CurrentTexas Children's Health PlanPolicy 4358

Durable Medical Equipment (DME) Service Procedure

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Governs access, benefit limitations, prior authorization, provider choice, and medical-necessity review for durable medical equipment and supplies for Texas Children's Health Plan members across STAR, STAR Kids, CHIP, and other applicable lines of business.

Policy Summary

PayerTexas Children's Health Plan

PolicyDurable Medical Equipment (DME) Service Procedure

Policy CodePolicy 4358

Change TypeNo material change

Effective DateNov 16, 2022

Next Review DateN/A

Key ActionSubmit a signed change-of-provider letter and new Physician Order when changing DME or medical supply providers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

27 daysMonthly billing interval

90 daysMaximum out-of-network authorization

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CurrentTexas Children's Health PlanPolicy 4358

Durable Medical Equipment (DME) Service Procedure

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Sign up for texaschildrenshealthplan Policy 4358 alerts

Get alerted when Policy 4358 changes without checking for updates manually.

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Policy Summary

PayerTexas Children's Health Plan

PolicyDurable Medical Equipment (DME) Service Procedure

Policy CodePolicy 4358

Change TypeNo material change

Effective DateNov 16, 2022

Next Review DateN/A

Key ActionSubmit a signed change-of-provider letter and new Physician Order when changing DME or medical supply providers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

27 daysMonthly billing interval

90 daysMaximum out-of-network authorization

Age 3 and youngerIncontinence supply age threshold

240/monthDiaper limit

2 boxes/monthWipes limit

120/monthUnderpad limit

Coverage Criteria

General DME coverage

DME and supplies are covered when all of the following requirements are met:

General DME coverage: The requested DME or supply is needed by the member; the item is covered under the member's benefit plan; medical necessity is supported under TCHP guidelines; and applicable TMHP/TCHP benefit limitations are satisfied or an approved exception applies.

DME monthly limits are applied every 27 days. Preauthorization addresses medical necessity but does not guarantee benefits or eligibility; all services remain subject to benefit limitations and exclusions.

Incontinence supplies

Incontinence supplies for members age 3 and younger may be considered when all of the following criteria are met:

Pediatric incontinence supplies: The member is age 3 or younger; a medical condition causes urine or stool output beyond what is typical for the member's age; and the requested supplies and quantities comply with applicable limits or are supported through prior authorization when limits are exceeded.Diapers: 240 per month; wipes: 2 boxes per month; underpads: 120 per month

Examples of qualifying conditions include short bowel syndrome, Crohn's disease, celiac disease, diabetes insipidus, radiation enteritis, and certain metabolic conditions. Wipes are for members receiving diapers, briefs, or pull-ons. Underpads are for members receiving diapers, briefs, pull-ons, liners, or urine or bowel collection devices.

Limited out-of-network services

Limited out-of-network authorization for tracheostomy- or gastrostomy-related supplies may be considered when either of the following conditions is met:

ONE of

The requested supplies are related to tracheostomy or gastrostomy status, such as ventilators or feeding tube pumps; and the provider was in network at the time of the initial rental request.
The requested supplies are related to tracheostomy or gastrostomy status, such as ventilators or feeding tube pumps; and the member previously received the requested services through another Managed Care Organization or Fee-for-Service provider.

CHIP benefit and medical-necessity review

For a CHIP member requesting a covered DME item that requires prior authorization, authorization review includes all of the following:

CHIP benefit and medical-necessity review: Review prior DME authorizations and paid amounts; identify the applicable HCPCS and/or CPT codes; calculate the remaining benefit; document medical necessity and the cost of the DME item; and approve only when the remaining benefit covers the item and TCHP medical-necessity guidelines are met.

If medical necessity is uncertain, or remaining benefits do not cover the item, refer the request to the Medical Director. When Medical Director approval establishes medical necessity despite insufficient remaining benefits, approval may be issued through the end of benefit coverage, with the potential benefit shortage and the insured's responsibility documented and approval correspondence stating that benefits may be exhausted during treatment or services.

Covered DME and supplies must be needed by the member, covered under the applicable benefit plan, medically necessary under TCHP guidelines, and within applicable TMHP/TCHP benefit limitations. An exception may be considered when the provider submits documentation supporting medical necessity and the exception is approved. Covered categories addressed by this procedure include durable medical equipment and related supplies used for catheterization, tracheostomy or gastrostomy care, enteral feeding, oxygen therapy, ostomy care, and incontinence management.

Gloves used to change diapers or briefs are not considered medically necessary unless the member has skin breakdown or a documented disease that can be transmitted through urine or stool. Requests must document the applicable exception.

Incontinence supplies are not medically necessary when the member does not have a qualifying medical condition causing urine or stool output beyond what is typical for the member's age. Glove requests are not medically necessary without skin breakdown or a documented disease transmissible through urine or stool. Requests exceeding the standard limits of 240 diapers per month, 2 boxes of wipes per month, or 120 underpads per month require prior authorization and supporting documentation.

Coding and Quantity Limits

Covered HCPCS Codes — TCHP Exceptions to TMHP DME LimitsHCPCSCovered

A4310	Insertion tray without drainage bag and without catheter (accessories only)
A4312	Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone
A4315	Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all cone
A4332	Lubricant, individual sterile packet, each
A4338	Indwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or
A4344	Indwelling catheter, Foley type, two-way, all silicone, each
A4351	Intermittent Catheters - must be accompanied with modifier SC when a hydrophilic catheter is used.
A4352	Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each
A4353	Intermittent urinary catheter, with insertion supplies; hydrophilic catheters
A4605	Tracheal suction catheter, closed system, each

1–10 of 12

1/2

A4310 Quantity Limits

CodeA4310

DescriptionInsertion tray without drainage bag and without catheter (accessories only)

TMHP limit2 per month

TCHP limit30 per month

A4312 Quantity Limits

CodeA4312

DescriptionInsertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone

Provider Actions and Authorization

Prior Authorization

Provider Change Authorization Timing

Prior authorization for a new DME provider may be issued only up to three business days before TCHP receives the change-of-provider letter and new Physician Order.

The member may choose or change a DME/medical supply provider.
The member is responsible for notifying the original provider of the change and effective date.

Documentation Required

Provider Change Documentation

To change DME providers, TCHP must receive a signed and dated change-of-provider letter and a new Physician Order.

The letter must be signed and dated by the member or legally appointed representative.
Include the previous provider’s name and the effective date of the change.

Policy Background

This procedure governs access, benefit limitations, prior authorization, provider choice, and medical-necessity review for durable medical equipment and related supplies provided to Texas Children's Health Plan members. It addresses ongoing medical support, including catheterization, tracheostomy or gastrostomy care, enteral feeding, oxygen therapy, ostomy care, and incontinence management. Coverage depends on the member's benefit plan, applicable TMHP limits, and documented medical necessity.

Definitions

Tracheostomy- and Gastrostomy-Related Supplies

DefinitionSupplies related to tracheostomy and gastrostomy status

ExamplesVentilators and feeding tube pumps

Out-of-network authorizationMay be approved for up to 90 days when a qualifying condition applies

Preauthorization

PurposeAddresses the medical necessity of the requested treatment or service

Benefits and eligibilityDoes not guarantee benefits or member eligibility

Limitations

Medical Necessity

Pediatric incontinence medical necessity

Incontinence supplies may be considered for a member age 3 or younger when all of the following medical-necessity criteria are met:

Pediatric incontinence medical necessity: The member is age 3 or younger; a qualifying medical condition results in urine or stool output beyond what is typical for the member's age group; and the requested supply and quantity are appropriate under applicable limits or are supported by an approved over-limit request.Diapers: 240 per month; wipes: 2 boxes per month; underpads: 120 per month

Qualifying examples include short bowel syndrome, Crohn's disease, celiac disease, diabetes insipidus, radiation enteritis, and certain metabolic conditions. Prior authorization is required for these supplies and for quantities exceeding 240 diapers per month, 2 boxes of wipes per month, or 120 underpads per month. Wipes are for members receiving diapers, briefs, or pull-ons; underpads are for members receiving diapers, briefs, pull-ons, liners, or urine or bowel collection devices.

Rental and Purchase Rules

Equipment	Rule	Related authorization condition
Tracheostomy- and gastrostomy-related supplies, including ventilators and feeding tube pumps	Rental	For continued services with an out-of-network DME provider, authorization may be approved for up to 90 days if the provider was in network at the time of the initial rental request or the member previously received the requested services through another MCO or Fee-for-Service provider.

Required Documentation

Documentation Required

Submit complete provider-change documentation

When changing DME or medical supply providers, submit a signed and dated change-of-provider letter and a new Physician Order. The letter must identify the previous provider and the effective date of the change.

The member or legally appointed representative must sign and date the letter.
The new Physician Order must accompany the letter.

Documentation Required

Support over-limit requests with medical-necessity records

For requests exceeding benefit limits or otherwise requiring review, submit documentation supporting medical necessity in accordance with the current Texas Medicaid Provider Procedure Manual.

Not Covered

Nonqualifying out-of-network requests are not authorized for general soft medical supplies, off-the-shelf DME equipment, enteral feeding formulas and supplements, catheters, dietary supplements, ostomy supplies, oxygen, or oxygen concentrators because these items are available through in-network providers. A limited exception may apply to qualifying tracheostomy- or gastrostomy-related supplies, including ventilators and feeding tube pumps, when the provider was in network at the initial rental request or the member previously received the requested services through another MCO or Fee-for-Service provider; authorization may be issued for up to 90 days.

Policy Summary

PayerTexas Children's Health Plan

PolicyDurable Medical Equipment (DME) Service Procedure

Policy CodePolicy 4358

Change TypeNo material change

Effective DateNov 16, 2022

Next Review DateN/A

Key ActionSubmit a signed change-of-provider letter and new Physician Order when changing DME or medical supply providers.

SourceLink

On This Page

TMHP limit2 per month

TCHP limit30 per month

A4315 Quantity Limits

CodeA4315

DescriptionInsertion tray with drainage bag with indwelling catheter, Foley type, two-way, all cone

TMHP limit2 per month

TCHP limit30 per month

A4332 Quantity Limits

CodeA4332

DescriptionLubricant, individual sterile packet, each

TMHP limit50 per

TCHP limit180 per month

A4338 Quantity Limits

CodeA4338

DescriptionIndwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or

TMHP limit2 per month

TCHP limit30 per month

A4344 Quantity Limits

CodeA4344

DescriptionIndwelling catheter, Foley type, two-way, all silicone, each

TMHP limit2 per month

TCHP limit30 per month

A4351 Quantity Limits

CodeA4351

DescriptionIntermittent Catheters - must be accompanied with modifier SC when a hydrophilic catheter is used.

TMHP limit150 per

TCHP limit180 per month

A4352 Quantity Limits

CodeA4352

DescriptionIntermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each

TMHP limit150 per

TCHP limit180 per month

A4353 Quantity Limits

CodeA4353

DescriptionIntermittent urinary catheter, with insertion supplies; hydrophilic catheters

TMHP limit150 per month

TCHP limit180 per month

A4605 Quantity Limits

CodeA4605

DescriptionTracheal suction catheter, closed system, each

TMHP limit10 per month

TCHP limit30 per month

A4628 Quantity Limits

CodeA4628

DescriptionOropharyngeal suction catheter

TMHP limit2 per month

TCHP limit4 per month

B9998 U2 Quantity Limits

CodeB9998 U2

DescriptionNonobturated gastrostomy or jejunostomy tube with insertion supplies and extensions

TMHP limit2 per rolling year

TCHP limit6 per rolling year

Incontinence Supply Quantity Limits

Diapers240 per month

Wipes2 boxes per month

Underpads120 per month

Prior authorizationRequired for members age 3 and younger and for requests exceeding the listed limits

Prior Authorization

Requests Exceeding TMHP Limits

When requesting DME above the applicable TMHP benefit limitation for a STAR or STAR Kids member age 20 or younger, submit prior authorization documentation that supports medical necessity. A prior authorization request may also be submitted for items that do not otherwise require authorization when the request is to exceed the limitation.

For CHIP members, justify the medical necessity of exceeding the TMHP limitation in the prior authorization request when authorization is required.
For items that do not require prior authorization, submit the request to TCHP Utilization Management to justify exceeding the benefit limitation.

Prior Authorization

Incontinence Supply Authorization

Incontinence supplies require prior authorization for members age 3 and younger when a medical condition causes urine or stool output beyond what is typical for the member’s age. Prior authorization is also required for requests exceeding the applicable quantity limits.

Monthly limits are 240 diapers, 2 boxes of wipes, and 120 underpads.
Wipes are for members receiving diapers, briefs, or pull-ons.
Underpads are for members receiving diapers, briefs, pull-ons, liners, or urine or bowel collection devices.

Prior Authorization

Limited Out-of-Network Authorization

Certain tracheostomy- and gastrostomy-related supplies may be authorized for up to 90 days for an out-of-network DME provider when a qualifying exception applies.

The provider was in-network when the initial rental was requested.
The member previously received the requested services through another MCO or a Fee-for-Service provider.

Unsupported block type: documentation

Unsupported block type: denial_risk

Note

Benefits or Eligibility Not Guaranteed

Preauthorization is based on medical necessity and does not guarantee benefits or member eligibility. 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 requirements; noncompliance may result in retrospective audit and potential financial recoupment.

All services remain subject to benefit limitations and exclusions