| (9) When an HHSC medical director, after conferring
with the recipient's treating physician, determines the requested
PDN services are not medically necessary to correct or ameliorate
the recipient's disability or physical or mental illness or condition,
as referenced in subsection (h)(6) of this section, the denial notice
will inform the recipient and address why the requested PDN services
are not medically necessary to correct or ameliorate the recipient's
disability or physical or mental illness or condition.
(10) When HHSC determines that the recipient's nursing
needs could be provided by a visiting nurse through Home Health Skilled
Nursing services, as referenced in subsection (h)(7) of this section,
the denial notice for PDN services will describe the basis for the
denial and explain how to request Home Health Skilled Nursing services.
(k) A provider's authorization for PDN services is
terminated if the recipient is no longer eligible for EPSDT.
(l) HHSC may ask a provider to take on an existing
authorization for PDN services if it becomes necessary to terminate
another provider's authorization for PDN services because the:
(1) recipient's health and safety needs are in jeopardy;
or
(2) PDN services provided are inconsistent with the
plan of care submitted for authorization.
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