do not contribute to the accommodative or therapeutic function of the shoe.

A foot-drop splint and recumbent positioning device and replacement interface are not considered medically necessary in a client with foot drop who is nonambulatory, because there are other more appropriate treatment modalities.

A static ankle-foot orthosis (AFO) or AFO component is not medically necessary if:

The contracture is fixed.

The client has foot drop without an ankle flexion contracture.

The component is used to address knee or hip positioning, because the effectiveness of this type of component is not established.

A pneumatic thoracic-lumbar-sacral orthosis is considered experimental and investigational and is not a benefit of Texas Medicaid.

2.2.18.2Prior Authorization and Documentation Requirements

Prior authorization is required for all orthoses and related services.

Before submitting a request for prior authorization for orthosis, the orthosis provider must have a completed CCP Prior Authorization Form requesting the orthosis or related services that has been signed and dated by a physician who is familiar with the client. The completed CCP Prior Authorization Form must include the procedure codes and quantities for requested services. A copy of the completed, signed, and dated form must be maintained by the orthosis provider in the client's medical record. The completed CCP Prior Authorization Form with the original dated signature must be maintained by the prescribing physician in the client's medical record.

To complete the prior authorization process electronically, the orthosis provider must complete the prior authorization requirements through any approved electronic method and retain a copy of the signed and dated CCP Prior Authorization Request form in the client's medical record at the provider's place of business.

To complete the prior authorization process by paper, the orthosis provider must fax or mail the completed CCP Prior Authorization Request Form to the CCP prior authorization unit and retain a copy of the signed and dated CCP form in the client's medical record at the provider's place of business.

To facilitate determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including documentation for medical necessity of the equipment and supplies requested. The physician must maintain documentation of medical necessity in the client's medical record. The provider may be asked for additional information to clarify or complete a request for the service or device.

All requests for prior authorization must include documentation of medical necessity including, but not limited to, documentation that the device is needed for one of the following general indications:

To reduce pain by restricting mobility of the affected body part.

To facilitate healing following an injury to the affected body part or related soft tissue.

To facilitate healing following a surgical procedure on the affected body part or related soft tissue.

To support weak muscles or a deformity of the affected body part.

Prior authorization requests for some types of orthosis require additional documentation. See the appro­priate sections for additional documentation needed for each service.

The provider must keep the following written documentation in the client's medical record:

The prescription for the device.

Orthotic devices must be prescribed by a physician (M.D. or D.O.) or a podiatrist. A podiatrist prescription is valid for conditions of the ankle and foot.

The prescription must be dated on or before the initial date of the requested dates of service, which can be no longer than 90 days from the signature date on the prescription.

Accurate diagnostic information that supports the medical necessity for the requested device. A retrospective review may be performed to ensure that the documentation included in the client's medical record supports the medical necessity of the requested service or device.

A prior authorization is valid for a maximum period of six months from the prescription signature date.

At the end of the six-month authorization period, a new prescription is required for prior authorization of additional services.

The actual date of service is the date the supplier has placed an order for the equipment and has incurred liability for the equipment.

2.2.18.2.1Spinal Orthoses

Spinal orthoses include, but are not limited to, cervical orthoses, thoracic rib belts, thoracic-lumbar­sacral orthoses (TLSO), sacroiliac orthoses, lumbar orthoses, lumbar-sacral orthoses (LSO), cervicalthoracic-lumbar-sacral orthoses (CTLSO), halo procedures, spinal corset orthoses, and spinal orthoses for scoliosis.

Spinal orthoses will be considered for prior authorization with documentation of one of the general indications.

2.2.18.2.2Lower-Limb Orthoses

Lower-limb orthoses include, but are not limited to, hip orthoses (HO), Legg Perthes orthoses, knee orthoses (KO), ankle-foot orthoses (AFO), knee-ankle-foot orthoses (KAFO), hip-knee-ankle-foot orthoses (HKAFO), fracture orthoses, and reciprocating gait orthoses (RGO).

In addition to the general indication requirements, lower-limb orthoses will be considered for prior authorization with documentation of the following criteria for specific orthotic devices:

Ankle-Foot Orthoses

AFOs used during ambulation will be considered for prior authorization for clients with documentation of all of the following:

Weakness or deformity of the foot and ankle.

A need for stabilization for medical reasons.

Anticipated improvement in functioning during activities of daily living (ADLs) with use of the device.

AFOs not used during ambulation (static AFO) will be considered for prior authorization for clients with documentation of one of the following conditions:

Plantar fasciitis.

Plantar flexion contracture of the ankle, with additional documentation that includes all of the following:

Dorsiflexion on pretreatment passive range of motion testing is at least ten degrees.

The contracture is interfering or is expected to interfere significantly with the client's functioning during ADLs.

The AFO will be used as a component of a physician-prescribed therapy plan care, which includes active stretching of the involved muscles or tendons.

There is reasonable expectation that the AFO will correct the contracture.

Knee-Ankle-Foot Orthoses

KAFOs used during ambulation will be considered for prior authorization for clients with documen­tation that supports medical necessity for additional knee stabilization.

KAFOs that are custom-fabricated (molded-to-patient model) for ambulation will be considered for prior authorization when at least one of the following criteria is met:

The client cannot be fit with a prefabricated AFO/KAFO.

The condition that necessitates the orthosis is expected to be permanent or of long-standing duration (more than six months).

There is a need to control the knee, ankle, or foot in more than one plane.

The client has a documented neurological, circulatory, or orthopedic status that requires custom fabrication to prevent tissue injury.

The client has a healing fracture that lacks normal anatomical integrity or anthropometric proportions.

Reciprocating Gait Orthoses

Reciprocating gait orthoses will be considered for prior authorization for clients with spina bifida or similar functional disabilities.

The prior authorization request must include a statement from the prescribing physician that indicates medical necessity for the RGO, the PT treatment plan, and documentation that the client and family are willing to comply with the treatment plan.

2.2.18.2.3Foot Orthoses

Foot orthoses include, but are not limited to, foot inserts, orthopedic shoes, wedges, and lifts.

Foot orthoses will be considered for prior authorization for clients with documentation of all of the following:

The client has symptoms associated with the particular foot condition.

The client has failed to respond to a course of appropriate, conservative treatment, including PT, injections, strapping, or anti-inflammatory medications.

The client has at least one of the following:

Torsional conditions, such as metatarsus adductus, tibial torsion, or femoral torsion

Structural deformities

Hallux valgus deformities

In-toe or out-toe gait

Musculoskeletal weakness

In addition to the general indication requirements, foot orthoses will be considered for prior authori­zation with documentation of the following criteria for specific orthotic devices:

Foot Inserts

Removable foot inserts will be considered for prior authorization for clients with documentation of at least one of the following medical conditions:

Diabetes mellitus.

History of amputation of the opposite foot or part of either foot.

History of foot ulceration or pre-ulcerative calluses of either foot.

Peripheral neuropathy with evidence of callus formation of either foot.

Deformity of either foot.

Poor circulation of either foot.

Removable foot inserts may be covered independently of orthopedic shoes with documentation that the client has appropriate footwear into which the insert can be placed.

A University of California at Berkeley (UCB) removable foot insert will be considered for prior authori­zation with documentation that the device is required to correct or treat at least one of the following conditions:

A valgus deformity and significant congenital pes planus with pain.

A structural problem that results in significant pes planus, such as Down syndrome.

Acute plantar fasciitis.

Orthopedic Shoes

Orthopedic shoes must be prescribed by a licensed physician (M.D. or D.O.) or a podiatrist. An ortho­pedic shoe is used by clients whose feet, although impaired, are essentially intact. An orthopedic shoe differs from a prosthetic shoe, which is used by clients who are missing all or most of the forefoot.

Orthopedic shoes will be considered for prior authorization when at least one of the following criteria is met:

The shoe is permanently attached to a brace.

The shoe is necessary to hold a surgical correction, postoperative casting, or serial or clubfoot casting.

An orthopedic shoe may be prior authorized up to one year from the date of the surgical procedure.

Only one pair of orthopedic shoes will be prior authorized every three months. Two pairs of shoes may be purchased at the same time; in such situations, however, additional requests for shoes will not be considered for another six months.

Requests for orthopedic shoes that do not meet the criteria listed above may be considered for prior authorization with documentation of medical necessity.

Wedges and Lifts

Wedges and lifts must be prescribed by a licensed physician (M.D. or D.O.) or a podiatrist and must be for treatment of unequal leg length greater than one-half inch.

2.2.18.2.4Upper-Limb Orthoses

Upper-limb orthoses include, but are not limited to, shoulder orthoses (SO), elbow orthoses (EO), elbow-wrist-hand orthoses (EWHO), elbow-wrist-hand-finger orthoses (EWHFO), wrist-hand-finger orthoses (WHFO), wrist-hand orthoses (WHO), hand-finger orthoses (HFO), finger orthoses (FO), shoulder-elbow-wrist-hand orthoses (SEWHO), shoulder-elbow orthoses (SEO), and fracture orthoses.

In addition to the general indication requirements, upper-limb orthoses will be considered for prior authorization with documentation of the following criteria for specific orthotic devices.

2.2.18.2.5Other Orthopedic Devices

Protective Helmets

Protective helmets will be considered for prior authorization for clients with a documented medical condition that makes the client susceptible to injury during ADLs. Covered medical conditions include the following:

Neoplasm of the brain

Subarachnoid hemorrhage

Epilepsy

Cerebral palsy

Requests for all conditions other than those listed above require submission of additional documen­tation that supports the medical necessity of the requested device.

Dynamic Splints

Static and dynamic mechanical stretching devices will be considered for prior authorization for a four month rental period when the request is submitted with the following documentation:

Client's condition

Client's current course of therapy

Rationale for the use of the static or dynamic mechanical stretching device

Agreement by the client or family that the client will comply with the prescribed use of the static or dynamic mechanical stretching device

After completion of the four-month rental period, the provider may submit a request for purchase of the static or dynamic mechanical stretching device. Requests for purchase of the static or dynamic mechanical stretching device must include documentation that the four-month rental period was successful and showed improvement in the client's condition as measured by the following:

Demonstrated increase in range of motion

Demonstrated improvement in the ability to complete ADLs or perform activities outside the home

2.2.18.2.6Related Services

Repairs, Replacements, and Modifications to Orthoses

Within the guarantee of the manufacturer, providers are responsible, without charge to the client or to Texas Medicaid, for replacement or repair of equipment or any part thereof that is found to be nonfunc­tional because of faulty material or workmanship.

Service and repairs must be handled under any warranty coverage an item may have. If there is no warranty, providers may request prior authorization for the necessary service and repairs.

A repair because of normal wear or a modification because of growth or change in medical status will be considered for prior authorization if it proves to be more cost effective than replacing the device.

The request for repairs must include a breakdown of charges for parts and the number of hours of labor required to complete the repairs. No charge is allowed for pickup or delivery of the item or for the assembly of Medicaid-reimbursed parts. The following information must be submitted with the request:

The description and procedure code of the item being serviced or repaired.

The age of the item.

The number of times the item has been previously repaired.

The replacement cost for the item.

The anticipated life expectancy of an orthotic device is six months. Requests for prior authorization for the replacement of a device before its usual life expectancy has ended must include documentation that explains the need for the replacement.

Replacement of orthotic equipment will be considered when the item is out of warranty and repairing the item is no longer cost-effective or when loss or irreparable damage has occurred. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent reoccurrence must be submitted with the prior authorization request.

2.2.18.3Cranial Molding Orthosis

2.2.18.3.1Services, Benefits, and Limitations

Cranial molding orthosis (procedure code S1040) may be a benefit when all of the following criteria are met:

The client is CCP eligible.

The client is 3 through 18 months of age.

The client requires a cranial molding orthosis as part of the treatment plan for a documented diagnosis of synostotic plagiocephaly.

The limitation for procedure code S1040 is one device per lifetime.

The definition for cosmetic, as it applies to cranial molding orthosis, includes surgery or other services used primarily to improve appearance and not to restore or correct significant deformity resulting from disease, trauma, congenital or developmental anomalies, or previous therapeutic process.

2.2.18.3.2Noncovered Services

A cranial molding orthosis that is used for the treatment of positional plagiocephaly is considered cosmetic, and therefore is not a benefit of Texas Medicaid.

The effective use of a cranial molding orthosis for the treatment of brachycephaly, or a high cephalic index without cranial asymmetry has not been clearly documented, is not medically necessary, and therefore is not a benefit of Texas Medicaid.

2.2.18.3.3Prior Authorization and Documentation Requirements

Cranial molding orthoses do not require prior authorization for clients with a diagnosis of synostotic plagiocephaly. Documentation of medical necessity must be maintained in the client's medical record.

Prior authorization requests for a cranial molding orthosis for congenital conditions that are not outlined in this section may be considered by the Medical Director on a case-by-case basis with documentation of medical necessity. Additional devices beyond the once-per-lifetime benefit may be considered for prior authorization with documentation of all of the following:

The initial device was obtained to treat synostotic plagiocephaly.

Treatment with the device has been effective.

The new device is needed due to growth.

To facilitate determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including documentation of medical necessity for the equipment requested. The physician must maintain documentation of medical necessity in the client's medical record. The requesting provider may be asked for additional information to clarify or complete a request for an additional cranial molding orthosis.

The completed CCP Prior Authorization Form, which includes the DME must be signed and dated by the prescribing physician familiar with the client's condition. The completed CCP Prior Authorization Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept by the physician in the client's medical record.

2.2.18.4Thoracic-Hip-Knee-Ankle Orthoses (THKAO) (Vertical or Dynamic Standers, Standing Frames, Braces, and Parapodiums)

2.2.18.4.1Services, Benefits, and Limitations

THKAO (vertical or dynamic standers, standing frames or braces, and parapodiums), including all accessories, require prior authorization. A THKAO may be considered if the client requires assistance to stand and remain standing.

Parapodium

A parapodium is used to help clients with neuromuscular diseases or conditions resulting in a lack of sufficient muscle power in the trunk and lower extremities to stand with their hands free. It helps develop a sense of balance and aids in learning functional movements such as standing with the hands free. A parapodium acts as an exoskeleton, providing side struts and chest, hip, knee, and foot bracing.

A parapodium may be considered for reimbursement for one of the following levels:

Level One: Small Parapodium—The client has a maximum axillary height of 35 inches and a maximum weight of 55 pounds (normal age range is 1 through 10 years of age).

Level Two: Medium parapodium—The client has a maximum axillary height of 41 inches and a maximum weight of 77 pounds (normal age range is 5 through 12 years of age).

Level Three: Large parapodium—The client has a maximum axillary height of 45 inches and a maximum weight of 115 pounds (normal age range is 10 through 16 years of age). Labor for parap­odium assembly may be prior authorized.

Procedure code E0638 must be submitted with one of the following modifiers:

UA-Standing frame/table system, one position (e.g., upright, supine, or prone stander), any size, including pediatric, with or without wheels. Medicaid level of care 10, as defined by each state

Note:Use modifier UA to identify an upright or prone system stander.

UB-Standing frame/table system, one position (e.g., upright, supine, or prone stander), any size, including pediatric, with or without wheels. Medicaid level of care 11, as defined by each state

Note:Use modifier UB to identify a supine stander.

Standing Frame or Brace

A standing frame or brace is used to help very young clients, who are 12 months of age and older, who have good head control in the upright position and who have a neuromuscular disease or condition resulting in a lack of sufficient muscle power in the trunk and lower extremities to stand with their hands free.

Providers must use procedure code E0638 for a standing frame or brace.

Vertical or Dynamic Stander

A vertical stander or dynamic stander is used to initiate standing for clients who cannot maintain a good standing posture or may never be able to stand independently. A vertical stander is used to develop weight bearing through the legs in order to decrease demineralization and to promote better body awareness. Documentation for these standers must address medical necessity for the standers to be mobile.

Providers must use procedure code E0642 for the purchase of a dynamic stander.

2.2.18.4.2Prior Authorization and Documentation Requirements

THKAO (vertical or dynamic standers, standing frames or braces, and parapodiums), including all accessories, requires prior authorization.

THKAO may be considered for clients who are CCP-eligible and who require assistance to stand and remain standing when documentation submitted clearly shows that it is medically necessary and will correct or ameliorate the client's disability or physical or mental illness or condition.

Prior authorization may be considered for the THKAOs with the following documentation:

Diagnoses relevant to the requested equipment, including functioning level and ambulatory status

Anticipated benefits of the equipment

Frequency and amount of time of a standing program

Anticipated length of time the client will require this equipment

Client's height, weight, and age

Anticipated changes in the client's needs, anticipated modifications, or accessory needs, as well as the growth potential of the stander

2.2.19Prosthetic Services

2.2.19.1Services, Benefits, and Limitations

External prostheses are a benefit of Texas Medicaid when provided by a licensed prosthetist or licensed prosthetist/orthotist through CCP for clients who are birth through 20 years of age.

The following prostheses and related services may be reimbursed when medical necessity criteria are met:

Lower limb

Upper limb

Craniofacial

External breast

Repair, replacements, and modifications

Prosthetic training

Accessories to prostheses

Prosthetic training by a physical or occupational therapist for a lower limb prosthesis or an upper extremity prosthesis is a benefit for clients who have not worn one previously or for a prolonged period or who are receiving a different type.

Refer to:  Section 5, “Children’s Therapy Services Clients birth through 20 years of age” in the Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (Vol. 2, Provider Handbooks).

To be considered for reimbursement, prostheses must be dispensed, fabricated, or modified by a licensed prosthetist or licensed prosthetist/orthotist enrolled with Medicare and CCP.

The date of service for a custom-made or custom-fitted prosthesis is the date the supplier places an order for the equipment and incurs a liability for the equipment. The custom-made or custom-fitted prosthesis will be eligible for reimbursement as long as the service is provided during a month the client is eligible for Medicaid.

The following items and services are included in the reimbursement for a prosthetic device and not reimbursed separately:

Evaluation of the residual limb and gait

Measurement, casting, or fitting of the prosthesis

Cost of base component parts and labor contained in the base procedure code description

Repairs due to normal wear and tear during the 90 days following delivery

Adjustments or modifications of the prosthesis or the prosthetic component made when fitting the prosthesis or component and for 90 days from the date of delivery when the adjustments are not necessitated by changes in the residual limb or the client's functional ability

In general, base codes do not represent a complete device. To include the additional components necessary for a complete device, providers may bill additional components with a code that is used in addition to a base code. Addition codes may also be used to indicate modifications to a device. The values assigned to the additional codes do not represent the actual value of the component or modifi­cation, but only the difference between the total value and the value of the base code. As a result, reimbursement of an addition does not involve subtraction of any amounts from the base code allowance.

2.2.19.1.1Noncovered Prosthetic Services

Prosthetic devices prescribed by a chiropractor are not a benefit of Texas Medicaid.

A vacuum-assisted socket system (procedure code L5781 or L5782), which is a specialized vacuum pump, is considered experimental and investigational, and is not a benefit of Texas Medicaid.

Myoelectric hand prostheses for conditions other than the absence of forearm(s) and hand(s) are considered experimental and investigational and are not a benefit of Texas Medicaid.

A prosthetic device customized with enhanced features is not considered medically necessary if ADLs can be met with a standard prosthetic device.

Accessories that are not required for the effective use of a prosthetic device are not considered medically necessary.

2.2.19.2Prior Authorization and Documentation Requirements

Prior authorization is required for all prosthetic devices.

A completed CCP Prior Authorization Form requesting the prosthesis must be signed and dated by a physician familiar with the client before requesting prior authorization for all prostheses. The completed CCP Prior Authorization Form must include the procedure codes and numerical quantities for services requested. A copy of the completed, signed, and dated form must be maintained by the prosthesis provider in the client's medical record. The completed CCP Prior Authorization Form with the original dated signature must be maintained by the prescribing physician in the client's medical record.

To complete the prior authorization process by paper, the prosthesis provider must fax or mail the completed CCP Prior Authorization Request Form to the CCP prior authorization unit and retain a copy of the signed and dated CCP form in the client's medical record at the provider's place of business.

To complete the prior authorization process electronically, the prosthesis provider must complete the prior authorization requirements through any approved electronic methods and retain a copy of the signed and dated CCP Prior Authorization Request form in the client's medical record at the provider's place of business.

To facilitate determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including documentation for medical necessity of the equipment or supplies requested. The physician must maintain documentation of medical necessity in the client's medical record. The provider may be asked for additional information to clarify or complete a request for the service or device.

All requests for prior authorization must include documentation of medical necessity including, but not limited to, documentation that the client meets the following general indications for the requested device:

The prosthesis replaces all or part of the function of a permanently inoperative, absent, or malfunc­tioning part of the limb, and identification of the specific limb that is being replaced by the prosthesis.

The prosthesis is required for ADLs or for rehabilitation purposes, and identification of the ADLs or rehabilitation purpose for which the prosthesis is required.

The provider must keep the following written documentation in the client's medical record:

The prescription for the device.

Prosthetic devices must be prescribed by a physician (M.D. or D.O.).

The prescription must be dated prior to or on the initial date of the requested dates of service, which can be no longer than 90 days from the signature date on the prescription.

Accurate diagnostic information that supports the medical necessity for the requested device. (A retrospective review may be performed to ensure that the documentation included in the client's medical record supports the medical necessity of the requested service or device.)

The specific make, model, and serial number of the prosthetic components.

The treatment plan outlining the therapy program prescribed by the treating physician, including expected goals with the use of the prosthesis.

A statement submitted by the physician that indicates that the client or client's family or caregiver demonstrates willingness to comply with the therapy program.

Prior authorization is valid for a maximum period of six months from the prescription signature date.

At the end of the six-month authorization period, a new prescription is required for prior authorization of additional services.

The actual date of service is the date the supplier has placed an order for the equipment and has incurred liability for the equipment.

2.2.19.2.1Lower-Limb Prostheses

Lower limb prostheses include, but are not limited to, the following:

Partial foot, ankle, and knee disarticulation sockets

Above-knee short prostheses

Hip and knee disarticulation prostheses

Postsurgical prostheses

Preparatory prostheses

Additions to lower extremity prostheses

Replacement sockets

A basic lower limb prosthesis consists of the following:

A socket or connection between the residual limb and the prosthesis

A suspension mechanism attaching the socket to the prosthesis

A knee joint that provides support during stance, smooth control during the swing phase, and unrestricted motion for sitting and kneeling

An exoskeleton or endoskeleton pylon (tube or shell) that attaches the socket to the terminal device

A terminal device (foot)

In addition to the general indication requirements, the following additional documentation is also required for all lower limb prostheses:

Written documentation of the client's current and potential functional levels. A functional level is defined as a measurement of the capacity and potential of the individuals to accomplish their expected post-rehabilitation daily function. The potential functional ability is based on reasonable expectations of the treating physician and the prosthetist and includes, but is not limited to, the following:

The client's history, including prior use of a prosthesis if applicable

The client's current condition, including the status of the residual limb and any coexisting medical conditions

The client's motivation to ambulate and ability to achieve independent transfers or ambulation with the use of a lower limb prosthesis

The following functional modifiers and levels have been defined by the Centers for Medicare & Medicaid Services (CMS):

Functional Level

Functional Modifier

Description

Level 0

K0

Does not have the ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance quality of life or mobility.

Level 1

K1

Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator

Level 2

K2

Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator.

Level 3

K3

Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

Level 4

K4

Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high-impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.

A client whose functional level is zero (0) is not a candidate for a prosthetic device; the device is not considered medically necessary.

Advanced knee, ankle, and foot prostheses procedure codes must be submitted with the appropriate functional modifier in the table above.

Microprocessor-Controlled Lower Limb Prostheses

Microprocessor-controlled lower limb prostheses (e.g., Otto Bock C-Leg, Intelligent Prosthesis, or Ossur Rheo Knee) will be considered for prior authorization for clients who have a transfemoral amputation from a nonvascular cause, such as trauma or tumor and a functional level of 3 or above, and who meet the following criteria:

The individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level of technology and to allow for faster than normal walking speed.

The individual demonstrates the ability to ambulate at a faster than baseline rate using a standard prosthetic application with a swing and stance control knee.

The individual has a demonstrated need for long-distance ambulation at variable rates (greater than 400 yards) on a daily basis. Use of the limb in the home or for basic community ambulation is not sufficient to justify provision of the computerized limb instead of standard limb applications.

The individual has a demonstrated need for regular ambulation on uneven terrain or for regular use on stairs. Use of the limb for limited stair climbing in the home or employment environment is not sufficient evidence for prescription of this device over standard prosthetic application.

The licensed prosthetist or licensed prosthetist/orthotist providing the device must be trained in the fitting and programming of the microprocessor-controlled prosthetic device.

Foot Prostheses

The following foot prostheses will be considered for prior authorization for clients whose documented functional level is 1 or above:

A solid ankle-cushion heel (SACH) foot

An external keel SACH foot or single axis ankle/foot

A flexible-keel foot or multi-axial ankle/foot will be considered for prior authorization for clients whose documented functional level is 2 or above.

A flex foot system, energy storing foot, multiaxial ankle/foot, dynamic response, or flex-walk system or equivalent will be considered for prior authorization for clients whose documented functional level is 3 or above.

A prosthetic shoe will be considered for prior authorization if it is an integral part of a prosthesis for clients with a partial foot amputation.

Ankle Prosthesis

An axial rotation unit will be considered for prior authorization for clients whose documented functional level is 2 or above.

Knee Prosthesis

A single-axis, constant-friction knee and other basic knee systems will be considered for prior authori­zation for clients whose documented functional level is 1 or above. A fluid, pneumatic, or electronic knee prosthesis will be considered for prior authorization for clients whose documented functional level is 3 or above. A high-activity knee control frame will be considered for prior authorization for clients whose documented functional level is 4.

Prosthetic Substitutions or Additions for Below-Knee Prostheses

Prosthetic substitutions or additions (procedure codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980) are not considered medically necessary when an initial below-knee prosthesis (procedure code L5500) or a preparatory below-knee prosthesis (procedure codes L5510, L5520, L5530, or L5540) is provided.

Prosthetic substitutions or additions (procedure codes L5620, L5629, L5645, L5646, L5670, L5676, L5704, and L5962) are not considered medically necessary when a below-knee preparatory, prefabri­cated prosthesis (procedure code L5535) is provided.

Sockets

Prior authorization for test (diagnostic) sockets for an individual prosthesis is limited to a quantity of two test sockets. Prior authorization for same-socket inserts for an individual prosthesis is also limited to a quantity of two. Requests for test sockets or same-socket inserts beyond these limitations must include documentation of medical necessity that supports the need for the additional sockets.

2.2.19.2.2Upper-Limb Prostheses

Upper limb prostheses include, but are not limited to, the following:

Partial hand prostheses

Wrist and elbow disarticulation prostheses

Shoulder and interscapular thoracic prostheses

Immediate postsurgical or early fitting prostheses

Preparatory prostheses

Terminal devices

Replacement sockets

Inner sockets-externally powered

Electric hand, wrist, and elbow prostheses

Upper limb prostheses will be considered for prior authorization with documentation of all of the general indication requirements. The additional criteria in the following sections apply for specific prosthetic devices.

Myoelectric Upper Limb Prostheses

A myoelectric upper limb prosthetic device is considered medically necessary when all of the following criteria have been met:

The client has sufficient neurological, myocutaneous, and cognitive function to operate the prosthesis effectively.

The client has an amputation or missing limb at the wrist or above (e.g., forearm, elbow, and so on).

The client is free of comorbidities that could interfere with maintaining function of the prostheses (e.g., neuromuscular disease).

The client retains sufficient microvolt threshold in the residual limb to allow proper function of the prostheses.

Standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of the patient in performing ADLs.

The client does not function in an environment that would inhibit function of the prosthesis (e.g., a wet environment or a situation involving electrical discharges that would affect the prosthesis).

2.2.19.2.3External Breast Prostheses

External breast prostheses will be considered for prior authorization for clients who have congenital absence of a breast or who have had a mastectomy.

2.2.19.2.4Craniofacial Prostheses

Craniofacial prostheses include, but are not limited to, external nasal, ear, and facial prostheses.

Craniofacial prostheses will be considered for prior authorization with documentation that the device is necessary to correct an absence or deformity of the affected body part.

2.2.19.2.5Related Services

Accessories to Prostheses

Accessories to prostheses, such as stump stockings and harnesses will be considered for prior authori­zation when they are essential to the effective use of the prosthetic device.

Repairs, Replacements, and Modifications to Prostheses

Repairs due to normal wear and tear will be considered for prior authorization after 90 days from the date of delivery of the initial prosthesis, when the repair is:

Necessary to make the equipment functional.

More cost-effective than the replacement of the prosthetic device.

Providers must include documentation that supports medical necessity when they request prior authorization.

Additional information from the provider may be requested to determine cost-effectiveness.

Replacement of prosthetic equipment will be considered for coverage when loss or irreparable damage has occurred. A copy of the police or fire report when appropriate and the measures to be taken to prevent re-occurrence must be submitted with the prior authorization request.

Socket replacements will be considered for prior authorization with documentation of functional or physiological need, including, but not limited to, changes in the residual limb, functional need changes, or irreparable damage or wear due to excessive weight or prosthetic demands of very active amputees.

Children typically require new prosthetic devices every 12 to 18 months, although the actual lifespan of a device depends on the child's rate of skeletal growth. Prosthetic devices for children must accom­modate growth and other physiological changes.

Components and systems that allow for growth or increase the lifespan of the prosthesis may include the following:

Growth-oriented suspension systems and modifications

Use of modular systems

Use of flexible sockets

Use of removable sockets (slip or triple-wall sockets)

Use of distal pads

Modification of socket liners

Increasing or decreasing sock thickness

Modifications due to growth or change in medical status will be considered for prior authorization with documentation of medical necessity.

Medical necessity for requested components or additions to the prosthesis is based on the client's current functional ability and the expected functional potential as defined by the prosthetist and the ordering physician.

2.2.20Phototherapy Devices

Phototherapy devices are not a benefit of Title XIX Home Health Services. Phototherapy devices are a benefit of Texas Medicaid through CCP for clients who are birth through 20 years of age.

2.2.20.1Services, Benefits, and Limitations

The rental of phototherapy devices (procedure code E0202) for use in the home are a benefit of Texas Medicaid for low-risk infants.

Low-risk infants are 35 or more weeks gestation at birth, without comorbidity, and with a total serum bilirubin (TSB) level within the following ranges:

Infant’s Gestation at Birth

TSB for infant 0-24 hours of age*

TSB for infant 25-48 hours of age*

TSB for infant 49-72 hours of age*

TSB for infant older than 72 hours of age*

35–37 weeks

3–7

7–13

10–15

13–18

38 weeks or greater

6–11

12–15

15–18

18–21

* Infant age when TSB level is drawn.

TSB levels are expressed in milligrams per deciliter (mg/dl).

The DME provider must perform routine maintenance and provide instructions to the parent or guardian on the safe use of the phototherapy device. Rental of a phototherapy device is reimbursed as a daily global fee and is limited to one per day, per client, any provider.

Providers may not bill for those days the phototherapy device is at the client's home and is not in use.

Skilled nursing (SN) visits for clients requiring phototherapy services may be reimbursed separately through Title XIX Home Health Services for nonroutine clinical teaching and assessment. Routine laboratory specimens are obtained during the SN visit, and may only be considered when the alternative to obtaining the specimen is to transport the client by ambulance.

If a client who is receiving PDN services requires phototherapy, instructions in the use of the equipment must be part of the existing PDN authorized hours. SN visits will not be allowed on the same day as PDN services.

In accordance with American Academy of Pediatrics (AAP) guidelines, providers must conduct ongoing assessments for risk of severe hyperbilirubinemia for all infants who receive home phototherapy.

Initiation of home phototherapy for medium- and high-risk infants is not a benefit of Texas Medicaid. As defined by the AAP, medium- and high-risk infants should be considered for more extensive initial treatment in an inpatient setting. Medium- and high-risk infants include, but are not limited to, those who have one of the following known risk factors:

Acidosis

Albumin less than 3.0 g/dl

Asphyxia

Glucose-6-phosphate dehydrogenase (G6PD) deficiency

Isoimmune hemolytic disease (blood group incompatibility)

Jaundice within the first 24 hours

Sepsis

Significant lethargy

Temperature instability

2.2.20.2Prior Authorization and Documentation Requirements

Home phototherapy devices require prior authorization and are provided only for the days that are medically necessary.

For low-risk infants, prior authorization will be considered for phototherapy services that begin in the home.

For stabilized infants who began phototherapy treatment during their hospitalization and have been discharged from the hospital, prior authorization will be considered for the continuation of photo- therapy services in the home. Initial prior authorization may be given for a maximum of seven days of home phototherapy. A new CCP Prior Authorization Request Form must be submitted to request more than seven days of home phototherapy.

The following documentation is required to support medical necessity when requesting home photo- therapy services:

A diagnostic evaluation, which must include, but is not limited to, a normal history and physical exam, and normal laboratory values for the following, as medically indicated:

Complete blood count with differential

Platelets

Blood smear for red blood cell morphology

Reticulocyte count

Urinalysis

Maternal and infant blood typing

Coombs test

TSB level (in mg/dl)

Gestational age

Documentation of adequate infant hydration, as demonstrated by 4-6 wet diapers per day and 3-4 stools per day

Documentation stating that infant weight loss does not exceed 10 percent of the infant's birth weight

Physician's plan of care

Anticipated number of days the client will need the phototherapy treatment

Documentation of parental education regarding the importance of monitoring and follow-up

When requesting prior authorization for a hospitalized infant that requires continued home photo- therapy, providers must submit documentation that indicates all pre-existing medium- or high-risk factors have resolved or stabilized.

Providers must submit the following additional documentation for prior authorization requests for previously hospitalized infants that require continued home phototherapy or for more than seven days of home phototherapy:

TSB level greater than 13 mg/dl and trending downward. TSB levels less than 13 will require medical review to determine medical necessity.

Note:According to AAP guidelines, phototherapy may be discontinued when the TSB level falls below 13-14 mg/dl; however, exceptions to the guidelines may be considered. As a result, documentation must include the rationale for not discontinuing phototherapy when the TSB level drops below 13 mg/dl.

Birth weight and current weight demonstrating weight gain.

Note:According to AAP guidelines, breast-fed infants are expected to gain 15-30 grams per day (1/2-1 ounce per day) through the first 2-3 months of life.

2.2.20.2.1Retroactive Eligibility

Newborn babies may not have a Medicaid number at the time that services are ordered by the physician and provided by the supplier. In these cases, prior authorization may be given retroactively for services rendered between the start date and the date that the client's Medicaid number becomes available.

The provider is responsible for finding out the effective dates of client eligibility.

The provider has 95 days from the date on which the client's Medicaid number becomes available (add date) to obtain prior authorization for services that were already rendered.

2.2.21Prothrombin Time/International Normalized Ratio (PT/INR) Home Testing Monitor

PT/INR home testing monitors are a benefit of Title XIX Home Health Services for clients who require chronic oral anticoagulation due to one of the following:

Mechanical heart valve

Chronic atrial fibrillation

Venous thromboembolism (including both deep vein thrombosis [DVT] and pulmonary embolism)

Ventricular assist device (VAD) awaiting a heart transplant

The PT/INR home testing monitor is a portable, battery-operated instrument for the quantitative deter­mination of PT/INR from whole blood obtained by finger-stick. This product is designed to aid in the management of high-risk clients who take oral anticoagulants.

Note:For clients who are 20 years of age and younger and do not meet criteria for coverage through Title XIX Home Health Services, home PT/INR monitors and related testing supplies may be considered through CCP.

The following procedure codes are included in this benefit:

Procedure code E1399 may be reimbursed for the rental or purchase of the monitor.

Procedure code A9900 may be reimbursed for the related testing supplies.

Procedure codes E1399 and A9900 may be reimbursed to DME providers for services rendered in the home setting.

2.2.21.1Prior Authorization

Prior authorization is required for the home PT/INR monitors and related testing supplies.

Prior authorization requests must be submitted within three business days of the date of service and must include documentation of medical necessity and a completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.

The completed Title XIX Form must be maintained by the requesting provider and the prescribing provider. The original signature copy must be kept in the provider’s medical record for the client.

To avoid unnecessary denials, the prescribing provider must provide correct and complete information, including documentation for medical necessity of the equipment and/or supplies requested. The prescribing provider must maintain documentation of medical necessity in the client’s medical record. The requesting provider may be asked for additional information to clarify or complete a request for the PT/INR monitor.

Prior authorization for the rental or purchase of a home PT/INR monitor and related testing supplies will be considered for clients who meet all the following criteria:

The client is on anticoagulation therapy and has a current prescription for Warfarin or other oral anticoagulant.

The client has been on anticoagulation therapy for at least three months prior to the request for the home PT/INR monitor.

The client is required to self-test at least every two weeks.

Additionally, the client must have at least one of the following conditions documented in the request for prior authorization:

Fluctuations of INR or PT/PTT levels with titration greater than once per week in anticoagulation dosing with copies of laboratory reports and resultant medication changes.

A medical condition that limits physical movement, places the client under medical restrictions for isolation, or requires non-emergency ambulance transport for the purpose of obtaining laboratory specimens.

Limited venous access that compromises the ability to obtain laboratory specimens for the adequate monitoring of anticoagulation therapy.

The prior authorization request will be evaluated upon receipt to determine whether the equipment will be rented, purchased, repaired, or modified based on the client’s needs, duration of use, and age of equipment.

Note:Skilled nursing (SN) visits will not be approved for the sole purpose of instructing the client on the use of the PT/INR home testing monitor. Any necessary instruction must be performed as part of the office visit with the prescribing physician.

2.2.22Respiratory Equipment and Supplies

Respiratory equipment and supplies may be provided in the home under Title XIX Home Health Services.

Respiratory equipment and supplies must be prescribed by a physician, be FDA approved for the medical condition, and have federal financial participation available to be considered a medically necessary benefit. An eligible client must have compromised health status without the requested equipment or supplies.

Equipment provided for rental may be new or used. Equipment provided for purchase must be new and unused.

HHSC or its designee will determine whether respiratory equipment will be rented, purchased, or repaired based on the client’s needs and expected duration of use.

Note:When new unused equipment is initially provided for rental and is subsequently authorized for purchase, the provider is not required to replace the equipment.

Rental of equipment includes all necessary supplies, adjustments, repairs, and replacement parts. Supplies needed for use with client-owned equipment may be purchased separately within the limitations.

Note:Respiratory equipment and related supplies that are not considered a benefit under Home Health Services may be considered for reimbursement through CCP for clients who are 20 years of age and younger, who are CCP eligible (e.g., clients who are residing in residential treatment centers).

Respiratory equipment and supplies are available without prior authorization up to the stated quantity limitation, unless otherwise specified in this handbook. Prior authorization is required for quantities exceeding the limitation.

2.2.22.1Prior Authorization

Unless otherwise indicated, prior authorization is required for rental or purchase of respiratory equipment provided through Home Health services.

All miscellaneous procedure codes listed in this handbook require prior authorization.

2.2.22.1.1Initial Request

A completed, signed, and dated prior authorization request form prescribing the DME or medical supplies must include the procedure codes and numerical quantities for services requested and must be signed and dated by the ordering physician and the representative of the DME and medical supply provider before requesting prior authorization for all DME and supplies.

A Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form must be submitted for all DME services and supplies, unless the ordering physician is requesting the following:

A continuous positive airway pressure (CPAP) or Bi-level positive airway pressure (BiPAP) and respiratory assist devices (RADs) are to be requested using a Texas Medicaid Prior Authorization Request for CPAP or RAD (Bi-level PAP) form.

Note:Home ventilators (procedure codes E0465 and E0466) requested with CPAP or RAD settings must also be submitted on the Texas Medicaid Prior Authorization Request for CPAP or RAD (Bi-level PAP) form with a letter of medical necessity explaining why CPAP or RAD is not medically appropriate for the client.

Oxygen Therapy is to be requested using a Texas Medicaid Prior Authorization Request for Oxygen Therapy Devices and Supplies form.

Secretion and mucus clearance device are to be requested using a Texas Medicaid Prior Authori­zation Request for Secretion and Mucus Clearance Devices - Initial Request form or a Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices -Renewal Request form for secretion and mucus clearance devices.

Note:It is not necessary to submit a Title XIX form if one of the prior authorization forms listed above are submitted.

The following completed, signed, and dated prior authorization request form must be maintained by the DME provider and the prescribing physician in the client’s medical record. The completed prior autho­rization request form with the original dated signature must be maintained by the prescribing physician. The following forms will not be accepted beyond 90 days from the date of the prescribing physician’s signature.

Title XIX Form

Texas Medicaid Prior Authorization Request for CPAP or RAD (Bi-level PAP) form

Texas Medicaid Prior Authorization Request for Oxygen Therapy Devices and Supplies form

Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices - Initial Request form

Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices -Renewal Request form

Prior authorization requests may be submitted to the TMHP Prior Authorization Department via mail, fax, or the electronic portal. Prescribing or ordering providers, dispensing providers, clients’ responsible adults, and clients may sign prior authorization forms and supporting documentation using electronic or wet signatures.

Refer to:  Subsection 5.5.1.2, “Document Requirements and Retention” in “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for additional information about electronic signatures.

To complete the prior authorization process electronically, the provider must complete the prior autho­rization requirements through any approved electronic methods and retain a copy of the signed and dated prior authorization form in the client’s medical record.

To complete the prior authorization process by paper, the provider must fax or mail the completed prior authorization request form to the Home Health prior authorization unit and retain a copy of the signed and dated prior authorization form in the client’s medical record.

To facilitate determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including documentation for medical necessity for the equipment or supplies requested. The physician must maintain documentation of medical necessity in the client’s medical record.

The requesting provider may be asked for additional information to clarify or complete a request.

Retrospective review may be performed to ensure documentation supports the medical necessity of the requested equipment or supplies.

A determination as to whether the equipment will be rented, purchased, repaired, or modified will be made by HHSC or its designee based on the client’s needs, duration of use, and age of the equipment.

Equipment that has been purchased may be considered for replacement when loss or irreparable damage has occurred outside the warranty terms, conditions, and limitations. A copy of the police or fire report when appropriate and the measures to be taken to prevent reoccurrence must be submitted with the prior authorization request.

2.2.22.1.2Respiratory Equipment for Clients not Meeting Required Criteria

Clients who are 20 years of age and younger

Requests for respiratory equipment or supplies for clients who are 20 years of age and younger who do not meet the criteria as outlined in this handbook or when requesting supplies above the defined limita­tions will be considered under Comprehensive Care Program (CCP). These requests require prior authorization with documentation supporting the medical need of the equipment or the quantity requested. The CCP Prior Authorization Request Form must be used to make these requests.

Clients who are 21 years of age and older

Requests for respiratory equipment or supplies for clients 21 years of age and older who do not meet the criteria as outlined in this handbook or when requesting supplies above the defined limitations will be reviewed by a medical director. These requests require prior authorization with documentation supporting the medical need of the equipment or the quantity requested. The Title XIX Form must be used to make these requests.

2.2.22.1.3Renewal Requests for all Respiratory Equipment

Providers are expected to submit documentation for recertification requests as outlined in this handbook. If no specific documentation requirements are outlined, providers are to submit the following:

A new prior authorization request form

All of the initial request requirements

A physician attestation that the treatment has been effective and the client has been compliant with treatment

2.2.22.1.4Repair to Client-Owned Equipment

Repairs to client-owned equipment may be prior authorized as needed with documentation of medical necessity. Technician fees are considered part of the cost of the repair.

HHSC or its designee reserves the right to request additional documentation about the need for repairs when there is evidence of abuse or neglect to equipment by the client, client’s family, or caregiver. When there is documented proof of abuse or neglect, requests for repairs will not be prior authorized.

Providers are responsible for maintaining documentation in the client’s medical record specifying the repairs and supporting medical necessity and must include all the following:

The date of purchase

The serial number of the current equipment (as applicable)

The cause of the damage or need for repairs

What steps the client or caregiver will take to prevent further damage if repairs are due to an accident

When requested, the cost of purchasing new equipment as opposed to repairing current equipment

Temporary replacement of client-owned respiratory equipment during the repair may be considered for prior authorization for one month using procedure code K0462.

Labor for repair of client-owned respiratory equipment may be considered for prior authorization using procedure code K0739 up to a maximum of two hours per day (maximum quantity of 8 units).

Routine maintenance of rental equipment is the provider’s responsibility.

2.2.22.2Small Volume Nebulizers (SVN)

Small volume nebulizers (SVNs) (procedure code E0570) and related supplies (procedure codes A7003, A7004, and A7005) may be considered for purchase without prior authorization for the conditions listed below:

   

Condition

Bronchiectasis - Any type

Cystic Fibrosis (CF) with pulmonary manifestations

Pneumonia - Any type

Influenza

Bronchitis - Any type

Emphysema - Any type

Asthma - Any type

Chronic Obstructive Pulmonary Disease (COPD) - any type

Pneumoconiosis - Any type

Acute, Sub-acute or Chronic Respiratory conditions

Respiratory conditions due to radiation, smoke, unspecified and specified external agents

Abnormal Sputum

Other diseases of the of the trachea and bronchus

Tracheostomy Status

Attention to tracheostomy

HIV with pulmonary manifestations

Pneumocystosis

Complications of a specified or unspecified transplanted organ, bone marrow or stem cells

Primary Pulmonary Hypertension

Other Chronic Pulmonary Heart Disease

Supporting documentation of medical necessity must be maintained in the client’s medical record, which must be available on request and is subject to retrospective review including but not limited to the following:

Completed Title XIX Form signed and dated by the client’s prescribing physician

Name of the medication(s) ordered for administration through the nebulizer treatments

Frequency and duration of the need for the prescribed nebulizer treatments

SVN and related supplies may be considered for conditions not listed above with prior authorization when submitted with the following documentation of medical necessity:

Completed Title XIX Form signed and dated by the client’s treating physician

Justification supporting the use of an SVN to treat the client’s diagnosis

Name of the medication(s) ordered for administration through the nebulizer

Frequency and duration of need for the prescribed nebulizer treatments

2.2.22.3Ultrasonic Nebulizers (USNs)

An ultrasonic nebulizer (USN) or electronic aerosol generator (procedure code E0574) is an electrically powered device that uses a piezoelectric crystal to generate aerosol. This crystal transducer converts radio waves into high-frequency mechanical vibrations (sound).

Ultrasonic nebulizers are a benefit when medically necessary and may be considered for purchase with prior authorization.

2.2.22.3.1Prior Authorization

Purchase of a USN may be considered medically necessary when submitted with all the following documentation:

Client meets the criteria for a SVN

Client requires equipment for delivery of one of the following:

Treprostinil to treat pulmonary arterial hypertension (PAH) when used to diminish symptoms associated with exercise

Tobramycin to treat cystic fibrosis (CF)

USN may also be considered medically necessary for conditions other than those listed only when all of the following criteria have been met:

Client meets the criteria for a SVN

Client’s treating physician attests that the client has been compliant with other nebulizer and medication therapy

Use of a SVN has failed to control the client’s disease, such as preventing the client from utilizing the hospital or emergency room

2.2.22.4Humidification Therapy and Heating Elements

Humidification involves adding water vapor and sometimes heat to the inspired gas. Humidification therapy and heating elements are provided using the following procedure codes:

Procedure Codes

Large Volume nebulizer jar (water jar)

A7007

A7017

E0575

E0580

Humidifiers

E0550

E0561

E0562

Other Supplies

E0565

E1372

E0585

2.2.22.4.1Heating Elements

Heated humidifiers (procedure code E0562) and heated nebulizers (procedure code E0585) are used for clients with bypassed upper airways, clients receiving mechanical ventilatory support, and clients with high flow positive airway pressure devices. If heat is required for use with a large volume nebulizer (LVN), an immersion element (procedure code E1372) can be added.

2.2.22.4.2Prior Authorization

Humidification therapy and heating elements may be considered for rental or purchase with prior authorization with documentation of medical necessity.

Indications for humidification and warming of inspired gases are humidifying dry medical gases and overcoming humidity deficit created when upper airway is bypassed.

Clinical signs and symptoms that may be an indication that airway humidification is medically necessary include the following:

Dry, nonproductive cough

Increased airway resistance

Increased incidence of infection

Increased work of breathing

Complaint of substernal pain and airway dryness

Thick, dehydrated secretions

Providers must specify the site of room air or oxygen delivery (e.g., nose or mouth, hypopharynx, trachea) and state how much heat and humidity is needed to mitigate the cold, dry gas delivered through the site.

Providers must submit a Title XIX form and all of the following documentation to obtain prior autho­rization for the monthly rental or purchase of humidification therapy or heating elements:

Evidence that the client has a tracheostomy or tracheobronchial stent

Evidence that the client has thick tenacious secretions not responsive to normal levels of humidifi­cation provided with routine humidifiers used with regulators or flow meters

Evidence that the client is not currently renting a ventilator

Evidence that the client is not currently renting a compressor for the delivery of humidification

Providers must specify the site of room air or oxygen delivery (e.g., nose or mouth, hypopharynx, trachea) and state how much heat and humidity is needed to mitigate the cold, dry gas delivered through the site.

2.2.22.5Large Volume Nebulizer Jars (Water Jars) and Compressors

Large volume nebulizer jars (procedure codes A7007 and A7017) used with compressors in humidifi­cation systems are a benefit when medically necessary and may be considered for purchase without prior authorization.

If heat is required, a heating element, such as an immersion element, can be added.

The autoclavable nebulizer (procedure code E0580 - glass or plastic) for use with a regulator or flow meter may be considered with prior authorization and documentation of medical necessity.

Equipment used with a large volume nebulizer to create a humidification system is a benefit when medically necessary with prior authorization.

A compressor (procedure code E0565) may be considered for rental or purchase with prior authori­zation. A compressor and heater (procedure code E0585), or large volume ultrasonic nebulizer (procedure code E0575) used to create the humidification systems when combined with a compressor are available for purchase and require prior authorization.

2.2.22.5.1Prior Authorization

A large volume ultrasonic nebulizer and a nebulizer with compressor and heater may be considered for purchase with prior authorization when all the following criteria are met:

The client has thick, tenacious secretions

The client has one of the following medical conditions:

Cystic fibrosis

Bronchiectasis

A tracheostomy

A tracheobronchial stent

The compressor may also be considered when all of the following criteria are met:

The compressor is needed for the administration of pentamidine using a filtered nebulizer

The client has one of the following medical conditions:

HIV with pulmonary complications

Pneumocystosis

Complications of organ transplants

2.2.22.6Intermittent Positive-Pressure Breathing (IPPB) Devices

IPPB is not the therapy of first choice for delivering aerosol or as a method of lung hyperinflation when other therapies can reliably meet the clinical objectives prescribed for the client. Prior authorization of an IPPB device (procedure code E0500) is available for rental or purchase and will be considered with documentation of ineffective response with use of other modalities such as treatment with a cough assist device.

Rental of the IPPB device includes all supplies, such as humidification and tubing.

In accordance with the American Association for Respiratory Care (AARC) recommendations, IPPB may be considered when one of the following indications is documented:

The client has a need to improve lung expansion

The need to deliver aerosol medication to a client when other methods of delivery have been unsuccessful

2.2.22.6.1Prior Authorization

IPPB requires prior authorization and may be considered with documentation of ineffective response to treatment when other modalities, such as a cough assist device, have failed, when prescribed in accor­dance with the AARC recommendations, and there is medical necessity to improve lung expansion due to one of the following:

The presence of clinically significant pulmonary atelectasis when other forms of therapy have been unsuccessful or the client cannot cooperate with the treatment

The inability to clear secretions adequately due to pathology that severely limits the client’s ability to ventilate or cough effectively and failure to respond to other modes of treatment, including but not limited to:

Neuromuscular disorders or kyphoscoliosis with associated decreases in lung volumes and capacities

Presence of acute severe bronchospasm or exacerbated COPD that fails to respond to other therapy

Deliver aerosol medication when other methods of delivery have been unsuccessful including, but not limited to:

The client who has fatigue as a result of ventilatory muscle weakness such as neuromuscular disease, kyphoscoliosis, or spinal cord injury

The clients with severe hyperinflation where IPPB may decrease dyspnea and discomfort during nebulized therapy

2.2.22.7Controlled Dose Inhalation Drug Delivery Systems

A controlled dose inhalation drug delivery system (procedure code K0730) is a benefit when it is medically necessary to deliver the drug iloprost (e.g. Ventavis) and is restricted to clients with pulmonary artery hypertension. The controlled dose inhalation drug delivery system is available for purchase with prior authorization when medically necessary.

2.2.22.7.1Prior Authorization

Prior authorization is required for purchase of a controlled dose inhalation drug delivery system when used with iloprost and may be considered when the client has a diagnosis of pulmonary artery hyper­tension and the pulmonary hypertension is not secondary to pulmonary venous hypertension or disorders of the respiratory system.

2.2.22.8Continuous Positive Airway Pressure (CPAP) and Respiratory Assist Devices (RAD) including Bi-Level PAP

Continuous positive airway pressure (CPAP) (procedure code E0601) and respiratory assist devices (RADs) (procedure code E0470) without set back up rate are available for rental or purchase with prior authorization.

RADs with set back up rate (procedure codes E0471 and E0472) are a benefit when medically necessary and may be considered for rental with prior authorization for clients requiring:

Treatment of obstructive sleep apnea

Restrictive thoracic disorders

Severe chronic obstructive pulmonary disease

Central sleep apnea

Complex sleep apnea

Hypoventilation syndrome

Note:Other conditions may be considered based on medical necessity.

RADs with a set backup respiratory rate are available for rental, only when medically necessary.

Humidification devices (heated and non-heated) may be a benefit with prior authorization when medically necessary for rental or purchase for use with CPAP devices and RADs.

Related supplies (procedure codes A7029 through A7039) are included in the CPAP and RAD rental and will not be reimbursed separately.

The following procedure codes will deny if billed in the same month by any provider as procedure code E0472:

Procedure Codes

A7029

A7030

A7031

A7032

A7033

A7034

A7035

A7036

A7037

A7038

A7039

2.2.22.8.1Prior Authorization

CPAP devices (procedure code E0601) and RADs (procedure codes E0470, E0471, and E0472) require prior authorization. CPAP devices deliver a single, fixed pressure to the client during the night while sleeping. Some sleep breathing disorders do not benefit from CPAP and require treatment with RADs that are able to recognize the client’s breathing patterns and adjust pressure during the respiratory cycle during sleep.

Note:CPAP and RAD criteria are based on CMS coverage determinations.

CPAP and RAD accessories (headgear, chin straps, face masks, nasal pillows, cushions, nasal interfaces, tubing and filters), when used with the following procedure codes and within the maximum allowed limits, do not require prior authorization with a fee-for-service history of a client-owned CPAP and RAD device:

Procedure Codes

A7029

A7030

A7031

A7032

A7033

A7034

A7035

A7036

A7037

A7038

A7039

Note:RAD with backup rate used with an invasive interface (procedure codes E0471 and E0472) do require prior authorization. Supplies are included in the rental of procedure code E0472 and will not be authorized separately.

In the case of a client-owned RAD with backup rate that is used with invasive interface (procedure code E0472) that was purchased as a result of a rental or purchased through another payer source, proof of ownership of the device is required for consideration of reimbursement of associated supplies and acces­sories. A statement from the treating physician providing the make and model of the client-owned device, submitted with the claims appeal, will meet this requirement if the claims history is not available.

A CPAP device or a RAD without a set backup rate may be considered for an initial three month rental period with prior authorization. Following the initial three month rental period, if the CPAP or RAD without a set backup rate is effective, the device may be considered for purchase. Both devices may also be considered for continued rental with renewal at three month intervals up to 12 months.

A CPAP device and a RAD without a set backup rate will be considered purchased after 12 months of rental through the same provider and a request for purchase or further rental will not be considered.

A RAD with a set backup respiratory may be considered for an initial 3 month rental period with prior authorization and will be considered for rental only.

Humidification devices (heated or non-heated) for use with a CPAP or RAD device may be a benefit with prior authorization when medically necessary. Documentation submitted must support why humidification is medically necessary for use with positive pressure ventilation.

Prior authorization may be considered for initial and renewal requests for CPAP and RAD devices with submission of the Texas Medicaid Prior Authorization Request for CPAP or RAD (Bi-level PAP) form (new with each request) completed, signed and dated by the treating physician with the following sections completed:

A and B for initial requests

A and C for renewal requests

Additional documentation (e.g., titration sleep studies) as necessary to support the medical necessity of the service required as outlined below for the initial and renewal requests.

Initial Request for a Continuous Positive Airway Pressure (CPAP) System

The American Academy of Sleep Medicine (AASM) Guidelines state that it is clinically appropriate to treat clients who are 18 through 20 years of age using adult criteria.

A CPAP device (procedure code E0601) may be considered for an initial three-month rental period based on documentation supporting the medical necessity and appropriateness of the device. Documen­tation must include that the client has had a sleep study, lasting minimum of two hours, and at least one of the following criteria:

For clients who are 17 years of age and younger, polysomnography results documenting an apnea-hypopnea index (AHI) greater than one event per hour may be used to establish medical necessity

For clients who are 18 years of age and older, polysomnography results documenting an AHI or a respiratory disturbance index (RDI) greater than or equal to 15 events per hour

For clients who are 18 years of age and older, an AHI or RDI greater than five events per hour with documentation of at least one of the following:

Excessive daytime sleepiness assessed by either the Epworth Sleepiness Scale (ESS) with a result greater than 10 or the Multiple Sleep Latency Test (MSLT) with a result less than 6

Symptoms of impaired cognition, mood disorders, or insomnia

Hypertension (systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mm Hg)

Ischemic heart disease or previous myocardial infarction

History of stroke

Greater than 20 episodes of oxygen desaturation to less than 85 percent during a full night sleep study

Any one episode of oxygen desaturation of less than 70 percent

Pulmonary hypertension

CPAP may be medically necessary for the treatment of obstructive sleep apnea (OSA) in clients younger than 18 years of age when one of the following criteria is documented:

Adenoidectomy or tonsillectomy is contraindicated

Adenoidectomy or tonsillectomy is delayed

Adenoidectomy or tonsillectomy has been unsuccessful in relieving symptoms of OSA

Documentation must be maintained in the client’s medical record that the client or responsible caregiver has received instruction from the DME provider on the proper use and care of the device and supplies.

Renewal Request for a CPAP System

Prior authorization for purchase or an additional three month CPAP rental after the initial three-month rental period will be considered with all of the following documentation completed, signed, and dated by the client’s treating physician:

A new Texas Medicaid Prior Authorization Request for CPAP or RAD (Bi-level PAP) form

Documentation of medical necessity supporting:

The client’s continuous use of the equipment for a minimum of four hours per 24 hour period

The client’s symptoms as documented by the treating physician are improved with use of the CPAP

Continued rental of CPAP may be considered for up to 12 months with renewal at 3 month intervals. A CPAP device will be considered purchased after 12 months of continuous rental through the same provider.

Initial Request for Respiratory Assist Devices (RADs), including BiPAP - with and without a Set Backup Respiratory Rate

A RAD with or without a set back up rate may be considered for prior authorization when the client has one of the following medical conditions as documented by a sleep study and meets criteria for medical necessity for the specific medical condition:

Obstructive sleep apnea (OSA)

Restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities)

Severe COPD

Central sleep apnea (CSA), complex sleep apnea (CompSA)

Hypoventilation syndrome

Initial Request for RAD for the Treatment of Obstructive Sleep Apnea (OSA)

A RAD without backup may be considered for an initial three month trial period for the treatment of OSA with prior authorization and submission of all of the following:

All the required documentation delineated on the Texas Medicaid Prior Authorization Request for CPAP or RAD (Bi-level PAP) form outlined in the section for CPAP

The client meets the criteria for the initial CPAP rental

The documentation supports that CPAP has been tried and one of the following is documented:

The client’s treating physician verifies that a therapeutic trial of CPAP was conducted in the home or a facility setting and failed to be effective in treating the client’s OSA

A CPAP device was found to be ineffective during the initial facility based or sleep laboratory titration trial testing

If a CPAP device is tried and found ineffective during the initial facility-based titration or home trial, substitution of a RAD does not require a new face-to-face clinical evaluation or a new sleep test.

Initial Request for RAD for the Treatment of Restrictive Thoracic Medical Conditions

A RAD without a set backup rate requires prior authorization and may be considered for the treatment of thoracic medical conditions when all of the following are met:

The client is diagnosed with a neuromuscular disorder (e.g., Duchenne muscular dystrophy, ALS, spinal cord injuries) or the client has a diagnosis of a severe thoracic cage abnormality (e.g., severe chest wall deformities) negatively impacting the client’s respiratory effort

Significant respiratory insufficiency is documented by one of the following:

An arterial blood gas (ABG) PaCO2 greater than or equal to 45 mm Hg, obtained while awake and breathing the client’s routinely prescribed fraction of inspired oxygen concentration (FiO2)

Sleep oximetry demonstrates oxygen saturation less than or equal to 88 percent for 5 minutes or longer of continuous nocturnal recording time (minimum recording time of 2 hours), obtained while client is breathing his or her routinely prescribed FiO2

Note:FIO2 is the concentration of oxygen prescribed for routine use by the client. For example, if the client does not normally use supplemental oxygen, their prescribed oxygen is room air (FiO2 of 21 percent).

For clients who have been diagnosed with a neuromuscular disorder only, documentation must support one of the following:

Maximal inspiratory pressure less than 60 cm H20

Forced vital capacity less than 50 percent of predicted volume

A RAD with a set backup rate requires prior authorization and may be considered for the treatment of thoracic medical conditions when all of the following are met:

The client meets the criteria for use of the RAD without a backup rate for the treatment of a thoracic medical condition

The ordering physician certifies to all of the following:

Client has tried a RAD without a backup rate for at least 60 days

The client was compliant in the use of the device (using the device on average 4 or more hours in a 24 hour day)

The desired therapeutic respiratory response was not achieved with the RAD without a set backup rate

Initial Request for RAD for the Treatment of Severe Chronic Obstructive Pulmonary Disease (COPD)

A RAD without a backup rate may be considered for the treatment of severe COPD, with prior authori­zation, when all of the following criteria are met:

An arterial blood gas PaCO2 less than 52 mm Hg, obtained while awake and when the client is either using 2 LPM of oxygen or the client’s prescribed FIO2 (the blood gas should be drawn while the client is using whichever concentration of oxygen is the higher of the two)

Sleep oximetry demonstrates oxygen saturation less than or equal to 88 percent for 5 minutes or longer of continuous nocturnal recording time (minimum recording time of 2 hours), obtained while breathing oxygen at 2 LPM or the client’s prescribed FIO2 (whichever is higher)

Prior to initiating therapy, documentation of sleep apnea and that treatment with CPAP has been considered with an explanation of why it was ruled out

To rule out the use of a CPAP, formal sleep testing is not required if there is sufficient information in the medical record submitted with the request to demonstrate that the client does not suffer from some form of sleep apnea (obstructive sleep apnea (OSA), CSA, or CompSA) as the predominant cause of awake hypercapnia or nocturnal arterial oxygen desaturation).

A RAD with a backup feature will be considered with prior authorization for severe COPD when the all of the following criteria are met:

The client meets the criteria for use of the RAD without a backup rate for COPD

The ordering physician certifies to all of the following:

Client has tried a RAD without a backup rate for at least 60 days

The client was compliant in the use of the device (using on average 4 or more hours in a 24 hour day)

The desired therapeutic respiratory response was not achieved with the RAD without a set backup rate

Initial Request for RAD for the Treatment of Central Sleep Apnea (CSA) or Complex Sleep Apnea (CompSA)

CSA or CompSA is characterized by the development of central apneas or central hypopneas during pressure titrations performed in a sleep lab titration study for CPAP or RAD without a backup rate.

A RAD without a backup rate will be considered with prior authorization for the treatment of CSA or CompSA when a facility based polysomnogram is performed and supports all of the following:

The client has a diagnosis of CSA or CompSA

The sleep study documents one of the following:

The sum total of central hypopneas plus central apneas is greater than 50 percent of the total apneas and hypopneas rate

A central hypopnea/apnea rate index greater than 5 events per hour; and significant improvement of the sleep-associated hypoventilation while breathing the clients prescribed FiO2

Documentation ruling out CPAP as effective therapy if either OSA or CSA is a component of the initially observed sleep associated hypoventilation

A RAD with a backup rate will be considered with prior authorization for the treatment of CSA or CompSA when all of the following are met:

The client meets the criteria for use of the RAD without a backup rate for the treatment of CSA or CompSA

The ordering physician certifies to all of the following:

Client has tried a RAD without a backup rate for at least 60 days

The client was compliant in the use of the device (using on average 4 or more hours in a 24 hour day)

The desired therapeutic respiratory response was not achieved with the RAD without a set backup rate

Initial Request for RAD for the Treatment of Hypoventilation Syndrome

A RAD without a backup rate may be considered for treatment of hypoventilation syndrome with prior authorization when all of the following criteria are met:

An initial arterial blood gas PaCO2, obtained while awake with the client breathing their prescribed FIO2, greater than or equal to 45 mm Hg

Spirometry shows a forced expired volume in 1 sec (FEV1) or the forced vital capacity (FVC) greater than or equal to 70 percent

A facility-based polysomnogram demonstrates oxygen saturation less than or equal to 88 percent for 5 minutes or longer of continuous nocturnal recording time (minimum recording time of 2 hours) not caused by obstructive upper airway events

A RAD with a set backup respiratory rate may be considered with prior authorization for the treatment of hypoventilation syndrome when one of the following are met:

The client has hypoventilation syndrome as determined by a facility-based polysomnogram that demonstrates the desired respiratory therapeutic effects were not achieved with a RAD without a backup rate

The client meets the criteria for RAD without a backup rate for hypoventilation syndrome, and the physician documents the desired respiratory therapeutic effects were not achieved with the RAD without a backup rate.

Renewal Request for RAD with or without a Backup Rate

Prior Authorization is required for renewal of a RAD with or without a backup rate.

Prior authorization for purchase of RAD without a set back up rate or continued rental of a RAD with or without a backup rate, after completion of the initial three-month rental period, may be considered with all of the following documentation completed, signed, and dated by the client’s treating physician:

A new Texas Medicaid Prior Authorization Request for CPAP or RAD (Bi-level PAP) form

Attestation from the treating physician that states the client is continuing to use the equipment at a minimum of four hours in a 24 hour period

Client symptoms are improved as documented by the client’s treating physician

When recertifying a RAD with or without a set backup rate for significant respiratory insufficiency, documentation of a capillary blood gas (CBG) demonstrating a PaCO2 greater than or equal to 45 mm Hg, obtained while awake and breathing the client’s routinely prescribed FiO2 may be submitted in lieu of an ABG.

2.2.22.9Mechanical Ventilation

Invasive and noninvasive ventilators (procedure codes E0465 and E0466) are considered for rental only with prior authorization and documentation of medical necessity indicating a clinical need for mechanical ventilation.

Mechanical ventilation may be considered for the treatment of, but not limited to:

Neuromuscular or musculoskeletal diseases and conditions affecting the respiratory muscles

Thoracic restrictive diseases

Chronic respiratory failure

The following procedure codes will deny if billed in the same month by any provider as procedure codes E0465 and E0466:

Procedure Codes

A4481

A4483

A4611

A4612

A4613

A4618

2.2.22.9.1Prior Authorization

All ventilators and related equipment require prior authorization.

The DME provider is responsible for ensuring that there is a contingency plan to manage interruptions in the use of equipment such as emergency situations and mechanical failures that would be life threat­ening for the client. Acceptable plans include input from the client’s treating practitioner that takes into account the severity of the client’s medical condition and time constraints in providing emergency support.

A ventilator may be considered for an initial 3-month rental period. Following the initial 3-month rental period, if the ventilator was effective, it may be considered for ongoing 6 month rental periods.

A home ventilator with an invasive or noninvasive interface (procedure codes E0465 and E0466) is not intended for use as a CPAP or RAD; however, a home ventilator may be considered when medically necessary. A home ventilator requested with CPAP or RAD settings must be submitted on the Texas Medicaid Prior Authorization Request for CPAP or RAD (Bi-level PAP) form with a letter of medical necessity explaining why a CPAP or RAD is not medically appropriate for the client.

Prior authorization may be considered for initial and renewal requests for mechanical ventilators with submission of all of the following:

A completed Title XIX Form signed and dated by the client’s treating physician (new with each request)

Attestation from the treating physician that the mechanical ventilator is medically necessary and the client is complaint with the use of the equipment

The completed Title XIX Form must specify all ventilator settings and must be maintained by the DME provider and the treating physician in the client’s medical record.

The monthly ventilator rental includes all ventilator related supplies regardless of the client’s duration of use, whether 24 hours per day or less, including, but not limited to:

Internal filters

External filters

Ventilator circuits with an exhalation valve

High and low pressure alarms

Humidification systems including supplies and solutions (e.g., sterile or distilled water)

In-line compressors and related supplies

Back-up ventilator

Tracheostomy tube filters and humidification devices, such as heat moisture exchangers (procedure code A4483)

Oxygen rental is not considered a ventilator supply and may be considered for separate prior authorization.

Refer to:  Subsection 2.2.22.11, “Oxygen Therapy” in this handbook for more information.

Heated or non-heated humidification requires a separate prior authorization for rental or purchase for client owned ventilators. Documentation submitted must support why it is medically necessary for the use with the ventilation.

Refer to:  Subsection 2.2.22.4, “Humidification Therapy and Heating Elements” in this handbook for more information.

A home ventilator using an invasive interface, such as a tracheostomy tube (procedure code E0465), or using a non-invasive interface, such as a mask or chest shell (procedure code E0466), will be prior autho­rized for rental when medically necessary for clients who require assisted mechanical ventilation and must be requested by the client’s treating physician.

An invasive home ventilator (procedure code E0465) may be prior authorized for rental for those clients who have a tracheostomy and require mechanical ventilation.

A noninvasive positive pressure or volume control ventilator (procedure code E0466) may be prior authorized for rental only for those clients who do not have a tracheostomy and require mechanical ventilation.

Rental of a chest shell (cuirass or “clam shell”) (procedure code E0457) and chest wrap (procedure code E0459) for use with a mechanical ventilator is limited to up to three months.

Purchase of a chest shell (cuirass or “clam shell”) may be prior authorized for purchase following the initial three-month rental period of the mechanical ventilator. The prescribing physician must include the predicted length of treatment and the client’s compliance with the equipment.

2.2.22.10Secretion and Mucus Clearance Devices

Secretion and mucus clearance devices are a benefit when medically necessary, and are typically needed by clients diagnosed with cystic fibrosis (CF), chronic bronchitis, bronchiectasis, and ciliary dyskinesia syndromes, some forms of asthma, neuromuscular degenerative disorders, post-operative atelectasis, or thoracic wall defects.

Secretion and mucus clearance devices may be considered when documentation clearly shows the client has one of the following indications for this form of therapy as described by the AARC in the Clinical Practices Guidelines for Postural Drainage Therapy:

Evidence of retained secretions

Evidence that the client is having difficulty with the secretion clearance

Presence of atelectasis caused by mucus plugging

The following secretion and mucus clearance devices or procedures do not require prior authorization:

Incentive spirometers (procedure code A9284)

Mucous clearance valved chamber (oscillating positive expiratory pressure (PEP), such as the Flutter Valve) (procedure code S8185)

Moisture exchangers (procedure code A4483) only when used for mechanically ventilated clients who own their ventilator

Tracheostoma filters, such as Thermovent T (procedure code A4481) for clients with a tracheotomy who are not mechanically ventilated

The following secretion and mucus clearance devices require prior authorization:

Insufflation-exsufflation devices (e.g. Cough Assist, Cofflator) (procedure code E0482)

Electrical percussors (procedure code E0480)

The high-frequency chest wall oscillation (HFCWO) system (procedure code E0483)

Percussion cup (procedure code E1399)

Intermittent positive pressure breathing (IPPB) devices (procedure code E0500)

Procedure codes A7025 and A7026 will deny if billed in the same month by any provider as rental of procedure code E0483.

2.2.22.10.1Prior Authorization

Prior authorization requests for the rental or purchase of secretion and mucus clearance devices requires submission of a Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices - Initial Request form or a Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices -Renewal Request form completed, signed, and dated by the client’s treating physician unless otherwise specified.

Clients requiring more than one secretion and mucus clearance device must have a pulmonologist as the treating physician who submits a signed and dated letter of medical necessity (LMN) on the physician’s letterhead stating the need of two devices.

Percussion Cups

Percussion cups, used when performing chest physiotherapy, may be medically necessary to loosen thick, mucus secretions, assist respiration, and prevent infections and require prior authorization. Percussion cups should be requested using the miscellaneous DME procedure code E1399.

Electrical Percussor

An electrical percussor (procedure code E0480) may be considered for rental or purchase with documentation of medical necessity including a description of all previous courses of therapy (such as manual percussion and postural drainage (P&PD) or valved devices) and why they did not adequately assist the client in airway mucus clearance.

Cough Augmentation Device (e.g., mechanical insufflation-exsufflation or cough assist machine)

A cough augmentation device (procedure code E0482) may be considered for prior authorization for rental only for those clients who have chronic pulmonary disease or neuromuscular disorders (including spinal cord injury) that affect the respiratory musculature, causing a weak, ineffectual, or absent cough.

Prior authorization of a cough augmentation device may be considered for an initial three-month rental period with all of the following documentation completed, signed, and dated by the client’s treating physician:

Diagnosis and background history including, as applicable, recent illnesses, complications, medica­tions used, history of recent hospitalizations, and results of pulmonary function studies (if applicable) due to diagnosis related complications

History of school, work, or extracurricular activity absences or other clinical evidence supporting natural deterioration to the level of requiring the use of a cough augmentation device to clear the airways, such as a weak, ineffective cough as demonstrated by pulmonary function studies (PFTs)

Medical reasons why the client, parent, guardian, or caregiver cannot perform chest physiotherapy, or why such therapies were previously not effective

Requests for prior authorization recertification must include documentation by the client’s treating physician that the client is compliant with the use of the equipment and that the treatment is effective.

High-Frequency Chest Wall Oscillation (HFCWO) System

A high-frequency chest wall oscillation (HFCWO) system (procedure code E0483) will not be prior authorized as first line treatment. The client must have trialed other percussion and postural drainage therapy, such as electric percussor or cough augmentation device, for a minimum of three months before a request for a HFCWO system will be considered for prior authorization.

A request for a HFCWO system may be considered for prior authorization for rental or purchase when submitted with documentation addressing why prior therapy was ineffective and documentation of one of the following conditions.

Bronchiectasis when it is confirmed by CT scan and characterized by either a continuous daily productive cough for 6 months or frequent exacerbations of pulmonary infections (i.e., more than 2 times per year) requiring antibiotic therapy

Cystic fibrosis or other documented chronic supperative endobronchitis

Chronic neuromuscular disorder affecting the client’s ability to cough or clear respiratory secretions

Weak ineffective or absent cough caused by chronic pulmonary disease or a neuromuscular disorder

Rental of the HFCWO System

An initial three-month rental may be prior authorized for the HFCWO system with hose and vest (procedure code E0483) when submitted with the following documentation of medical necessity that is completed, signed, and dated by the client’s treating physician:

A Texas Medicaid Prior Authorization Request for Secretion and Mucus Clearance Devices form (Initial or Renewal Request) form

Client history of a chronic respiratory illness with exacerbation or change in baseline respiratory condition in the past 6 months, including extra nebulizer treatments for respiratory secretions, I.V. antibiotics, and hospitalizations

Client history of school, work, or extracurricular activity absences due to diagnosis related symptoms, or pulmonary function testing in (PFTs) in past 6 months, if applicable

Other appropriate (age, ability, skill) modes of chest physiotherapy (such as percussion and postural drainage therapy or mechanical device) that have been trialed by the client, parent, guardian, or caregiver for a minimum of three months before the HFCWO request and the reasons the trialed therapy was ineffective or contraindicated

Documentation that any previous use of an HFCWO device did not result in aspiration, exacer­bation of a gastrointestinal or pulmonary issue, or an exacerbation of seizure activity

If at the end of the initial three-month rental a determination of purchase cannot be made, an additional three month-rental may be considered for prior authorization when the request is submitted with the above documentation and documentation of compliance with ordered therapy.

Purchase of the HFCWO System

If at the end of the initial three-month rental, the HFCWO system (procedure code E0483) is documented to be effective, purchase of the system may be considered for prior authorization when submitted with all the following required documentation:

A physician’s statement of the HFCWO system trial in a clinic, hospital, or the home setting documenting:

The results of the HFCWO system therapy

The effectiveness and tolerance of the system that includes evidence of vest tolerance

An explanation of the trial outcome

The treating physician’s description and assessment of the effectiveness and tolerance of the system that includes the client’s diagnosis and the following background history:

Respiratory related complications and evidence of a decrease in these complications

Medications used, including IV antibiotic therapy with dosage, frequency and duration, including evidence of decreased respiratory-related medication use

Recent hospitalizations related to the client’s respiratory condition and evidence of shorter hospital length(s) of stay

Evidence of decreased hospitalizations

Evidence of fewer school, work, or extracurricular activity absences due to a diagnostic related condition or other clinical evidence supporting natural deterioration to the level of requiring the use of a HFCWO system to clear the airways, such as a weak, ineffective cough as demonstrated by pulmonary function studies (PFTs)

Evidence of the frequency and compliance graphs for the 3-month period showing the frequency prescribed by the physician for each day and use of the system at least 50 percent of the time

A statement from the treating physician that the previous use of the HFCWO device has not resulted in aspiration, exacerbation of a gastrointestinal or pulmonary issue, or exacerbation of seizure activity.

A HFCWO system purchase will be reimbursed only once per lifetime, due to the lifetime warranty provided by the manufacturer. Requests for a vest replacement (procedure code A7025) must include documentation that supports the client can no longer wear the vest due to changes in the client’s condition such as changes in height, weight, or skin abrasions.

2.2.22.11Oxygen Therapy

Devices used for in-home oxygen therapy including stationary oxygen concentrators (procedure code E1390), compressed gas (procedure code E0424), liquid oxygen (procedure code E0439), portable compressed gas cylinder (procedure code E0431), or liquid oxygen reservoir (procedure code E0433) systems are a benefit when medically necessary and require prior authorization.

Oxygen system rental includes, but is not be limited to:

Oxygen concentrator or oxygen tanks

Regulator

Flow meter

Humidifier

Cannula or mask

Tubing

Oxygen system supplies, including but not limited to a cannula or mask, refills, and tubing do not require prior authorization for client owned equipment.

Devices used for in-home oxygen therapy may be considered for the treatment of hypoxemia which may be the result of, but not limited to:

Bronchopulmonary dysplasia or other respiratory diagnoses due to prematurity

Respiratory failure or insufficiency; musculoskeletal weakness, such as that caused by Duchenne’s muscular dystrophy or spinal muscle atrophy

Diagnosis of cluster headaches

Severe lung disease, such as COPD, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, or widespread pulmonary neoplasm

Humidification during oxygen therapy may be a benefit with prior authorization and is provided as a component of the oxygen therapy rental. Humidification during oxygen delivery with client-owned equipment may be a benefit for rental or purchase with prior authorization when medically necessary.

The following procedure codes will deny if billed in the same month by any provider as procedure codes E0424, E0431, E0433, E0434, E0439, E1390, and K0738:

Procedure Codes

A4615

A4616

A4617

A4619

A4620

E0441

E0442

E0443

E0444

E0580

E1353

E1355

2.2.22.11.1Prior Authorization

Oxygen therapy criteria are based on AARC, American Thoracic Society, and British Thoracic Society Treatment Guidelines. Oxygen therapy related supplies, other than humidification, do not require prior authorization for client owned equipment. Humidification during oxygen delivery with client-owned equipment may be a benefit for rental or purchase with prior authorization when medically necessary.

All oxygen therapy equipment requires prior authorization and prior authorization may be considered for monthly rental only. A completed Texas Medicaid Prior Authorization Request for Oxygen Therapy Devices and Supplies form completed, signed, and dated by a the client’s treating physician must be submitted.

Prescribing providers must maintain an original, completed, signed, and dated Texas Medicaid Prior Authorization Request for Oxygen Therapy Devices and Supplies form in the client’s medical record. The DME provider must maintain a copy of the complete, signed, and dated in the client’s record.

Stationary oxygen concentrators are the preferred oxygen therapy home delivery system. If other types of oxygen therapy home delivery systems are required, documentation of medical necessity to support an exception, such as frequent interruptions in electrical service or medical necessity for a higher oxygen concentration than can be obtained with a concentrator, must be provided. The other types of delivery systems include:

Compressed gas cylinder systems (nonportable tanks).

Liquid oxygen reservoir systems.

Multiple oxygen types (e.g., liquid and gas) will not be authorized concurrently.

Initial Oxygen Therapy Medical Necessity Certification

Oxygen ordered for ’as needed’ or ’PRN’ use does not provide a basis to determine if intermittent oxygen is reasonable and medically necessary for the client. Documentation must support the need for inter­mittent use of oxygen.

Prior authorization of home oxygen therapy for an initial three month rental period may be considered with submission of all of the following documentation in addition to the request:

Evidence from the client’s treating physician of a determination that the client has severe lung disease or hypoxia-related symptoms that are expected to improve with oxygen therapy and the client’s blood gas studies meet the criteria indicated below

A Texas Medicaid Prior Authorization Request for Oxygen Therapy Devices and Supplies form with Sections A and B that is completed, signed, and dated by the client’s treating physician documenting the client’s specific medical needs and the testing performed to determine the need for oxygen therapy including all of the following criteria:

The client’s medical diagnosis requiring oxygen therapy

The oxygen flow rate

An estimate of the frequency, duration of use (e.g. 2 liters per minute, 12 hours per day), and duration of need (e.g., 3 months)

A qualifying blood gas assessment may be supported by the results of either pulse oximetry or an arterial blood gas and includes all of the following:

Date of the testing

Results of the testing

If the blood gas assessment occurred during the client’s inpatient hospital stay, a blood gas performed no more than two days before discharge is acceptable.

If a blood gas is obtained while the client is at home, the assessment must be performed while the client is in a stable chronic state (i.e., not during a period of acute illness or an exacerbation of their underlying disease) within the 30 day period prior to the request for service.

Oxygen therapy coverage is available under one of the three group categories outlined below, if the client has an eligible condition as described above.

Group I Oxygen Therapy Category

Group I - Prior authorization may be considered for clients of any age with significant hypoxemia with documentation of any of the following:

An arterial pO2 (partial pressure of oxygen) equal to or less than 55 mm Hg or an arterial oxygen saturation equal to or less than 88 percent, taken at rest, breathing room air

An arterial pO2 equal to or less than 55 mm Hg or arterial oxygen saturation at or below 88 percent, taken during sleep and lasting for at least 5 continuous minutes for clients who have a pO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent while awake

A decrease in arterial pO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation of more than 5 percent, for at least 5 continuous minutes taken during sleep with symptoms or signs reasonably attributable to hypoxemia (e.g., impairment of cognitive processes and nocturnal restlessness or insomnia)

An arterial pO2 equal to or less than 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a member who demonstrates a pO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, supple­mental oxygen may be provided for use during exercise if there is evidence the use of oxygen improves the hypoxemia that was demonstrated during exercise when the client was breathing room air

Group I Oxygen Therapy for Clients who are 20 Years of Age and Younger

Prior authorization may be considered for clients 20 years of age and younger when evidenced by any of the above or the following documentation:

A neonate, and premature infant of any age who have not reached their 40th week of gestational maturity with an arterial pO2 of less than 60 mmHg or an arterial oxygen saturation level is less than 92 percent

An infant with chronic neonatal lung disease with an arterial oxygen saturation equal to or less than 92 percent

Other medical conditions that may be considered with supporting documentation include, but are not limited to:

Infants with bronchopulmonary dysplasia

Infants with apnea of prematurity, or recurrent cyanotic apneic episodes

Children with severe pulmonary hypotension

Children who have sickle cell anemia with respiratory conditions

Infants or children who have idiopathic pulmonary hypertension with sleep associated desatu­rations or a documented need for an emergent use of oxygen

Oxygen Saturation

pO2 in mm HG

Required Parameters

Clients/Comments

Less than or equal to 88 percent

Less than or equal to 55

At rest on room air

Infants, children and adults

Less than or equal to 88 percent

Less than or equal to 55

For greater than or equal to 5 minutes during sleep, when “at rest” criteria not met

Infants, children and adults

Less than or equal to 88 percent

Less than or equal to 55

During exercise, when criteria for “at rest” is not met

Tests provided must document the following results:

At rest on room air

Exercising without oxygen

Exercising with oxygen

Infants, children and adults

 

If only criteria - documentation from physician: client’s hypoxemia improved with use of O2 with exercise

Decrease of greater than 5 percent

Decrease of greater than 10 mm HG

For greater than 5 minutes taken during sleep and

Client has signs or symptoms attributable to hypoxemia

Infants, children and adults

Less than 92 percent

Less than 60

At rest on room air

Neonates, premature infants who are < than their 40 week gesta­tional maturity

Less than or equal to 92 percent

 

At rest on room air

Chronic neonatal lung disease

Infants and children

Greater than or equal to 89 percent

Greater than or equal to 56

Documentation from physician supporting the medical need for the oxygen therapy due to medical conditions requiring different parameters

Clients of any age

Intermittent acute oxygen therapy at home is not routinely recommended for seizures as there is no evidence that it reduces seizure duration, reduces harm from prolonged seizures, or improves quality of life for the child or family.

Group II Oxygen Therapy Category

Group II-Prior authorization may be considered for clients of any age whose arterial pO2 is 56-59 mm Hg or whose arterial blood oxygen saturation is 89 percent with documentation of any of the following:

Dependent edema suggesting congestive heart failure (CHF)

Cor pulmonale (pulmonary hypertension)

Erythrocythemia with a hematocrit greater than 56 percent

Group III Oxygen Therapy Category

Group III-Prior authorization may be considered for clients with a diagnosis of cluster headaches with documentation of all of the following:

Neurological evaluation with diagnosis of cluster headache

Documentation of failed medication therapy

For clients whose only diagnosis is OSA, documentation must support the client’s oxygen sleep desatu­ration was not corrected with use of CPAP or other RADs.

Oxygen Therapy Recertification

Prior authorization of oxygen therapy rental after an initial three-month rental period may be considered for periods of six month at a time with the submission of all of the following documentation:

A new Texas Medicaid Prior Authorization Request for Oxygen Therapy Devices and Supplies form with Sections A and C completed, signed, and dated by the client’s treating physician

Evidence of a continued need for oxygen therapy

Evidence from the client’s treating physician of the client’s compliance with the oxygen therapy

A new arterial blood gas assessment using either pulse oximetry or arterial blood gases

Evidence that the client meets the criteria for any of the above Groups (I, II, or III) for oxygen therapy

If the above criteria for oxygen therapy are not met medical necessity for recertification of oxygen therapy will be considered by a medical director with documentation from the treating physician supporting the client’s need for oxygen therapy.

Stationary Oxygen Systems

Rental of a stationary oxygen system includes, but is not limited to, the nasal cannula or mask, tubing, and a basic bubble humidification system.

The types of covered stationary oxygen delivery systems include:

Oxygen concentrators

Compressed oxygen gas cylinder systems

Liquid oxygen cylinder systems

Portable Oxygen Systems

Portable oxygen therapy may be considered for prior authorization when medical necessity documen­tation indicates that the client requires the use of oxygen in the home and would benefit from the use of a portable oxygen system when traveling outside of the home environment.

Portable oxygen systems will not be considered for prior authorization for travel outside of the home environment for clients who qualify for oxygen usage based solely on oxygen saturation levels during sleep.

The types of covered portable oxygen and portable oxygen related delivery systems include:

Portable tanks for compressed oxygen gas cylinder systems

Portable tanks for liquid oxygen cylinder systems

Home compressor attachment used on an oxygen compressor to fill oxygen tanks

Portable gaseous oxygen system home compressor

2.2.22.12Cardiorespiratory Monitor (CRM)

A cardiorespiratory monitor (CRM) (procedure codes E0618 and E0619) for purchase or rental may be a benefit when medically necessary and may be considered for clients who require moment-to-moment cardiac and respiratory monitoring due to potential for sudden unexpected deterioration. For infants who are four months of age and younger, a CRM with recording feature (procedure code E0619) may be considered for rental without prior authorization for a maximum of two months. Prior authorization is required for clients who are 5 months of age and older.

Note:The American Academy of Pediatrics (AAP) recommends that infant monitoring using an infant CRM should not be used as a strategy to prevent sudden infant death syndrome (SIDS).

Procedure codes A4556 and A4557 will deny if billed in the same month by any provider as procedure codes E0618 and E0619.

2.2.22.12.1Prior Authorization

For infants who are four months of age and younger, a CRM with recording feature (procedure code E0619) may be considered for rental without prior authorization for a maximum of two months with documentation of one of the following conditions:

Central apnea (respiratory control disorders)

Cardiac rhythm issues

A completed Title XIX Form signed and dated by the client’s treating physician must be maintained in the client’s medical record.

If a two-month rental has expired for infants who are 4 months of age and younger and continued CRM is medically necessary, a submitted prior authorization request on a completed Title XIX Form signed and dated by the client’s treating physician (new with each request) must include the following:

The client has on-going, documented cardiorespiratory episodes (e.g. apnea or dysrhythmia)

A physician interpretation, signed and dated by the physician, of the most recent two-month’s CRM data recorded downloads

A CRM with or without recording feature (procedure code E0618 or E0619) may be considered for prior authorization for rental or purchase for clients who are 5 months of age and older when submitted with a completed Title XIX Form signed and dated by the client’s treating physician (new with each request) for one of the following conditions:

An episode of apparent life-threatening event (ALTE) in an infant who is 12 months of age or younger

Symptomatic central apnea

Technology dependence such as:

Mechanical ventilation

Tracheostomy with a critical airway obstruction

Assisted ventilation dependence

Cardiac dysrhythmia with significant risk of morbidity or mortality

2.2.22.13Tracheostomy Tubes and Related Supplies

Tracheostomy tubes (procedure codes A7520, A7521, and A7522) are medically necessary for clients with a tracheostomy and are available for purchase with prior authorization.

Tracheostomy supplies, including inner cannulas, are available for purchase when medically necessary without prior authorization within the stated benefit limits.

A tracheostomy speaking valve is considered a medically necessary accessory that enhances the function of the tracheostomy and is available for purchase without prior authorization when requested within the stated benefit limits.

A tracheostomy speaking valve (procedure code L8501) is available for purchase and is limited to one per six months without prior authorization.

2.2.22.13.1Prior Authorization

For the initial tracheostomy tube request, three tubes may be considered for prior authorization in the first month of service (two the same size and one smaller for emergencies).

For the next five months of the initial prior authorization period and for subsequent requests, one tracheostomy tube will be prior authorized per month.

More than one tracheostomy tube per month may be considered on a case-by-case basis with medical documentation supporting why the tracheostomy tube must be changed more frequently in order to meet the client’s medical needs.

Requesting tracheostomy supplies above the defined limitation

Tracheostomy supplies requests for clients 20 years of age and younger that exceed the defined limits require prior authorization with documentation supporting the medical need of the quantity requested and may be considered under the Comprehensive Care Program and must be requested on a CCP Prior Authorization Request Form.

Tracheostomy supplies requests for clients who are 21 years of age and older that exceed the defined limits require prior authorization with documentation supporting the medical need of the quantity requested and may be considered by a medical director with documentation of medical necessity and must be requested on a Title XIX Form.

Modifiers for Tracheostomy Tubes

When requesting prior authorization for non-customized or non-specialized tracheostomy tubes without specialized functions, providers must submit the most appropriate procedure code with no modifier.

When requesting prior authorization for specialized but non-customized tracheostomy tubes with specialized functions, providers submit the request with modifier U1.

When requesting prior authorization for customized tracheostomy tubes, providers must submit the request with modifier U2.

With the use of either modifier U1 or U2, the following documentation is required:

A physician statement of the reason the client cannot use a standard tracheostomy tube

The manufacturer’s information on the specialized functions of the tracheostomy tube or the order form describing the customization of the tracheostomy tube

Manufacturer’s retail or invoice pricing information is required when using modifier U2.

Tracheostomy Tube Inner Cannula and Required Modifier

Clients with a tracheostomy tube with a reusable inner cannula (procedure code A4623) are allowed one reusable inner cannula per month without prior authorization.

Requests for more than one reusable inner cannula per month require prior authorization and medical documentation from the client’s physician to support the need for more than one reusable inner cannula per month.

Clients with a tracheostomy tube with a disposable inner cannula (procedure code A4623 with modifier U3) are allowed 31 disposable inner cannulas per month without prior authorization. Request for more than 31 disposable inner cannulas per month require prior authorization and documentation from the client’s treating physician to support the medical need for more than 31 disposable inner cannulas per month.

Custom tracheostomy tubes are manufactured with reusable inner cannulas. The reusable inner cannulas are included in the prior authorization for any custom tracheostomy tube authorized.

2.2.22.14Suction Machines and Related Supplies

A suction machine (procedure code E0600) may be considered for purchase with prior authorization if medically necessary for clients who have difficulty raising and clearing secretions. Suction supplies (suction canisters, suction tubing, tracheal suction catheters, and oropharyngeal suction catheters) (procedure codes A4605, A4624, A4628, A7000, and A7002) are medically necessary for use with a suction machine. These supplies are available, if medically necessary, for purchase without prior autho­rization, up to the stated benefit limits unless otherwise indicated. Only one type of tracheal suction catheter is allowed per month.

In most cases in the home setting, sterile suction catheters (procedure codes A4605 and A4624) and sterile saline for suctioning (procedure code A4216) are considered medically necessary only for trache­ostomy suctioning. Sterile saline for tracheal suctioning (procedure code A4216) does not require prior authorization when requested within the stated benefit limits.

Procedure code A4605 will deny if billed in the same month by any provider as procedure code A4624.

2.2.22.14.1Prior Authorization

Suction machines, suction canisters, suction tubing, tracheal suction tubes, and oropharyngeal suction catheters are a benefit with documented medical need to have oral, nasopharyngeal, or tracheal suctioning performed. Suction supplies do not require prior authorization within the stated benefit limits.

Suction canister filters are limited to one every two months with prior authorization and should be requested using the miscellaneous DME procedure code A9900. Suction equipment and supplies requests for clients who are 20 years of age and younger that exceed the allowed limits require prior authorization with documentation supporting the medical need of the quantity requested, may be considered under Comprehensive Care Program, and must be requested on a CCP Prior Authorization Request Form.

Suction equipment and supplies requests for clients who are 21 years of age and older that exceed the allowed limits require prior authorization with documentation supporting the medical need of the quantity requested and may be considered by a medical director with documentation of medical necessity supporting the medical need of the quantity requested and must be requested on a Title XIX Form.

2.2.22.15Other Respiratory Supplies

Other respiratory supplies are a benefit when medically necessary and are available without prior autho­rization up to the stated quantity limitation unless otherwise indicated:

Non-sterile (clean) respiratory supplies are considered standard of care and are clinically appro­priate in the home setting

Sterile respiratory supplies are a benefit with prior authorization when medically necessary and documentation clearly demonstrates that the client’s medical needs cannot be met with non-sterile (clean) supplies

2.2.22.15.1Prior Authorization

Respiratory supplies are included in the rental of the respiratory equipment and will not be prior autho­rized separately, but may be prior authorized for equipment that is owned by the client.

To request prior authorization for respiratory supplies for use with client-owned equipment, the following documentation must be provided by the client’s treating physician:

A completed Title XIX Form signed and dated by the client’s treating physician (new with each request)

Accurate diagnostic information pertaining to the underlying diagnosis or condition as well as any other medical diagnoses or conditions, to include the client’s overall health status

The prescribed respiratory care regimen, to include frequency, duration, and supplies needed

Treatment for infection, if present

Quantity of disposable supplies requested per month by the physician

Medical justification for the quantity and type of supply requested

2.2.22.16Bag Valve Mask (BVM) Resuscitator

A bag valve mask (BVM) resuscitator or handheld resuscitation bag for a ventilator-dependent client (procedure code S8999) is commonly used when the client is temporarily removed from mechanical ventilation. A BVM for a ventilator dependent client may be a benefit for purchase when medically necessary without prior authorization.

A BVM for a non-ventilator client with or without a tracheotomy and with an appropriately sized face mask when appropriate who requires manual respiratory assistance due to inadequate or no breathing may be a benefit when medically necessary and requires prior authorization using the miscellaneous DME procedure code E1399 and will be reviewed by a medical director.

2.2.22.17Respiratory Equipment for Clients not Meeting Required Criteria or who have Conditions not Listed

Respiratory equipment may be considered for clients not meeting the required criteria, or for those with conditions not listed, when prior authorization is submitted with documentation of medical necessity and will be reviewed by a medical director. The prior authorization request must include all the following documentation:

Identification of the client’s specific medical needs that can only be met by the respiratory equipment requested

A letter of medical necessity from the client’s treating physician documenting alternative measures and alternative respiratory equipment, which have been tried and failed to meet the client’s medical need(s), or have been ruled out, along with an explanation of why the equipment failed or was ruled out

A minimum of two articles from evidence-based medical peer-reviewed literature that demonstrate supportive data for use of the requested respiratory equipment to treat the client’s specific medical condition, and that the respiratory equipment requested has been found to be safe and effective for the requested use

2.2.22.18Short Term Pulse Oximetry Services, Benefits, and Limitations

A pulse oximeter (procedure code E0445) may be rented for short term use for no more than one calendar month in a six calendar month period. The short term rental of a pulse oximeter may be a benefit when medically necessary and does not require prior authorization for clients with one of the following conditions:

Weaning the client from home oxygen

Change in the client’s condition that requires an adjustment in the liter flow of their home oxygen treatment

To determine the client’s appropriate home oxygen liter flow for ambulation, exercise, or sleep

To determine the client’s appropriate home oxygen liter flow for those who have neuromuscular disease involving the respiratory muscles, with chronic lung disease, or with severe cardiopul­monary disease.

2.2.22.19Long Term Pulse Oximetry Services, Benefits, and Limitations

Long term pulse oximetry (procedure code E0445 with modifier U4) may be a benefit of Texas Medicaid through the Comprehensive Care Program (CCP) with prior authorization. Long-term rental and purchase of a pulse oximeter is a benefit for clients who are birth through 20 years of age. A pulse oximeter for long-term use is defined as equipment rented for more than one calendar month in a six- month period. Long-term pulse oximetry is limited to clients eligible for CCP who qualify for medically necessary services beyond the limits of the home health benefit.

A long-term pulse oximeter must be a device that:

Is a bedside or tabletop device.

Provides continuous oxygen saturation monitoring.

Requires use of wired probes.

Has battery and alternating current (A/C) capability.

2.2.22.19.1Long Term Pulse Oximeter Prior Authorization

Prior Authorization for Clients 21 Years of Age and Older

Pulse oximetry that is medically necessary for more than one calendar month in a six calendar month period requires prior authorization and will be considered for clients 21 years of age and older by a medical director when submitted with a complete Title XIX form, signed and dated by the treating physician and with documentation of medical necessity, such as:

When weaning from a ventilator or oxygen and an earlier weaning attempt was unsuccessful that includes why it was unsuccessful

Documentation of changes in the client's condition since the failed weaning attempt

Prior Authorization for Clients Birth through 20 Years of Age

Prior authorization is required for rental or purchase of a long-term pulse oximeter (procedure code E0445 with modifier U4) for clients who are birth through 20 years of age. HHSC or its designee will determine whether the long term pulse oximeter equipment will be rented, purchased, or repaired based on the client's needs and expected duration of use. Only new, unused equipment will be purchased.

The prior authorization request must include the following documentation:

A completed CCP Prior Authorization Request form

Documentation of the cause of the oxygen lability

Documentation that a caregiver or medical healthcare provider is present who has been trained in use of the oximeter and how to respond to readings in a medically safe and appropriate manner, and the client meets one of the following criteria:

Client is oxygen or ventilator dependent and has respiratory system instability as noted in the documentation

Client experiences respiratory complications that require equipment that has oxygen saturation monitoring capabilities

A long-term pulse oximeter may be prior authorized for monthly rental up to a maximum of six months. Recertification for an additional six-month period may be considered for a maximum of six additional months.

A long-term pulse oximeter will be considered purchased and owned by the client when the total monthly payments equal the purchase cost for the equipment. Prior authorization for purchase or continued rental of the long-term pulse oximeter at the end of a 12-month rental period will not be considered. A long-term pulse oximeter may be prior authorized for purchase when a purchase is deter- mined to be more cost effective than leasing the device with supplies.

Long-term pulse oximeter equipment that has been purchased is anticipated to last a minimum of five years. Replacement of equipment may also be considered for prior authorization when loss or irrepa- rable damage has occurred outside the warranty terms, conditions, and limitations. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent reoccurrence must be submitted with prior authorization request.

A long-term pulse oximeter used to monitor a client with a history of seizure activity is not routinely recommended for seizures as there is no evidence that it reduces seizure duration, reduces harm from prolonged seizures, or improves quality of life for the child or family.

Pulse Oximetry Supplies

Pulse oximeter probes for client-owned equipment do not require prior authorization and are limited as follows:

Disposable pulse oximeter probes (procedure code A4606) are limited to four per month

Reusable pulse oximeter sensor probes (procedure code A4606 with modifier U5) are limited to one every six months

Procedure code A4606 and procedure code A4606 with modifier U5 will deny if billed in the same month by any provider as procedure code E0445.

Prior authorization may be considered for quantities greater than four per month with documentation supporting medical necessity.

Pulse oximeter probes (procedure code A4606 [disposable] or A4606 [reusable] with modifier U5) are included in the pulse oximeter equipment rental. Pulse oximeter probes will be denied if billed with rental of pulse oximeter equipment (procedure code E0445 or E0445 with modifier U4) in the same month of service by any provider.

The rental of equipment includes all necessary supplies, adjustments, repairs, and replacement parts.

2.2.22.20Procedure Codes and Limitations for Respiratory Equipment and Supplies

Procedure Code

Maximum Limitations

Requires Prior Authorization

A4216

40 per calendar month

No

A4481

31 per calendar month

No

A4483

15 per calendar month

Included in ventilator rental, No prior authorization for client-owned equipment if within policy limit

A4556

15 per calendar month

No

A4557

2 per calendar month

No

A4605

10 per calendar month

Only 1 type of tracheal catheter is allowed per month. A4605 will deny as part of A4624 if billed in same month.

No

A4606

4 per calendar month

Included in pulse oximeter rental, No prior authorization for client-owned equipment if within policy limit

A4606 with modifier U5

1 per 6 calendar months

Included in pulse oximeter rental, No prior authorization for client-owned equipment if within policy limit

A4611

1 per 5 rolling years

Included in ventilator rental, No prior authorization for client-owned equipment if within policy limit

A4612

1 per 5 rolling years

Included in ventilator rental, No prior authorization for client-owned equipment if within policy limit

A4613

1 per 5 rolling years

Included in ventilator rental, No prior authorization for client-owned equipment if within policy limit

A4614

1 per 6 calendar months

No

A4615

2 per calendar month

Included in O2 rental, No prior autho­rization for client-owned equipment if within policy limit

A4616

4 per calendar year

Included in O2 rental, No prior autho­rization for client-owned equipment if within policy limit

A4617

2 per calendar month

Included in O2 rental, No prior autho­rization for client-owned equipment if within policy limit

A4618

4 per calendar month

Included in ventilator rental, No prior authorization for client-owned equipment if within policy limit

A4619

2 per calendar month

Included in O2 rental, No prior autho­rization for client-owned equipment if within policy limit

A4620

2 per calendar months

Included in O2 rental, No prior autho­rization for client-owned equipment if within policy limit

A4623

1 per calendar month

No

A4623 with modifier U3

31 per month

No

A4624

85 per calendar month

Only 1 type of tracheal catheter is allowed per month

No

A4627

1 per 6 calendar months

No

A4628

2 per calendar month

No

A4629

30 per calendar month

No

A7000

5 per calendar month

No

A7002

8 per calendar month

No

A7003

2 per calendar month

No

A7004

2 per calendar month

No

A7005

1 per 6 calendar months

No

A7006

1 per calendar month

No

A7007

2 per calendar month

No

A7009

1 per calendar year

No

A7010

1 per 2 calendar months

No

A7012

2 per calendar month

No

A7013

2 per calendar month

No

A7014

1 per 3 calendar months

No

A7015

1 per calendar month

No

A7016

2 per calendar year

No

A7017

1 per 3 rolling years

No

A7018

4 per calendar month

No

A7025

1 per lifetime

Yes

A7026

1 per 6 calendar months

No

A7027

1 per 3 calendar months

No

A7028

1 per calendar month

No

A7029

2 per calendar month

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7030

1 per 3 calendar months

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7031

1 per calendar month

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7032

2 per calendar month

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7033

2 per calendar month

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7034

1 per 3 calendar months

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7035

1 per 6 calendar months

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7036

1 per 6 calendar months

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7037

1 per calendar month

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7038

2 per calendar month

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7039

1 per 6 calendar months

Included in CPAP or RAD rental, No prior authorization for client-owned equipment if within policy limit

A7520

1 per calendar month

Yes

A7520 with modifier U1

1 per calendar month

Yes

A7520 with modifier U2

1 per calendar month

Yes

A7521

1 per calendar month

Yes

A7521 with modifier U1

1 per calendar month

Yes

A7521 with modifier U2

1 per calendar month

Yes

A7522

4 per calendar year

Yes

A7523

1 per 2 years

No

A7525

4 per calendar month

No

A7526

20 per calendar month

No

A9900

As needed

Yes

A9284

1 per 6 calendar months

No

E0424 (Rental)

1 per calendar month

Yes

E0431 (Rental)

1 per calendar month

Yes

E0433 (Rental)

1 per calendar month

Yes

E0434 (Rental)

1 per calendar month

Yes

E0439 (Rental)

1 per calendar month

Yes

E0441

1 per calendar month

Yes

E0442

1 per calendar month

Yes

E0443

1 per calendar month

Yes

E0444

1 per calendar month

Yes

E0445 (Rental)

1 per 6 calendar months

Yes

E0457 (Purchase)

1 per 5 rolling years

Yes

E0457 (Rental)

1 per calendar month

Yes

E0459 (Purchase)

1 per lifetime

Yes

E0459 (Rental)

1 per calendar month

Yes

E0465 (Rental)

1 per calendar month

Yes

E0466 (Rental)

1 per calendar month

Yes

E0470 (Purchase)

1 per 5 rolling years

Yes

E0470 (Rental)

1 per calendar month

Yes

E0471 (Rental)

1 per calendar month

Yes

E0472 (Rental)

1 per calendar month

Yes

E0480 (Purchase)

1 per rolling 5 years

Yes

E0480 (Rental)

1 per calendar month

Yes

E0482 (Rental)

1 per calendar month

Yes

E0483 (Purchase)

1 per lifetime

Yes

E0483 (Rental)

1 per calendar month

Yes

E0500 (Rental)

1 per calendar month

Yes

E0500

1 per 5 rolling years

Yes

E0550 (Rental)

1 per calendar month

Yes

E0550 (Purchase)

1 per 3 rolling years

Yes

E0561 (Purchase)

1 per 5 rolling years

Yes

E0561 (Rental)

1 per calendar month

Yes

E0562 (Purchase)

1 per 5 rolling years

Yes

E0562 (Rental)

1 per calendar month

Yes

E0565 (Purchase)

1 per 5 rolling years

Yes

E0565 (Rental)

1 per calendar month

Yes

E0570 (Purchase)

1 per 5 rolling years

No for conditions listed in policy.

Yes for conditions not listed in policy.

E0574 (Purchase)

1 per 5 rolling years

Yes

E0575 (Purchase)

1 per 5 rolling years

Yes

E0580 (Purchase)

1 per 3 rolling years

Yes

Included in O2 rental.

E0580 (Rental)

1 per calendar month

Yes

Included in O2 rental.

E0585 (Purchase)

1 per 3 rolling years

Yes

E0600 (Purchase)

1 per 5 rolling years

Yes

E0601 (Purchase)

1 per 5 rolling years

Yes

E0601 (Rental)

1 per calendar month

Yes

E0618 (Purchase)

1 per 5 rolling years

Yes

E0618 (Rental)

1 per calendar month

Yes

E0619 (Purchase)

1 per 5 rolling years

Yes

Exception: No prior authorization required for maximum 2 months for infants birth through 4 months of age

E0619 (Rental)

1 per calendar month

Yes

E1353 (Purchase)

1 per rolling year

No. Included in O2 rental, No prior authorization for client-owned equipment if within policy limit

E1355 (Purchase)

1 per 3 rolling years

No. Included in O2 rental, No prior authorization for client-owned equipment if within policy limit

E1372 (Purchase)

1 per 3 rolling years

Yes

E1390 (Rental)

1 per calendar month

Yes

E1399 (Rental)

As needed

Yes

E1399 (Purchase)

As needed

Yes

K0462 (Rental)

1 per calendar month

Yes

K0730 (Purchase)

1 per 5 rolling years

Yes

K0738 (Rental)

1 per calendar month

Yes

K0739

2 hours per day

Yes

L8501

1 per 6 calendar months

No

S8101

1 per 6 calendar months

No

S8185 (Purchase)

1 per 5 rolling Years

No

S8189 (Purchase)

As needed

Yes

S8999 (Purchase)

1 per calendar year

No

2.2.22.21Services that are not a Benefit

The following respiratory equipment and supplies are not a benefit of Title XIX Home Health Services if they are requested primarily for the convenience of the caregiver:

Rental of:

Mucus clearance valved chamber

Medication small volume nebulizer

Intrapulmonary percussive ventilation (IPV) system

Ultrasonic nebulizers

Oxygen supplies for rented equipment

Intermittent or spot-check pulse oximetry

Purchase of:

Bi-level PAP with set backup respiratory rate

Intrapulmonary percussive ventilation (IPV)

Ventilators

Pulse oximeter as a Home Health benefit

Intermittent or spot-check pulse oximetry

Long term (greater than 1 calendar month) pulse oximeter is not a benefit of Home Health services.

Note:Clients 20 years of age and younger who qualify for medically necessary services beyond the limits of the short-term pulse oximeter benefit may request those long-term pulse oximeter services through the Comprehensive Care Program (CCP).

Respiratory equipment or supplies requested primarily for the convenience of the caregiver

The following items are not a benefit of Title XIX Home Health Services because they either have no federal financial participation (FFP) available, are considered environmental equipment, or are considered ineffective or detrimental and as such are not considered medically necessary:

Cool mist humidifiers

Room air humidifiers

Vaporizers

Dehumidifiers

Air conditioners

Back-up generators

Sterile water is not medically necessary for humidifiers in the home setting and is therefore not a benefit.

2.2.23Special Needs Car Seats and Travel Restraints

2.2.23.1Special Needs Car Seats

A special needs car seat may be considered for reimbursement with prior authorization for a client who has outgrown an infant car seat and is unable to travel safely in a booster seat or seat belt.

A special needs car seat must have a top tether installed. The top tether is essential for proper use of the car seat. The installer is reimbursed for the installation by the manufacturer.

Providers must use procedure code E1399 for a special needs car seat.

Car seat accessories available from the manufacturer may be considered for reimbursement with prior authorization when medically necessary for correct positioning.

A stroller base for a special needs car seat is not a benefit of Texas Medicaid.

A special needs car seat may be considered for reimbursement with prior authorization for a client who has outgrown an infant car seat and is unable to travel safely in a booster seat or seat belt. Consideration must be given to the manufacturer’s weight and height limitations and must reflect allowances for at least 12 months of growth.

The provider must maintain a statement that has been signed and dated by the client’s parent or legal guardian in the client’s medical record that states the following:

A top tether has been installed in the vehicle in which the client will be transported, by a manufac­turer-trained vendor.

Training in the correct use of the car seat has been provided by a manufacturer-trained vendor.

The client’s parent or legal guardian has received instruction and has demonstrated the correct use of the car seat to a manufacturer-trained vendor.

To request prior authorization for a special needs car seat or accessories, the following documentation must be provided:

The client’s weight must be at least 40 pounds, or the client’s height must be at least 40 inches.

Supporting documentation must include the following and must be submitted for prior authorization:

Accurate diagnostic information pertaining to the underlying diagnosis or condition as well as any other medical diagnoses or conditions, to include the client’s overall health status.

A description of the client’s postural condition specifically including head and trunk control (or lack of control) and why a booster chair or seatbelt will not meet the client’s needs (the car seat must be able to support the head if head control is poor).

The expected long-term need for the special needs car seat.

A copy of the manufacturer’s certification for the installer’s training to insert the specified car seat.

A request for a client who does not meet the criteria may be considered on a case-by-case basis on review by HHSC or its designee.

2.2.23.2Travel Safety Restraints

Providers must use procedure code E0700 for the purchase of travel safety restraints, such as ankle and wrist belts.

A travel safety restraint and ankle or wrist belts may be considered for reimbursement through CCP without prior authorization for clients with a medical condition requiring them to be transported in either a prone or supine position. The DME provider and the prescribing physician familiar with the client must maintain documentation in the client’s medical record supporting the medical necessity of the travel safety restraint.

2.2.24Subcutaneous Injection Ports

A subcutaneous injection port is a sterile medication delivery device through which physician-prescribed medications can be injected directly into the subcutaneous tissue using a standard syringe and needle, an injection pen, or other manual injection device. The device can be used for multiple subcutaneous injections for a period of up to 72 hours, thereby avoiding repeated needle punctures of the skin. The device cannot be used with an injection pump.

A subcutaneous injection port, such as the I-Port or Insuflon, is a benefit of Texas Medicaid as a Title XIX Home Health service with prior authorization. Claims for a subcutaneous injection port must be submitted with procedure code A4211 and modifier U4.

Texas Medicaid may reimburse the device for clients who require multiple daily injections of a physician-prescribed medication and who meet the medical necessity criteria.

The subcutaneous injection port is not a benefit of Texas Medicaid as an item of convenience or for clients who are already receiving the medication through an ambulatory infusion pump. The device is considered an item of convenience if the client does not meet the criteria for medical necessity.

2.2.24.1Prior Authorization

Prior authorization is required for a subcutaneous injection port. Initial prior authorizations will be issued for a trial period of up to 3 months. Prior authorizations that are issued after the successful completion of the initial trial period may be issued for a period of up to 6 months. Prior authorizations for subcutaneous injection ports are limited to a quantity of 10 individual ports per month. Additional ports will be considered for prior authorization with documentation of medical necessity.

2.2.24.2Documentation Requirements

The initial request for prior authorization must include documentation that indicates the client meets the following criteria for medical necessity:

The client has a medical condition that requires multiple (i.e., 2 or more) subcutaneous, self-admin­istered injections on a daily basis and has a current prescription for the injectable medication. Documentation must indicate the specific medical condition that is being treated, the name of the injectable medication, and the dosage and frequency of the injections.

Note:“Self-administered” includes those injections administered by the client through a subcuta­neous injection or by the caregiver to the client through a subcutaneous injection.

The client or the caregiver has been unsuccessful with the self-administration of injections using a standard needle and syringe because the client demonstrates trypanophobia (i.e., severe needle phobia), as evidenced by documented physical or psychological symptoms. Documented symptoms may include, but are not limited to, the following:

Condition

Possible Exhibited Symptoms

Vaso-vagal trypanophobia

Physical symptoms such as changes in blood pressure, syncope, sweating, nausea, pallor, and tinnitus

Associate trypanophobia

Psychological symptoms such as extreme anxiety, insomnia, and panic attacks

Resistive trypanophobia

Signs and symptoms such as combativeness, elevated heart rate, high blood pressure, and violent resistance to procedures involving needles or injections

The prescribing physician must include with the prior authorization request a written statement of medical necessity that identifies the client as an appropriate candidate for the subcutaneous injection port device. The physician’s statement or medical record documentation that is submitted with the prior authorization request must indicate the following:

The client or caregiver has received instruction during an office visit on the proper placement and use of the device, with successful return demonstration. (Prior authorization requests for skilled nursing visits for the sole purpose of client instruction on the use of the subcutaneous injection port device will not be approved. Necessary instruction must be performed as part of the office visit with the prescribing physician.)

The client has no known allergies or sensitivities to adhesives, silicone, or similar materials.

The client has no skin infection at potential injection sites.

The client’s most recent lab results related to the medical condition requiring treatment with daily subcutaneous injections must also be submitted with the prior authorization request. Lab results may include, but are not limited to, hemoglobin A1c (HbA1c) levels for clients with insulin dependent diabetes mellitus (IDDM) and partial thromboplastin time (PTT) for clients who are receiving anticoagulant therapy.

Requests for the renewal of the prior authorization after the initial trial period has ended must include documentation of the following:

Ongoing signs and symptoms associated with the client’s trypanophobia.

Improved compliance with the physician-prescribed injection regimen.

Successful use of the device with no persistent pattern of the client’s dislodging the device during the initial trial period.

Results of relevant lab tests performed upon completion of the initial trial period, including, but not limited to, HbA1c levels for clients with IDDM and PTT for clients who are receiving anticoagulant therapy.

Note:For clients with IDDM, if the HbA1c level has not declined with use of the subcutaneous injection port, additional documentation must be submitted by the physician who documents the clinical determination about the lack of significant improvement in the HbA1c level. The renewal of the prior authorization will not be approved without this information.

2.2.25Total Parenteral Nutrition (TPN) Solutions

2.2.25.1Services, Benefits, and Limitations for Clients Birth through 20 Years of Age

In-home TPN for clients who are birth through 20 years of age may be considered through CCP. Eligible clients may receive short-term or long-term nutritional support when oral or enteral intake are unable to maintain adequate nutrition. Covered services must be medically necessary and prescribed by the physician.

Parenteral nutrition solution, supplies, and infusion pumps services may be reimbursed with the following procedure codes:

Procedure Codes

Solution Procedure Codes

B4164

B4168

B4172

B4176

B4178

B4180

B4185

B4189

B4193

B4197

B4199

B4216

B5000

B5100

B5200

Supply Procedure Codes

B4220

B4222

B4224

B9999

Infusion Pump Procedure Codes

B9004

B9006

 

2.2.25.2Prior Authorization and Documentation Requirements for Clients Birth through age 20

Prior authorization is required for TPN solutions, lipids, supply kits, and infusion pumps that are provided through CCP for clients birth through 20 years of age. Renewal of the prior authorization will be considered on the basis of medical necessity.

TPN solutions, lipids, supply kits, and infusion pumps will be considered with prior authorization when documentation submitted clearly shows that it is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition. Documentation must include the following:

Conditions that result in a loss of function of the gastrointestinal (GI) tract and the inability to obtain adequate nutrition by the enteral route, such as:

Infections of the pancreas, intestines, or other body organs that result in a loss of GI function

Inflammatory bowel disease

Necrotizing enterocolitis

Malnutrition

Trauma

Overwhelming systemic infections

Serious burns

Conditions that result in an inability of the bowel to absorb nutrition, such as:

Extensive bowel resection

Severe, advanced bowel disease. Examples include short bowel syndrome (SBS), chronicintes- tinal pseudo-obstruction (CIPS), Hirshprungs disease (HD), Crohn’s disease, and ulcerative colitis

Prematurity

Leukemias

Congenital gastrointestinal anomalies

Acquired immunodeficiency syndrome

To facilitate determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including documentation of medical necessity for the equipment and supplies requested.

Prior authorization requests for TPN must include the following information:

Medical condition for which TPN is necessary

Documentation of any trials with oral and enteral feedings

Percent of daily nutritional needs from TPN

A copy of the TPN formula or prescription that includes amino acids and lipids and is signed and dated by the physician

A copy of the most recent laboratory results that includes potassium, calcium, liver function studies, and albumin

Note:Conditions or durations of need that are not listed above may be considered by HHSC or its designee with documentation of medical necessity.

The requesting provider may be asked for additional information to clarify or complete a request for TPN services.

The physician must also maintain documentation of medical necessity in the client’s medical record. Retrospective review may be performed to ensure that the documentation supports the medical necessity of the TPN services.

2.2.25.3Services, Benefits, and Limitations for Clients 21 years of age and older

In-home TPN for clients who are 21 years of age and older may be considered through home health services. Eligible clients may receive long-term nutritional support when oral or enteral intake are unable to maintain adequate nutrition. “Long-term nutritional support” refers to treatment lasting 30 days or longer. Covered services must be medically necessary and prescribed by the physician.

Conditions that may require TPN include, but are not limited to the following:

Bowel disease or disorder

Cancer

AIDS

Coma

Burns

Peritonitis

Note:Conditions or a duration of need not listed above may be considered by HHSC or its designee with documentation of medical necessity.

TPN services are not a benefit when oral or enteral intake will maintain adequate nutrition.

Parenteral nutrition solution services may be reimbursed using the following procedure codes:

Procedure Codes

B4164

B4168

B4172

B4176

B4178

B4180

B4185

B4189

B4193

B4197

B4199

B4216

B5000

B5100

B5200

2.2.25.4Prior Authorization and Documentation Requirements for Clients who are 21 Years of Age and Older

TPN solutions, lipids, supply kits, and infusion pumps must be prior authorized. Renewal of the prior authorization will be considered on the basis of medical necessity.

The administration of intravenous fluids and electrolytes cannot be billed as in-home TPN.

Claims for TPN must contain the 9-character prior authorization number in Block 23. Providers must consult with their vendor for the location of this field in the electronic claims format. The prescribing physician name and provider identifier must be in Block 17 and 17a or in the appropriate field of the provider’s electronic software.

Requests for prior authorization must include the following information:

Medical condition necessitating the need for TPN and long-term nutritional support.

Documentation of any trials with oral or enteral feedings.

Percent of daily nutritional needs from TPN.

A copy of the TPN formula or prescription, including amino acids and lipids, signed and dated by the physician.

A copy of the most recent laboratory results (to include potassium, calcium, liver function studies and albumin).

The requesting provider may be asked for additional information to clarify or complete a request for TPN services.

Retrospective review may be performed to ensure that the documentation supports the medical necessity of the TPN services.

2.2.25.5Infusion Pumps and Supplies (All Ages)

Parenteral nutrition supplies may be reimbursed using procedure codes B4220, B4222, B4224, and B9999.

Prior authorization requests for miscellaneous procedure code B9999 must include the following:

A detailed description of the requested item or supply.

Documentation supporting the medical necessity for the requested item or supply.

Prior authorization requests for a portable parenteral nutrition infusion pump (procedure code B9004) must also include documentation of medical necessity demonstrating that:

The client requires continuous feedings

Feeding intervals exceed the time that the client must be away from home to:

Attend school or work.

Participate in extensive, physician-ordered outpatient therapies.

Attend frequent, multiple medical appointments.

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.

The infusion pump may be rented once a month or purchased once every five years.

2.2.25.6