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Effective March 1, 2021, Immobilized Lipase Cartridges to Become a Benefit of Texas Medicaid

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after March 1, 2021, immobilized lipase cartridges (procedure code B4105) will become a benefit of Texas Medicaid.

Procedure code B4105 will be a benefit when provided by medical supplier (durable medical equipment) providers in the home setting.

Prior Authorization Criteria

Procedure code B4105 will require prior authorization, and may be considered with documentation of medical necessity indicating that the client meets all the following criteria:

  • The client has exocrine pancreatic insufficiency.
  • The client utilizes an enteral feeding pump.
  • The client utilizes a compatible formula and the amount of formula (mL) the client is receiving daily is documented.

Note: One cartridge can be used with up to 500mL of formula, with a maximum of two cartridges used per day. Procedure code B4105 will be limited to 62 per month.

For clients who are 5 through 20 years of age, procedure code B4105 will be considered through the Comprehensive Care Program (CCP).

For more information, call the TMHP Contact Center at 800-925-9126.