• Certification and Ongoing Responsibilities
  • Introduction
  • Other Facilities
  • Responsibilities
  • Supervision Requirements
    • Introduction
    • Declaration of Supervision
    • Supervision Waiver
  • Durable Medical Equipment and Disposable Medical Supplies
• Provider Communication
  • Introduction
  • Coordination with School-Based Services Providers
  • Coordination with County Birth to 3 Programs
  • Therapy Services for Children Brochure
  • Guide to Obtaining Augmentative Communication Devices and Accessories
  • Directory of Used Medical Equipment
• Documentation Requirements
  • Introduction
  • Prescriptions
  • Evaluations
  • Plan of Care
  • Daily Entries
• Services and Requirements
  • Introduction
  • Initial Spell of Illness
  • Daily Limitations
  • Duplicate Services
  • Evaluations
  • Group Therapy
  • Natural Environments
  • Durable Medical Equipment and Disposable Medical Supplies
  • HealthCheck "Other Services"
  • Services Not Separately Reimbursable
  • Reimbursement Not Available
• Codes
  • Procedure Codes
    • Introduction
    • Unit of Service
  • Modifiers
  • Place of Service Codes
  • Diagnosis Codes
• Prior Authorization
  • Introduction
  • Prior Authorization Forms and Attachments
  • Medical Necessity
    • Introduction
    • Relationship of Medical Necessity to Clinical Practice Principles
  • Flexibility of Approved Services
    • Introduction
    • Plan of Care Must Reflect Flexibility of Approved Services
    • Duration of Approved Services
    • Coordinating Multiple Prior Authorization Requests
• Requesting Extension of Therapy, Maintenance Therapy, and Services That Always Require Prior Authorization
  • Introduction
  • Approval Criteria
  • Extension of Therapy
  • Maintenance Therapy
    • Introduction
    • Direct Maintenance
    • Monitoring Maintenance
    • Discontinuing Maintenance
  • Services That Always Require Prior Authorization
    • Introduction
    • Cotreatment
    • Dual Treatment
    • Unlisted Procedure Codes
    • Decubitus Ulcers
• Requesting Spell of Illness
  • Introduction
  • Maximum Allowable Treatment Days
    • Introduction
    • Unused Treatment Days
• Extension of Therapy vs. Spell of Illness
• Requesting Services for Birth to 3 Participants
  • Introduction
  • Situations That Do Not Qualify for Birth to 3
• Requesting Amendments
  • Introduction
  • Approval Criteria
  • Reasons for Denial
• Claims
  • Introduction
  • 837 Health Care Claim: Professional
  • CMS 1500
  • Provider Numbers
    • Individual Providers
    • Groups, Clinics, and Nursing Homes
    • Rehabilitation Agencies
    • Hospitals
  • Referring Provider
  • Evaluations
  • Services Provided Beyond Daily Limits
  • Unlisted Procedure Codes
  • Multiple Services During One Session
  • Submitting Claims for Birth to 3 Services
• Reimbursement
  • Maximum Allowable Fees
  • Reimbursement Methods
    • Introduction
    • Natural Environment Enhanced Reimbursement
  • Copayment
    • Introduction
    • Annual Copayment Maximum
• Appendix
• PDF

Appendix

Appendix 16 — Examples of Standards of Medical Necessity As Evaluated on Prior Authorization Requests

The following information and case examples are offered to illustrate how the standards of medical necessity, as defined in HFS 101.03(96m), Wis. Admin. Code, are applied when prior authorization (PA) requests for physical therapy (PT), occupational therapy (OT), or speech and language pathology (SLP) services are reviewed by Wisconsin Medicaid.

HFS 101.03(96m), Wis. Admin. Code, “medically necessary” means a medical service under ch. 107 that is:

• Required to prevent, identify or treat a recipient’s illness, injury or disability; and

Example 1: Many individuals having the same diagnosis may have certain characteristics in common; however, the physical expression and functional severity of their conditions can vary greatly. As a result, documentation in the PA request must include a medical diagnosis as well as a problem statement (treatment diagnosis) related to the medical diagnosis that identifies the specific treatment needs of the individual.

For example, physical therapy is requested for a four-year-old child with spastic diplegic cerebral palsy and a gross motor age equivalency of 44-48 months. A plan of care (POC) to address “continued development of age-appropriate mobility skills” would not meet the Medicaid application of this standard because no impairments, functional limitations, or disabilities have been identified. The reviewer would question how the requested service treats an illness, injury, or disability. If the therapist identified tight hamstrings but provided no evidence that hamstring contractures were causing any functional problems, the same questions remain.

If instead, the physical therapist’s evaluation identified functional limitations including problems with climbing, frequent falls when walking from the bus to home, or other restrictions in outdoor mobility due to tight hamstrings, it may be appropriate to authorize a limited course of PT. In this case, PT may be necessary to improve dynamic range of motion and lower extremity strength, to facilitate functional skill acquisition, and to educate the recipient/caregivers on a home program including recommendations about when to seek medical attention for developing problems, such as worsening contractures.

Example 2: A nine-year-old is an independent household ambulator and presents with hypotonic trunk muscles. He has been receiving OT for the past six months. The new PA request includes continued treatment strategies of trunk elongation and rib cage mobilization with ongoing goals of preparing for strengthening/stability exercises and preventing frequent respiratory infections. No documentation of trunk range of motion, upper body strength testing, or frequency of respiratory infection is provided.

Measurable goals reflect treatment that is expected to reduce identified impairments, produce sustained changes in function, and are necessary to describe how treatment will affect injury, illness, or disability. The medical necessity of the POC would be questioned because no deficits are reported and no evidence is provided to support that soft tissue mobilization has resulted or would likely result in any sustainable change in the client’s trunk control or any improvement in functional performance over time. The PA documentation does not support that a correlation exists between improving rib cage mobility and decreasing the client’s susceptibility to respiratory infections. The PA request would be returned requesting this additional information.

Example 3: A PA is submitted for SLP services for a four-year-old child. The child only speaks at home and was referred by the family doctor for an SLP assessment. The standardized/non-standardized tests performed by the SLP provider indicate that the child’s receptive and expressive language skills are age appropriate. The PA requests SLP services twice per week to improve the child’s social language skills. In this situation, the Medicaid consultant may question if the services of an SLP provider are required, since the standardized tests indicate the child’s language skills are age appropriate and do not identify an injury, illness, or disability potentially remediable by an SLP provider.

• Meets the following standards:

 
• Is consistent with the recipient’s symptoms, or with prevention, diagnosis or treatment of the recipient’s illness, injury or disability;

  Example 1: The client is a 35-year-old with cerebral palsy who is seven weeks post ankle fusion. Prior to surgery, she had been able to ambulate with a walker in her home. The PA request includes a PT POC to assess and/or teach transfer skills and evaluate orthotics and equipment needs. This POC reflects a situation where episodic therapy is warranted to maximize functional capacity following an orthopedic intervention. This PA request would be approved because it is consistent with treatment of the client’s recent change in medical condition.

  Example 2: A 16-year-old with a remote history of anoxic brain injury is dependent for all activities of daily living. An OT PA request is submitted to increase head control at midline from the recipient’s current level of 3-5 seconds to 5-10 seconds. No progress has been documented in this area following extensive intervention to improve head control. When functional limitations persist for long periods and have not been remediable, compensatory strategies may be more appropriate. The PA request would be returned for additional information to support the benefit of continued direct treatment for improving head control as an effective or functional intervention.

  Example 3: A PA is submitted for SLP services for a 45-year-old recipient diagnosed with mental retardation, emotional disturbance, and seizure disorder. His sheltered workshop supervisor referred the client for an SLP evaluation because over the past two months, both workshop staff and home caregivers have had difficulties understanding him due to decreased speaking rate and slurred speech. Upon assessment, the recipient’s regression appears to coincide with the start of a new medication.

  Without additional information, the Medicaid consultant would return the PA request questioning whether the recipient’s decreased intelligibility may be related to the medication. Documentation of sufficient clinical information may then result in approval of SLP services for a brief episode of care to improve intelligibility.

• Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided;

Example: A PA request for sensory integration therapy is submitted for a nine-year-old with pervasive developmental disorder. Goals include decreased behavioral outbursts in natural environments like a noisy gym or shopping mall, improved sleeping patterns, and better ability to “self regulate.” The PA would be returned asking the provider to explain how skills learned in therapy would be generalized from the controlled environment of the clinic setting to the child’s natural environment(s) of home, school, or community. The Medicaid consultant may further question whether these issues would be more appropriately addressed by a behavioral therapist or through a consistent behavioral management home program.

• Is appropriate with regard to generally accepted standards of medical practice;

Example 1: A PA is submitted with the therapist reporting that an individual is “not testable” or with the majority of the therapy evaluation obtained from unstructured observation or from other sources. If the treating therapist is unable to establish an individual’s baseline functional skills and limitations, it will be impossible to later evaluate and document any changes that may result from therapeutic intervention. Initiating treatment without performing a comprehensive assessment that includes baseline measurements of the individual’s abilities and physical impairments is not appropriate with regard to generally accepted standards of practice. If a problem area is not/ cannot be tested during the initial evaluation, it should be explained why data could not be obtained and that subsequent PAs will contain baseline data for reported problem areas as well as interval progress. This PA would be returned asking for additional information.

Example 2: An occupational therapist working with a child with a history of dysphagia submits a PA request with a goal for the child to tolerate a wider variety of foods. No clinical assessment of the child’s oral motor/swallowing skills or results from a radiological swallow study have been documented to indicate that the proposed oral intake is safe. The PA request would be returned requesting this additional clinical information to assure that the treatment goals are appropriate.

• Is not medically contraindicated with regard to the recipient’s diagnoses, the recipient’s symptoms or other medically necessary services being provided to the recipient;

Example: An 85-year-old is eight weeks post hip fracture with subsequent open reduction and internal fixation. The POC submitted with the PA includes goals of transferring with assistive device, achieving independence on stairs, and increasing unilateral weight bearing for improved balance, strength, and endurance while walking. No weight bearing restrictions or hip precautions are included in the information submitted. In the absence of this standard medical information, the reviewer may question whether the goals are appropriate (or possibly contraindicated) depending on the recommended postoperative hip precautions. Also, the requested frequency or intensity of therapy may be inappropriate depending on the recipient’s weight bearing status.

Example 2: For a recipient with the recent onset of dysphagia and a swallow study that indicates aspiration, an oral motor evaluation and initial course of treatment is medically necessary to see if swallowing abilities can be improved. If a subsequent request is submitted that indicates the individual has been unable to maintain his or her weight with oral feedings or if clinical signs of aspiration such as cough or respiratory infection persist, then continued SLP services to address improving oral feeding skills without assessing the need for further dietary modifications (change in liquid/solid consistency) may be medically contraindicated. This PA would be returned for additional clinical information to support the safety of the requested therapy.

• Is of proven medical value or usefulness and, consistent with s. HFS 107.035, is not experimental in nature;

In assessing whether a service is experimental in nature, the Department of Health and Family Services (DHFS) shall consider whether the service is a proven effective treatment for the condition for which it is intended or used, as evidenced by:

• The current and historical judgment of the medical community (as reflected by medical research, studies, or publications in peer-reviewed journals).
• The extent to which other health insurers provide coverage for the service.
• The current judgment of experts or specialists in the medical area for which the service is to be used.
• The judgment of the Wisconsin Medicaid Medical Audit Committee of the Wisconsin Medical Society or of any other committee that may be under contract to the DHFS as identified in Wisconsin Administrative Code.

The following interventions have been determined to be experimental: Facilitated Communication and Auditory Integration Therapy. The Wisconsin Medical Society has also determined that electrical stimulation for the treatment of open wounds can only be applied to Stage III or IV decubiti. Prior authorization for continued treatment is considered only if granulation tissue has formed or a 25 percent reduction in the affected area has occurred within 45 days of initiating electrical stimulation. Any PA request for electrical stimulation that falls outside these parameters is considered unproven and would be denied.

• Is not duplicative with respect to other services being provided to the recipient;

Example 1: A 78-year-old with a diagnosis of Alzheimer’s disease resides in a nursing home that specializes in the care of Alzheimer patients. The client transfers with moderate assistance and receives PT two times per week for gait training and to improve transfer skills. The client’s transfer and ambulation skills have not progressed over the past month and the nursing staff has been instructed in safe transfer and ambulation techniques. The PT POC recommends continued PT services designed to maintain the client’s abilities, stating that the client requires the skills of a therapist because she has Alzheimer’s. Caregivers who have been properly instructed by a physical therapist regarding the client’s unique set of problems should be skilled in working with this patient. Therefore, this PA request would be denied because it is duplicative to the client’s maintenance care program.

Example 2: A child with autism is receiving intensive behavioral services with treatment goals of improved peer play, turn taking, sharing, and concentrating on conversation. The OT PA request includes goals for the child to participate in a group game following rules with proper sequencing and attention to task. In this case, the requested therapy is not coordinated with the goals and activities of all other medical, educational, and vocational disciplines involved with the client. The clinical intent of both services appears to be directed toward achieving the same outcome. Therefore, the PA request would be returned for clarification.

Example 3: A PA request is submitted for SLP services for a six-year-old child diagnosed with developmental delays and dysphagia. All of the child’s nutrition is provided by mouth. The diet is modified to ground consistency solids and thickened liquids. The child currently receives SLP services at school and the Individualized Education Plan (IEP) includes facilitation of oral motor exercises supervised by an aide five times per week for 20-30-minute sessions. The school SLP provider re-evaluates the child’s oral motor skills monthly. The POC submitted by the community-based provider focuses on oral motor exercises. In this situation, the Medicaid consultant may question if the requested service is duplicative of the services being performed in the school.

• Is not solely for the convenience of the recipient, the recipient’s family or a provider;

Example 1: A child with a history of traumatic brain injury receives PT services at school during the academic year. The IEP does not include recommendations for Extended School Year PT over the summer months. Physical therapy services are being requested at a community-based clinic during the summer because, without therapy, the client’s day lacks structured activities. Unless the services being requested require the professional skills of a therapist, the request may be viewed as an alternative to recreational or other community-based activities and appears to be submitted solely for convenience.

Example 2: An OT PA request is submitted to provide range of motion and strengthening. The individual has skills that are sufficient to perform the program at home with supervision or in a community or recreational setting. In this case, the PA would be returned for additional information to explain why the skills of a therapist are required.

Example 3: A PA request is submitted for SLP services for a 38-year old diagnosed with developmental delays.The recipient lives in a group home and communicates with an augmentative communication device. Previous therapy and product manuals have been provided for the client and caregivers to program and use the device. The PA requests SLP services for the purpose of creating a new communication page for the device. In this case, the Medicaid consultant would question if the service being requested is solely for convenience and if the recipient’s caregiver or family member familiar with the device could create a new page.

• With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and

Example 1: A physical therapist has requested therapy services three times per week to work on a POC that is focused on repetition of skills to build endurance. A PA request for PT services at this frequency would be modified or denied. It would be more cost-effective for the client to work on building endurance through a home exercise program. Modification would allow the therapist to monitor the client’s progress and to revise the home program as needed, instead of providing direct therapy to work on repetition of an already achieved skill. Programs that involve ongoing muscle strengthening and fitness often involve instructing the client to carry out activities independent of assistance or stressing recreational activities that encourage mobility and reinforce functional movement.

Example 2: An OT PA request is received to provide range of motion for a client who resides in a nursing home. A restorative nursing plan is in place and meets the functional needs of this individual. The therapy POC being requested does not include more advanced functional outcomes requiring the skills of a therapist. Occupational therapy services, in addition to restorative nursing, are not cost-effective and the PA request would be denied.

• Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient.

Example: A 10-year-old child with cerebral palsy has received many years of OT. His current level of functional upper extremity dressing skills includes the ability to push his arm through his sleeve only when the shirt is held over his head and the sleeve is held in place for him. No volitional grasp or release is demonstrated. The OT POC is submitted for ongoing direct treatment to improve independent living skills. For this individual, it appears that he has reached a plateau, that no functional gains in upper extremity dressing skills can reasonably be anticipated, and that compensatory strategies and equipment are the most appropriate level of service that can be effectively provided. The direct skills of an occupational therapist may no longer be necessary at this time to maximize his functional performance. A more appropriate level of service may be provided by an occupational therapist on a consultative basis to monitor compensatory strategies and equipment and to evaluate further direct OT needs.

Example 2: A PA is submitted for SLP services to improve intelligibility in a nine-year-old child with a diagnosis of dyskinetic cerebral palsy. A review of the child’s extensive therapy history indicates that there has been little functional improvement in the child’s intelligibility. Standardized tests and subjective reporting also indicate that the child’s intelligibility has not changed appreciably in three years despite receiving both school and community-based SLP services. The child has acquired an augmentative communication device to supplement his speech. In this situation, the Medicaid consultant would question if community-based SLP services focused on improving intelligibility remains the most appropriate level of service that can be effectively provided to this recipient.

Next — Appendix 17 — General Principles for Physical Therapy, Occupational Therapy, and Speech and Language Pathology Prior Authorization Requests
Previous — Appendix 15 — Allowable Place of Service Codes for Physical Therapy, Occupational Therapy, and Speech and Language Pathology Services