Chapter DHS 107

DHS 107.18 Note Note: For more information on prior authorization, see s. DHS 107.02 (3).

DHS 107.18(3) (3) Other limitations.

DHS 107.18(3)(a) (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:

DHS 107.18(3)(a)1. 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

DHS 107.18(3)(a)2. 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.

DHS 107.18(3)(b) (b) Restorative therapy services. Restorative therapy services shall be covered services except as provided under sub. (4) (b).

DHS 107.18(3)(c) (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.

DHS 107.18(3)(d) (d) Maintenance therapy services. Preventive or maintenance therapy services shall be covered services only when one or more of the following conditions are met:

DHS 107.18(3)(d)1. 1. The skills and training of a therapist are required to execute the entire preventive and maintenance program;

DHS 107.18(3)(d)2. 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

DHS 107.18(3)(d)3. 3. When, due to the severity or complexity of the recipient’s condition, nursing personnel cannot handle the recipient safely and effectively.

DHS 107.18(3)(e) (e) Extension of therapy services. Extension of therapy services shall not be approved in any of the following circumstances:

DHS 107.18(3)(e)1. 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;

DHS 107.18(3)(e)2. 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;

DHS 107.18(3)(e)3. 3. The recipient has achieved independence in daily activities or can be supervised and assisted by restorative nursing personnel;

DHS 107.18(3)(e)4. 4. The evaluation indicates that the recipient’s abilities are functional for the person’s present way of life;

DHS 107.18(3)(e)5. 5. The recipient shows no motivation, interest, or desire to participate in therapy, which may be for reasons of an overriding severe emotional disturbance;

DHS 107.18(3)(e)6. 6. Other therapies are providing sufficient services to meet the recipient’s functioning needs; or

DHS 107.18(3)(e)7. 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.

DHS 107.18(4) (4) Non-covered services. The following services are not covered services:

DHS 107.18(4)(a) (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”;

DHS 107.18(4)(b) (b) Those services that can be performed by restorative nursing, as under s. DHS 132.60 (1) (b) to (d); and

DHS 107.18(4)(c) (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.

DHS 107.18 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.18 History 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 DHS 107.19 Audiology services.

DHS 107.19(1) (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:

DHS 107.19(1)(a) (a) Audiological evaluation;

DHS 107.19(1)(b) (b) Hearing aid or other assistive listening device evaluation;

DHS 107.19(1)(c) (c) Hearing aid or other assistive listening device performance check;

DHS 107.19(1)(d) (d) Audiological tests;

DHS 107.19(1)(e) (e) Audiometric techniques;

DHS 107.19(1)(f) (f) Impedance audiometry;

DHS 107.19(1)(g) (g) Aural rehabilitation; and

DHS 107.19(1)(h) (h) Speech therapy.

DHS 107.19(2) (2) Prior authorization.

DHS 107.19(2)(a) (a) Services requiring prior authorization. The following covered services require prior authorization from the department:

DHS 107.19(2)(a)1. 1. Speech therapy;

DHS 107.19(2)(a)2. 2. Aural rehabilitation:

DHS 107.19(2)(a)2.a. a. Use of residual hearing;

DHS 107.19(2)(a)2.b. b. Speech reading or lip reading;

DHS 107.19(2)(a)2.c. c. Compensation techniques; and

DHS 107.19(2)(a)2.d. d. Gestural communication techniques; and

DHS 107.19(2)(a)3. 3. Dispensing of hearing aids and other assistive listening devices.

DHS 107.19(2)(b) (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:

DHS 107.19(2)(b)1. 1. The type of treatment and number of treatment days requested;

DHS 107.19(2)(b)2. 2. The name, address and MA number of the recipient;

DHS 107.19(2)(b)3. 3. The name of the provider of the requested service;

DHS 107.19(2)(b)4. 4. The name of the person or agency making the request;

DHS 107.19(2)(b)5. 5. The attending physician’s diagnosis, an indication of the degree of impairment and justification for the requested service;

DHS 107.19(2)(b)6. 6. An accurate cost estimate if the request is for the rental, purchase or repair of an item; and

DHS 107.19(2)(b)7. 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.

DHS 107.19 Note Note: For more information on prior authorization, see s. DHS 107.02 (3).

DHS 107.19(3) (3) Other limitations.

DHS 107.19(3)(a) (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:

DHS 107.19(3)(a)1. 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

DHS 107.19(3)(a)2. 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.

DHS 107.19(3)(b) (b) Restorative therapy services. Restorative therapy services shall be covered services.

DHS 107.19(3)(c) (c) Maintenance therapy services. Preventive or maintenance therapy services shall be covered services only when one of the following conditions are met:

DHS 107.19(3)(c)1. 1. The skills and training of an audiologist are required to execute the entire preventive or maintenance program;

DHS 107.19(3)(c)2. 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

DHS 107.19(3)(c)3. 3. When, due to the severity or complexity of the recipient’s condition, nursing personnel cannot handle the recipient safely and effectively.

DHS 107.19(3)(d) (d) Evaluations. Evaluations shall be covered services. The need for an evaluation or a re-evaluation shall be documented in the plan of care.

DHS 107.19(3)(e) (e) Extension of therapy services. Extension of therapy services shall not be approved in the following circumstances:

DHS 107.19(3)(e)1. 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;

DHS 107.19(3)(e)2. 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;

DHS 107.19(3)(e)3. 3. The recipient has achieved independence in daily activities or can be supervised and assisted by restorative nursing personnel;

DHS 107.19(3)(e)4. 4. The evaluation indicates that the recipient’s abilities are functional for the person’s present way of life;

DHS 107.19(3)(e)5. 5. The recipient shows no motivation, interest, or desire to participate in therapy, which may be for reasons of an overriding severe emotional disturbance;

DHS 107.19(3)(e)6. 6. Other therapies are providing sufficient services to meet the recipient’s functioning needs; or

DHS 107.19(3)(e)7. 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.

DHS 107.19(4) (4) Non-covered services. The following services are not covered services:

DHS 107.19(4)(a) (a) 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; and

DHS 107.19(4)(b) (b) Services performed by individuals not certified under s. DHS 105.31.

DHS 107.19 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.19 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (b), (c) and (h), (2) (a) 1. and 3., Register, May, 1990, No. 413, eff. 6-1-90; corrections in (1) (intro.) and (4) (b) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.20 DHS 107.20 Vision care services.

DHS 107.20(1) (1) Covered services. Covered vision care services are eyeglasses and those medically necessary services provided by licensed optometrists within the scope of practice of the profession of optometry as defined in s. 449.01, Stats., who are certified under s. DHS 105.32, and by opticians certified under s. DHS 105.33 and physicians certified under s. DHS 105.05.

DHS 107.20(2) (2) Services requiring prior authorization. The following covered services require prior authorization by the department:

DHS 107.20(2)(a) (a) Vision training, which shall only be approved for patients with one or more of the following conditions:

DHS 107.20(2)(a)1. 1. Amblyopia;

DHS 107.20(2)(a)2. 2. Anopsia;

DHS 107.20(2)(a)3. 3. Disorders of accommodation; and

DHS 107.20(2)(a)4. 4. Convergence insufficiency;

DHS 107.20(2)(b) (b) Aniseikonic services for recipients whose eyes have unequal refractive power;

DHS 107.20(2)(c) (c) Tinted eyeglass lenses, occupational frames, high index glass, blanks (55 mm. size and over) and photochromic lens;

DHS 107.20(2)(d) (d) Eyeglass frames and all other vision materials which are not obtained through the MA vision care volume purchase plan;

DHS 107.20 Note Note: Under the department’s vision care volume purchase plan, MA-certified vision care providers must order all eyeglasses and component parts prescribed for MA recipients directly from a supplier under contract with the department to supply those items.

DHS 107.20(2)(e) (e) All contact lenses and all contact lens therapy, including related materials and services, except where the recipient’s diagnosis is aphakia or keratoconus;