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Benefit Criteria to Change for IV Therapy Equipment and Supplies Effective March 1, 2022

Last updated on 1/14/2022

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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, 2022, benefit criteria will change for intravenous (IV) therapy equipment and supplies in Texas Medicaid.

The following list summarizes the changes to the benefit language:

  • Procedure codes A4221, A4223, and A4649 will be added as benefits for IV maintenance supplies.
  • Ambulatory infusion pump language will be added.
  • Infusion equipment rented for the four-month rental period per lifetime limit to a maximum rental period of ten months, same provider, within a one-year period will be considered purchased.
  • Prior authorization requirements will be removed for sterile syringes and replacement batteries. Quantity limitations will be added.
  • Prior authorization and documentation requirements will be expanded.

Prior Authorization

The following standards will be updated for consideration of prior authorization of IV therapy equipment and supplies:

  • IV maintenance supplies (procedure code A4221, with or without a dial flow regulator) are changed at least weekly but not more frequently than every 72 hours.
  • IV infusion supplies (procedure codes A4222, A4223, and K0552, with or without a dial flow regulator), extension set (with or without a dial flow regulator), and any add-on devices are changed every 72 hours.
  • One syringe to flush the catheter and one syringe for each additional lumen(s) is used if applicable before administration of an intermittent infusion.
  • Two syringes to flush the catheter and two syringes for each additional lumen(s) are used if applicable after intermittent infusion.

Procedure code A4649 must be submitted for prior authorization requests for stopcocks and inline filters.

All the following criteria must be met for prior authorization of a stationary 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 through push technique).

Rental of an infusion pump (ambulatory or stationary) may be prior authorized monthly for a maximum of 10 months with the same provider. Rentals for the same infusion pump exceeding 10 months with the same provider within a one-year period will be considered for purchase.

All repairs and replacement parts, including batteries, within the first six months after delivery are considered part of the purchase price.

Reimbursement

Rental of equipment includes all necessary accessories, supplies, adjustments, repairs, and replacement parts. Reimbursement for related supplies, repairs, and replacement parts will be denied as part of the rental.

Procedure codes A4221, A4223, and A4649 will require prior authorization and will be reimbursed only to durable medical equipment (DME) suppliers for services rendered in the home setting.

The limitations will be updated for the following procedure codes without prior authorization:

Procedure Codes

Limitations

A4206

30 per month

A4207

30 per month

A4208

30 per month

A4209

180 per month

A4212

2 per month

A4245

1 box per month

A4247

1 box per month

A4248

1 box per month

A4300

4 per month

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