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    v1.0.30
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)Texas Children's Health Plan DME Prior Auth | Open…
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    CurrentTexas Children's Health PlanPolicy E1399

    Miscellaneous Durable Medical Equipment (DME) When Billed Amount Exceeds $500

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    Guideline for prior authorization and medical-necessity review of miscellaneous durable medical equipment billed with E1399, A9900, or T1999 when charges exceed $500 for Texas providers and members.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicyMiscellaneous Durable Medical Equipment (DME) When Billed Amount Exceeds $500
    Policy CodePolicy E1399
    Change TypeNo material change
    Effective DateNovember 8, 2021
    Next Review DateN/A
    Key ActionObtain prior authorization when miscellaneous DME charges exceed $500 and submit the required clinical and equipment documentation.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3Codes requiring authorization over threshold
    >$500Prior authorization threshold

    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.

    60 days
    Maximum physician-order age
    Case-by-caseUnlisted EPSDT equipment review

    Coverage Criteria

    Miscellaneous DME Code Use

    Use miscellaneous DME codes only when no more appropriate code is available.

    E1399, A9900, and T1999 must be used only when a more appropriate code is not available. When an appropriate code exists, that code must be used.

    Apply the most specific and appropriate available code.

    TMHP Manual Criteria

    When applicable, medical necessity is established using the current TMHP manual criteria for the specific equipment requested.

    TCHP will follow the medical-necessity guidance in the current TMHP manual for the specific equipment requested.

    Apply the current TMHP manual criteria when the requested equipment is addressed there.

    Vehicle modifications and mechanical or structural equipment, including wheelchair lifts, are not payable.

    Structural changes to homes, domiciles, or other living arrangements are not payable.

    Environmental equipment, supplies, or services are not payable, including room dehumidifiers, air conditioners, filters, space heaters, fans, water purification systems, vacuum cleaners, and treatments for dust mites, rodents, and insects.

    Ancillary power sources and other types of standby equipment are not payable, except for technology-dependent members, such as members who are ventilator-dependent for more than six hours per day.

    Educational programs, supplies, or equipment, including personal computers and software.

    Equine or hippotherapy, and therapy involving any breed of animal.

    Exercise equipment, home spas or gyms, toys, therapeutic balls, and tricycles.

    Tennis shoes.

    Respite care, including relief to caregivers.

    Aids for daily living, including toothbrushes, spoons, reachers, and foot stools.

    Take-home drugs from hospitals. Eligible hospitals may enroll in and bill the Vendor Drug Program (VDP); pharmacies seeking enrollment should call 1-512-491-1429.

    Applicable Codes and Billing Thresholds

    Miscellaneous DME when billed amount exceeds $500HCPCS
    E1399Miscellaneous Durable Medical Equipment (DME)
    A9900Miscellaneous Durable Medical Equipment (DME)
    T1999Miscellaneous Durable Medical Equipment (DME)
    Billed-charge threshold
    Prior-authorization thresholdBilled charges greater than $500
    Physician order or prescription age
    Order or prescription ageNo more than 60 days from the date of request

    Prior Authorization and Review Actions

    Prior Authorization

    Prior Authorization Required Over $500

    Prior authorization is required for durable medical equipment billed under E1399, A9900, or T1999 when billed charges exceed $500. Requests may be submitted by fax, phone, online submission, or mail to the Utilization Management Department during normal business hours.

    • Complete the prior-authorization form.
    • Submit the request before services or equipment are provided.
    Documentation Required

    Equipment and Billing Documentation

    Requests for E1399, A9900, or T1999 must include sufficient equipment and billing documentation to identify the item, establish its cost, and support use of a miscellaneous code.

    • Equipment identification and detailed description.
    • Invoice showing the manufacturer's logo, address, and phone number.

    EPSDT Medical Necessity Review

    Medical Necessity for Unlisted EPSDT Equipment

    For unlisted equipment submitted under EPSDT, all of the following must support medical necessity.

    EPSDT DME medical necessity

    • The equipment corrects or ameliorates the member's disability, physical or mental illness, or chronic condition.

    • Efficacy support

      • The equipment has a well-established history of efficacy.
      • For novel or unique equipment, valid peer-reviewed evidence demonstrates that the equipment serves a medical purpose.
    • The equipment can withstand repeated use.

    Required Documentation

    Documentation Required

    Provide complete equipment documentation

    Submit complete identification, description, pricing, and manufacturer documentation for the requested equipment. When applicable, the invoice must include the manufacturer's logo, address, and phone number, along with the model and serial number, detailed item description, modifications and catalog numbers, cost or charge, and an explanation of how the item differs from an existing code description when required.

    Documentation Required

    Provide a current signed physician order

    Submit a physician-signed order or prescription with the request. The order or prescription must be dated no more than 60 days from the request date.

    Documentation Required

    Provide additional item-specific information

    When requested by TCHP, provide item-specific documentation for certain DME, including tricycles, floor sitters, activity chairs, and corner chairs. Documentation may include the condition's effects on mobility, how the equipment would correct or ameliorate the disability, evaluations and equipment trials, pictures of the requested equipment, and consideration of less costly alternatives.

    Policy Background

    Miscellaneous DME codes are intended for use only when a more appropriate billing code is unavailable. When applicable, medical-necessity review follows the current TMHP manual for the specific equipment requested. Equipment not referenced in the TMHP manual as billable under the applicable miscellaneous DME codes and submitted under EPSDT is reviewed case by case to determine whether it corrects or ameliorates a disability, physical or mental illness, or chronic condition and is safe and appropriate for repeated use in the home.

    Not Covered Items

    Payment is not available for services, supplies, or equipment for which federal financial participation is unavailable. Not-covered examples include vehicle modifications; mechanical or structural equipment such as wheelchair lifts; structural changes to homes or other living arrangements; 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; animal-assisted therapy; exercise equipment; home spas or gyms; toys; therapeutic balls; tricycles; tennis shoes; respite care; aids for daily living; and take-home drugs from hospitals.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicyMiscellaneous Durable Medical Equipment (DME) When Billed Amount Exceeds $500
    Policy CodePolicy E1399
    Change TypeNo material change
    Effective DateNovember 8, 2021
    Next Review DateN/A
    Key ActionObtain prior authorization when miscellaneous DME charges exceed $500 and submit the required clinical and equipment documentation.
    SourceLink
    On This Page
    Coverage CriteriaApplicable Codes and Billing ThresholdsPrior Authorization and Review ActionsEPSDT Medical Necessity ReviewRequired DocumentationPolicy BackgroundNot Covered Items
  1. Equipment model and serial number, when applicable.
  2. Details of required modifications, including product or accessory numbers from the manufacturer's catalog.
  3. Cost or charge for each item.
  4. Detailed explanation of how the item differs from an existing code description when the TMHP manual does not identify the miscellaneous code as appropriate.
    5. Documentation Required

    Clinical Support and Physician Order

    Submit clinical documentation supporting medical necessity and a physician order or prescription for the requested equipment.

    • The physician order or prescription must be signed by the physician and dated no more than 60 days before the request.
    • TCHP follows applicable medical-necessity guidance in the current TMHP manual.
    • For equipment submitted under EPSDT that is not referenced in the TMHP manual as billable under E1399, A9900, or T1999, TCHP reviews the request case by case.
    Documentation Required

    Additional Item-Specific Documentation

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

    • Effects of the member's condition on mobility.
    • How the equipment would correct or ameliorate the member's disability.
    • Details of evaluations leading to the recommendation, including trials of one or more equipment options.
    • Pictures of the requested equipment.
    • Consideration of less costly alternatives.
    Denial Risk

    Miscellaneous Code and Criteria Requirements

    E1399, A9900, and T1999 are miscellaneous codes and may be used only when a more appropriate code is unavailable. Requests may be denied or referred for physician review when an appropriate code exists or guideline criteria are not met.

    • Use the appropriate available code instead of E1399, A9900, or T1999.
    • The requested equipment must meet applicable medical-necessity requirements.
    • For novel or unique equipment, provide valid peer-reviewed evidence that it serves a medical purpose, can withstand repeated use, and is appropriate and safe for home use.
    Denial Risk

    Federal Financial Participation Exclusion

    Payment cannot be made for any service, supply, or equipment for which federal financial participation (FFP) is unavailable.

    • Vehicle modifications, mechanical or structural changes, including wheelchair lifts.
    • Structural changes to homes or other living arrangements.
    • Environmental equipment, supplies, or services, including dehumidifiers, air conditioners, filters, space heaters, fans, water purification systems, vacuum cleaners, and treatments for dust mites, rodents, or insects.
    • Ancillary power sources and standby equipment, except for technology-dependent members such as those ventilator-dependent for more than six hours per day.
    • Educational programs, supplies, or equipment, including personal computers or software.
    • Equine or hippotherapy; therapy involving any breed of animal.
    • Exercise equipment, home spas or gyms, toys, therapeutic balls, or tricycles.
    • Tennis shoes; respite care; and aids for daily living such as toothbrushes, spoons, reachers, and foot stools.
    • Take-home drugs from hospitals, which may be billed by eligible hospitals enrolled in the Vendor Drug Program.
    Denial Risk

    Failure to Meet Guideline Criteria

    Requests that do not meet the guideline criteria will be referred to a TCHP Medical Director or Physician Reviewer, and the Denial Policy will be followed. Preauthorization addresses medical necessity only and does not guarantee benefits or eligibility; benefit limitations, exclusions, regulatory requirements, retrospective audit, and potential financial recoupment still apply.

    • TCHP reviews DME for medical necessity even when the item is non-payable.
    • Services remain subject to benefit limitations and exclusions.
    • Providers must comply with state and federal regulations.
    The equipment is appropriate and safe for use in the home.