Wisconsin Legislature: DHS 107.18(3)(a)2.

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EmR2421

4. Hearing/auditory training:

a. Hearing screening and referral;

b. Auditory training;

c. Lip reading;

d. Hearing aid orientation; and

e. Non-verbal communication.

(2) Services requiring prior authorization.

(a) Definition. In this subsection, “spell of illness” means a condition characterized by a demonstrated loss of functional ability to perform daily living skills, caused by a new disease, injury or medical condition or by an increase in the severity of a pre-existing medical condition. For a condition to be classified as a new spell of illness, the recipient must display the potential to reachieve the skill level that he or she had previously.

(b) Requirement. Prior authorization is required under this subsection for speech and language pathology services provided to an MA recipient in excess of 35 treatment days per spell of illness, except that speech and language pathology services provided to an MA recipient who is a hospital inpatient or who is receiving speech therapy services provided by a home health agency are not subject to prior authorization under this subsection.

Note: Speech and language pathology services provided by a home health agency are subject to prior authorization under s. DHS 107.11 (3).

(c) Conditions justifying spell of illness designation. The following conditions may justify designation of a new spell of illness:

1. An acute onset of a new disease, injury or condition such as:

a. Neuromuscular dysfunction, including stroke-hemiparesis, multiple sclerosis, Parkinson’s disease and diabetic neuropathy;

b. Musculoskeletal dysfunction, including fracture, amputation, strains and sprains, and complications associated with surgical procedures; or

c. Problems and complications associated with physiologic dysfunction, including severe pain, vascular conditions, and cardio-pulmonary conditions;

2. An exacerbation of a pre-existing condition including but not limited to the following, which requires speech therapy intervention on an intensive basis:

a. Multiple sclerosis;

b. Rheumatoid arthritis; or

c. Parkinson’s disease; or

3. A regression in the recipient’s condition due to lack of speech therapy, as indicated by a decrease of functional ability, strength, mobility or motion.

(d) Onset and termination of spell of illness. The spell of illness begins with the first day of treatment or evaluation following the onset of the new disease, injury or medical condition or increased severity of a pre-existing medical condition and ends when the recipient improves so that treatment by a speech and language pathologist for the condition causing the spell of illness is no longer required, or after 35 treatment days, whichever comes first.

(e) Documentation. The speech and language pathologist shall document the spell of illness in the patient plan of care, including measurable evidence that the recipient has incurred a demonstrated functional loss of ability to perform daily living skills.

(f) Non-transferability of treatment days. Unused treatment days from one spell of illness shall not be carried over into a new spell of illness.

(g) Other coverage. Treatment days covered by medicare or other third-party insurance shall be included in computing the 35-day per spell of illness total.

(h) Department expertise. The department may have on its staff qualified speech and language pathologists to develop prior authorization criteria and perform other consultative activities.

Note: For more information on prior authorization, see s. DHS 107.02 (3).

(3) Other limitations.

(a) Plan of care for therapy services. Services shall be furnished to a recipient under a plan of care established and periodically reviewed by a physician. The plan shall be reduced to writing before treatment is begun, either by the physician who makes the plan available to the provider or by the provider of therapy when the provider makes a written record of the physician’s oral orders. The plan shall be promptly signed by the ordering physician and incorporated into the provider’s permanent record for the recipient. The plan shall:

1. State the type, amount, frequency, and duration of the therapy services that are to be furnished the recipient and shall indicate the diagnosis and anticipated goals. Any changes shall be made in writing and signed by the physician or by the provider of therapy services or physician on the staff of the provider pursuant to the attending physician’s oral orders; and

2. Be reviewed by the attending physician, in consultation with the therapist providing services, at whatever intervals the severity of the recipient’s condition requires but at least every 90 days. Each review of the plan shall contain the initials of the physician and the date performed. The plan for the recipient shall be retained in the provider’s file.

(b) Restorative therapy services. Restorative therapy services shall be covered services except as provided under sub. (4) (b).

(c) Evaluations. Evaluations shall be covered services. The need for an evaluation or re-evaluation shall be documented in the plan of care. Evaluations shall be counted toward the 35-day per spell of illness prior authorization threshold.

(d) Maintenance therapy services. Preventive or maintenance therapy services shall be covered services only when one or more of the following conditions are met:

1. The skills and training of a therapist are required to execute the entire preventive and maintenance program;

2. The specialized knowledge and judgment of a speech therapist are required to establish and monitor the therapy program, including the initial evaluation, the design of the program appropriate to the individual recipient, the instruction of nursing personnel, family or recipient, and the re-evaluations required; or

3. When, due to the severity or complexity of the recipient’s condition, nursing personnel cannot handle the recipient safely and effectively.

(e) Extension of therapy services. Extension of therapy services shall not be approved in any of the following circumstances:

1. The recipient has shown no progress toward meeting or maintaining established and measurable treatment goals over a 6-month period, or the recipient has shown no ability within 6 months to carry over abilities gained from treatment in a facility to the recipient’s home;

2. The recipient’s chronological or developmental age, way of life or home situation indicates that the stated therapy goals are not appropriate for the recipient or serve no functional or maintenance purpose;

3. The recipient has achieved independence in daily activities or can be supervised and assisted by restorative nursing personnel;

4. The evaluation indicates that the recipient’s abilities are functional for the person’s present way of life;

5. The recipient shows no motivation, interest, or desire to participate in therapy, which may be for reasons of an overriding severe emotional disturbance;

6. Other therapies are providing sufficient services to meet the recipient’s functioning needs; or

7. The procedures requested are not medical in nature or are not covered services. Inappropriate diagnoses for therapy services and procedures of questionable medical necessity may not receive departmental authorization, depending upon the individual circumstances.

(4) Non-covered services. The following services are not covered services:

(a) Services which are of questionable therapeutic value in a program of speech and language pathology. For example, charges by speech and language pathology providers for “language development — facial physical,” “voice therapy — facial physical” or “appropriate outlets for reducing stress”;

(b) Those services that can be performed by restorative nursing, as under s. DHS 132.60 (1) (b) to (d); and

(c) Activities such as end-of-the-day clean-up time, transportation time, consultations and required paper reports. These are considered components of the provider’s overhead costs and are not covered as separately reimbursable items.

Note: For more information on non-covered services, see s. DHS 107.03.

History: Cr Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (a), (b) (intro.), (c) (intro.) (2) (b), (d), (e), (h) and (4) (a), Register, February 1988, No. 386, eff. 3-1-88; emerg. am. (2) (b), (d), (g) and (3) (c), eff. 7-1-88; am. (2) (b), (d), (g), and (3) (c), Register, December, 1988, No. 396, eff. 1-1-89; correction in (4) (b) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.19 Audiology services.

(1) Covered services. Covered audiology services are those medically necessary diagnostic, screening, preventive or corrective audiology services prescribed by a physician and provided by an audiologist certified pursuant to s. DHS 105.31. These services include:

(a) Audiological evaluation;

(b) Hearing aid or other assistive listening device evaluation;

(d) Audiological tests;

(e) Audiometric techniques;

(f) Impedance audiometry;

(g) Aural rehabilitation; and

(h) Speech therapy.

(2) Prior authorization.

(a) Services requiring prior authorization. The following covered services require prior authorization from the department:

1. Speech therapy;

2. Aural rehabilitation:

a. Use of residual hearing;

b. Speech reading or lip reading;

c. Compensation techniques; and

d. Gestural communication techniques; and

3. Dispensing of hearing aids and other assistive listening devices.

(b) Conditions for review of requests for prior authorization. Requests for prior authorization of audiological services shall be reviewed only if these requests contain the following information:

1. The type of treatment and number of treatment days requested;

2. The name, address and MA number of the recipient;

3. The name of the provider of the requested service;

4. The name of the person or agency making the request;

5. The attending physician’s diagnosis, an indication of the degree of impairment and justification for the requested service;

6. An accurate cost estimate if the request is for the rental, purchase or repair of an item; and

7. If out-of-state non-emergency service is requested, a justification for obtaining service outside of Wisconsin, including an explanation of why the service cannot be obtained in the state.

Note: For more information on prior authorization, see s. DHS 107.02 (3).

(3) Other limitations.

(a) Plan of care for therapy services. Services shall be furnished to a recipient under a plan of care established and periodically reviewed by a physician. The plan shall be reduced to writing before the treatment is begun, either by the physician who makes the plan available to the provider or by the provider of therapy when the provider makes a written record of the physician’s oral orders. The plan shall be promptly signed by the ordering physician and incorporated into the provider’s permanent record for the recipient. The plan shall:

2. Be reviewed by the attending physician in consultation with the therapist providing services, at whatever intervals the severity of the recipient’s condition requires but at least every 90 days. Each review of the plan shall contain the initials of the physician and the date performed. The plan for the recipient shall be retained in the provider’s file.

(b) Restorative therapy services. Restorative therapy services shall be covered services.

(c) Maintenance therapy services. Preventive or maintenance therapy services shall be covered services only when one of the following conditions are met:

1. The skills and training of an audiologist are required to execute the entire preventive or maintenance program;

2. The specialized knowledge and judgment of an audiologist are required to establish and monitor the therapy program, including the initial evaluation, the design of the program appropriate to the individual recipient, the instruction of nursing personnel, family or recipient, and the re-evaluations required; or

3. When, due to the severity or complexity of the recipient’s condition, nursing personnel cannot handle the recipient safely and effectively.

(d) Evaluations. Evaluations shall be covered services. The need for an evaluation or a re-evaluation shall be documented in the plan of care.

(e) Extension of therapy services. Extension of therapy services shall not be approved in the following circumstances: