CurrentTexas Children's Health PlanPolicy N/A

Durable Medical Equipment (DME) Authorization and Medical Necessity

Customize your policy alerts

Sign up for all texaschildrenshealthplan policy alerts

Know when texaschildrenshealthplan releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This guideline governs Texas Children's Health Plan authorization and medical necessity review for durable medical equipment and certain miscellaneous DME and supply codes, including requests reviewed under EPSDT and exceptional-circumstances processes.

Policy Summary

PayerTexas Children's Health Plan

PolicyDurable Medical Equipment (DME) Authorization and Medical Necessity

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 18, 2024

Next Review DateN/A

Key ActionSubmit prior authorization and complete equipment, clinical, financial, coding, and ordering documentation for miscellaneous-code DME requests exceeding $500.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$500Authorization threshold

6 monthsInitial authorization period

12 months

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentTexas Children's Health PlanPolicy N/A

Durable Medical Equipment (DME) Authorization and Medical Necessity

Customize your policy alerts

Sign up for all texaschildrenshealthplan policy alerts

Know when texaschildrenshealthplan releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerTexas Children's Health Plan

PolicyDurable Medical Equipment (DME) Authorization and Medical Necessity

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 18, 2024

Next Review DateN/A

Key ActionSubmit prior authorization and complete equipment, clinical, financial, coding, and ordering documentation for miscellaneous-code DME requests exceeding $500.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$500Authorization threshold

6 monthsInitial authorization period

12 months

Recertification period

60 daysOrder age limit

13Nonpayable examples

Coverage Criteria

EPSDT and case-by-case medical necessity

EPSDT-covered requests, DME not referenced in the TMHP manual as billable under E1399, A9900, or T1999, and non-payable DME are reviewed case by case and approved when all of the following criteria are met:

All criteria required

Condition-related benefit: The requested DME corrects or ameliorates a disability, physical or mental illness, or chronic condition.
Evidence and equipment suitability
- Established efficacy: The equipment has a well-established history of efficacy.
- Novel or unique equipment: Valid peer-reviewed evidence supports that the equipment serves a medical purpose, can withstand repeated use, and is appropriate and safe for use in the home.

Payment is unavailable when federal financial participation (FFP) is not available. This includes vehicle modifications or mechanical or structural vehicle equipment, such as wheelchair lifts, and structural changes to homes, domiciles, or other living arrangements. Other examples include environmental equipment, supplies, or services; ancillary power sources and standby equipment, except for technology-dependent members who are ventilator-dependent for more than six hours per day; educational programs, supplies, or equipment; equine or hippotherapy; exercise equipment, home spas or gyms, toys, therapeutic balls, or tricycles; tennis shoes; respite care; aids for daily living; take-home hospital drugs; and therapy involving any breed of animal.

DME does not meet the medical necessity criteria when it does not correct or ameliorate a disability, physical or mental illness, or chronic condition. Equipment must have a well-established history of efficacy. For novel or unique equipment, valid peer-reviewed evidence must show that it serves a medical purpose, can withstand repeated use, and is appropriate and safe for use in the home.

Medical Necessity Standard

General medical necessity

DME is medically necessary when the applicable TMHP guidance and, where applicable, EPSDT criteria are satisfied.

Medical necessity: The requested equipment corrects or ameliorates a disability, physical or mental illness, or chronic condition and is supported by established efficacy or qualifying peer-reviewed evidence for novel or unique equipment.

TCHP follows the current TMHP manual for medical necessity for the specific equipment requested. Novel or unique equipment must serve a medical purpose, withstand repeated use, and be appropriate and safe for home use.

Coding and Billing Requirements

Miscellaneous DME and supply codesHCPCS

E1399	Durable medical equipment, miscellaneous
A9900	Miscellaneous durable medical equipment supply, accessory, or service component
T1999	Miscellaneous therapeutic items and supplies, rental purchases, not otherwise classified

Miscellaneous-Code Authorization Threshold

ThresholdInvoice price or billed charges exceed $500.

Applicable codesE1399, A9900, and T1999.

Required actionPrior authorization is required for durable medical equipment billed under these codes when the threshold is exceeded.

Order or Prescription Age

Document typeSigned physician order or prescription.

Authorized signerThe order or prescription must be signed by a physician or allowed practitioner.

Maximum age

Authorization and Provider Actions

Prior Authorization

When Prior Authorization Is Required

Prior authorization is required when durable medical equipment (DME) is subject to utilization review or is billed with E1399, A9900, or T1999 and the invoice price or billed charges exceed $500. Requests are received by TCHP's Utilization Management Department by fax, phone, online submission, or mail during normal business hours.

Use E1399, A9900, and T1999 only when a more appropriate code is unavailable; when an appropriate code exists, submit the more specific code.
Miscellaneous DME or supplies exceeding applicable TMHP benefit limitations are subject to prior authorization and medical-necessity review.

Prior Authorization

Authorization Duration and Recertification

Initial prior authorization may be issued for up to 6 months. Recertification may be granted for up to 12 months when documentation from the ordering physician or Allowed Practitioner supports the ongoing medical necessity of the requested nutritional products.

Required Documentation

Documentation Required

Submit complete DME documentation

For E1399, A9900, or T1999 requests with invoice price or billed charges exceeding $500, submit complete equipment, clinical, financial, coding-justification, and ordering documentation with the prior authorization request.

Completed prior authorization form
Equipment identification, detailed description, model and serial number, applicable manufacturer invoice, modifications and catalog numbers, and cost or charge
Explanation distinguishing the requested item from an existing code description when required
Clinical medical-necessity documentation
Signed physician or allowed-practitioner order or prescription dated no more than 60 days from the request date

Documentation Required

Provide additional item-specific documentation

For tricycles, floor sitters, activity chairs, corner chairs, and other items identified by TCHP, provide additional clinical and comparative documentation when requested to support the equipment recommendation.

DME Background

Durable medical equipment (DME) consists of equipment or appliances primarily and customarily used for a medical purpose. DME is generally not useful to an individual without a disability, illness, or injury, is capable of repeated use, and is reusable or removable.

Definitions and Code References

Allowed Practitioner

Prescriptive authorityMaintains a valid and registered prescriptive authority agreement in accordance with Texas Occupations Code, Chapter 157, Subchapter B.

Physician assistantA physician assistant licensed in Texas under Texas Occupations Code Chapter 204.

Advanced practice registered nurseAn advanced practice registered nurse licensed by the Texas Board of Nursing as a certified nurse practitioner or clinical nurse specialist.

Durable Medical Equipment (DME)

Primary purposeEquipment and appliances primarily and customarily used to serve a medical purpose.

Individual useGenerally not useful to an individual in the absence of a disability, illness, or injury.

Noncovered Items and Situations

The following items and situations are not covered because payment is unavailable when federal financial participation is not available: vehicle modifications, mechanical or structural vehicle changes such as wheelchair lifts, structural changes to homes or other living arrangements, environmental equipment or services, and ancillary power sources or standby equipment except for technology-dependent members ventilator-dependent for more than six hours per day. Other exclusions include educational programs or equipment, equine or hippotherapy, exercise equipment, home spas or gyms, toys, therapeutic balls, tricycles, tennis shoes, respite care, aids for daily living such as toothbrushes, spoons, reachers, and foot stools, take-home drugs from hospitals, and therapy involving any breed of animal.

Policy Summary

PayerTexas Children's Health Plan

PolicyDurable Medical Equipment (DME) Authorization and Medical Necessity

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 18, 2024

Next Review DateN/A

Key ActionSubmit prior authorization and complete equipment, clinical, financial, coding, and ordering documentation for miscellaneous-code DME requests exceeding $500.

SourceLink

On This Page

No more than 60 days from the date of request.

Prior Authorization

Change in Member Status

If the member's status changes before the authorization expires, the DME provider must work with the requesting physician or Allowed Practitioner to modify the plan of care and obtain a new authorization or a change to the existing authorization.

Documentation Required

Required Miscellaneous-Code Documentation

For DME billed with E1399, A9900, or T1999 when the invoice price or billed charges exceed $500, submit complete documentation with the prior authorization request.

Completed prior authorization form.
Identification and description of the equipment requested, including, when applicable: an invoice showing the manufacturer's logo, address, and phone number; equipment model and serial number; detailed item description; required modifications and corresponding product or accessory numbers from the manufacturer's catalog; and the cost or charge for each item.
A detailed explanation of how the requested item differs from an existing code description when the TMHP manual does not identify E1399, A9900, or T1999 as appropriate for billing the requested equipment.
Clinical documentation supporting medical necessity.
A physician order or prescription signed by the Physician or Allowed Practitioner and dated no more than 60 days before the request date.

Documentation Required

Additional Item-Specific Documentation

TCHP may request additional information for certain DME items, including tricycles, floor sitters, activity chairs, and corner chairs.

Effects of the member's condition on mobility.
How the equipment would correct or ameliorate the member's disability.
Details of evaluations supporting the current recommendation, including trials of one or more pieces of equipment.
Pictures of the requested equipment.
Consideration of less costly alternatives.

Prior Authorization

Exceptional-Circumstances Submission

Providers must submit requests for medically necessary DME and supplies that are not listed as covered Texas Medicaid benefits through TCHP's exceptional-circumstances process. DME and supplies allowed under that provision must be prior authorized by TCHP.

Denial Risk

Failure to Meet Criteria or Benefit Limitations

Requests that do not meet this guideline's criteria or exceed TMHP benefit limitations will be referred to a TCHP Medical Director or Physician Reviewer, and the Denial Policy will be followed.

For EPSDT-covered DME, including DME not referenced in the TMHP manual as billable with E1399, A9900, or T1999, and for non-payable DME, approval is case-by-case when the equipment corrects or ameliorates a disability, physical or mental illness, or chronic condition and has an established efficacy history or, for novel or unique equipment, valid peer-reviewed evidence supporting a medical purpose, repeated use, and safe, appropriate home use.
Payment is unavailable for services, supplies, or equipment for which federal financial participation is unavailable, including vehicle or home structural modifications; environmental equipment; most ancillary power or standby equipment; educational equipment; equine or hippotherapy and other animal therapy; exercise equipment, home spas or gyms, toys, therapeutic balls, or tricycles; tennis shoes; respite care; aids for daily living; and take-home hospital drugs.

Denial Risk

Incomplete or Technically Deficient Submission

The exceptional-circumstances process is not available for members whose DME or supply requests were denied for medical necessity or technical reasons, including missing essential information or incomplete documentation.

Submit complete and technically sufficient documentation to avoid denial or referral based on missing information, incomplete documentation, or other technical deficiencies.

Denial Risk

Benefit or Eligibility Limitation

Preauthorization is based on medical necessity and does not guarantee benefits, eligibility, or payment. Approval applies only to the medical necessity of the authorized treatment or service; all services remain subject to benefit limitations and exclusions.

Providers must comply with state and federal regulations; noncompliance may result in retrospective audit and potential financial recoupment.

Effect of the member’s condition on mobility
How the equipment will correct or ameliorate the disability
Evaluations and equipment trials supporting the recommendation
Pictures of the requested equipment
Less costly alternatives considered

Durability and useCan withstand repeated use and can be reusable or removable.

Medical Supplies

Consumable or disposableHealth care-related items that are consumable or disposable.

Repeated useItems that cannot withstand repeated use by more than one individual.

Medical needRequired to address an individual's medical disability, illness, or injury.

Plan of Care (POC)

FormA written regimen.

Establishment and reviewEstablished and periodically reviewed by a physician or allowed practitioner in consultation with home health agency staff.

Applicable standardsMeets the plan-of-care standards at 42 CFR §484.60 and 1 TAC §354.1037.

E1399

Code descriptionHealthcare Common Procedure Coding System code for durable medical equipment, miscellaneous.

UseMay be used to bill for durable medical equipment without a specific code.

Coding requirementIntended for use when a more appropriate code is not available; when an appropriate code exists, the more specific code must be used.

A9900

Code descriptionHCPCS code for a miscellaneous durable medical equipment supply, accessory, or service component.

Component useCan be used to describe a part of another HCPCS code.

Coding requirementIntended for use when a more appropriate code is not available; when an appropriate code exists, the more specific code must be used.

T1999

Code descriptionHCPCS code for miscellaneous therapeutic items and supplies.

Purchase classificationIncludes rental purchases.

Other classificationNot otherwise classified.