Reminder: Flowcharts Must Accompany TARs Submitted for Therapeutic Anti-Decubitus Mattresses and Bed Products

October 20, 2021

All initial and reauthorization Treatment Authorization Requests (TARs) for support surfaces must be accompanied by the appropriate flowchart(s), based upon the patient’s medical condition and the specific support surface needed to meet the patient’s medical need(s).

  • The provider must indicate (circle or highlight) the appropriate answer to all questions on the flowchart(s), based upon the documentation in the patient’s medical record.

  • If the appropriate flowchart(s) is not submitted with the TAR or the information provided on the flowchart(s) and TAR is not sufficient to determine medical necessity for the requested support surface, the TAR shall be deferred for the required information. If the TAR has been previously deferred and the required information has not been submitted by the provider, the medical consultant shall deny the TAR.

  • For unlisted procedure codes, the provider must submit the most appropriate flowchart(s), based upon the documentation in the patient’s medical record. The flowchart(s) must be completed to the extent possible, along with justification for the requested unlisted procedure code.

Flowcharts can be found on pages 19 through 22 in the Durable Medical Equipment (DME): Therapeutic Anti-Decubitus Mattresses and Bed Products section of the Part 2 Medi-Cal Provider Manual.