• 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

Prior Authorization

Medical Necessity

Wisconsin Medicaid relies on its definition of medically necessary, as stated in HFS 101.03(96m), Wis. Admin. Code, to determine whether a particular service may be reimbursed by Wisconsin Medicaid. Medical necessity for PT, OT, and SLP services is focused on intervention activities that are designed to produce specific outcomes.

Wisconsin Medicaid uses the PA process to determine whether the standards of medical necessity are met and to assure that appropriate PT, OT, and SLP services are provided to Medicaid recipients. Medicaid consultants evaluate PA requests for PT, OT, and SLP services on a case-specific basis. A PA request may be approved only if the documentation submitted in the PA request establishes that the standards of medical necessity, in addition to all other program requirements, are met. Refer to Appendix 16 of this handbook for examples of how the standards of medical necessity are evaluated on PA requests.

Common reasons for finding a “lack of medical necessity” include the following:

• Baseline performance is not documented in terms of the recipient’s current functional abilities and limitations.
• Clinical information is not provided in sufficient detail to suggest that both of the following are true:
• Treatment goals are reasonable given the current age and health status of the recipient.
• Attainment of treatment goals would result in predictable functional improvement to the recipient.
• Documentation fails to support that the professional skills of a PT, OT, or SLP provider are required to meet the recipient’s functional needs and therapy treatment needs.
• The recipient has failed to make progress toward the targeted goals and objectives in a reasonable time period, and the PT, OT, or SLP provider has not modified the treatment plan or objectives in spite of the anticipated outcomes not being achieved.

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