Chapter DHS 107

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;

DHS 107.20(2)(f) (f) Ptosis crutch services and materials;

DHS 107.20(2)(g) (g) Eyeglass frames or lenses beyond the original and one unchanged prescription replacement pair from the same provider in a 12-month period; and

DHS 107.20(2)(h) (h) Low vision services.

DHS 107.20 Note Note: For more information on prior authorization, see s. DHS 107.02 (3).

DHS 107.20(3) (3) Other limitations.

DHS 107.20(3)(a) (a) Eyeglass frames, lenses, and replacement parts shall be provided by dispensing opticians, optometrists and ophthalmologists in accordance with the department’s vision care volume purchase plan. The department may purchase from one or more optical laboratories some or all ophthalmic materials for dispensing by opticians, optometrists or ophthalmologists as benefits of the program.

DHS 107.20(3)(b) (b) Lenses and frames shall comply with ANSI standards.

DHS 107.20(3)(c) (c) The dispensing provider shall be reimbursed only once for dispensing a final accepted appliance or component part.

DHS 107.20(3)(d) (d) The department may define minimal prescription levels for lenses covered by MA. These limitations shall be published by the department in the MA vision care provider handbook.

DHS 107.20(4) (4) Non-covered services. The following services and materials are not covered services:

DHS 107.20(4)(a) (a) Anti-glare coating;

DHS 107.20(4)(b) (b) Spare eyeglasses or sunglasses; and

DHS 107.20(4)(c) (c) Services provided principally for convenience or cosmetic reasons, including but not limited to gradient focus, custom prosthesis, fashion or cosmetic tints, engraved lenses and anti-scratch coating.

DHS 107.20 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.20 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.21 DHS 107.21 Family planning services.

DHS 107.21(1) (1) Covered services.

DHS 107.21(1)(a) (a) General. Covered family planning services are the services included in this subsection when prescribed by a physician and provided to a recipient, including initial physical exam and health history, annual office visits and follow-up office visits, laboratory services, prescribing and supplying contraceptive supplies and devices, counseling services and prescribing medication for specific treatments. All family planning services performed in family planning clinics shall be prescribed by a physician, and furnished, directed or supervised by a physician, registered nurse, nurse practitioner, licensed practical nurse or nurse midwife under s. 441.15 (1) and (2) (b), Stats.

DHS 107.21(1)(b) (b) Physical examination. An initial physical examination with health history is a covered service and shall include the following:

DHS 107.21(1)(b)1. 1. Complete obstetrical history including menarche, menstrual, gravidity, parity, pregnancy outcomes and complications of pregnancy or delivery, and abortion history;

DHS 107.21(1)(b)2. 2. History of significant illness-morbidity, hospitalization and previous medical care, particularly in relation to thromboembolic disease, any breast or genital neoplasm, any diabetic or prediabetic condition, cephalalgia and migraine, pelvic inflammatory disease, gynecologic disease and venereal disease;

DHS 107.21(1)(b)3. 3. History of previous contraceptive use;

DHS 107.21(1)(b)4. 4. Family, social, physical health, and mental health history, including chronic illnesses, genetic aberrations and mental depression;

DHS 107.21(1)(b)5. 5. Physical examination. Recommended procedures for examination are:

DHS 107.21(1)(b)5.a. a. Thyroid palpation;

DHS 107.21(1)(b)5.b. b. Examination of breasts and axillary glands;

DHS 107.21(1)(b)5.c. c. Auscultation of heart and lungs;

DHS 107.21(1)(b)5.d. d. Blood pressure measurement;

DHS 107.21(1)(b)5.e. e. Height and weight measurement;

DHS 107.21(1)(b)5.f. f. Abdominal examination;

DHS 107.21(1)(b)5.g. g. Pelvic examination; and

DHS 107.21(1)(b)5.h. h. Examination of extremities.

DHS 107.21(1)(c) (c) Laboratory and other diagnostic services. Laboratory and other diagnostic services are covered services as indicated in this paragraph. These services may be performed in conjunction with an initial examination with health history, and are the following:

DHS 107.21(1)(c)1. 1. Routinely performed procedures:

DHS 107.21(1)(c)1.a. a. CBC, or hematocrit or hemoglobin;

DHS 107.21(1)(c)1.b. b. Urinalysis;

DHS 107.21(1)(c)1.c. c. Papanicolaou smear for females between the ages of 12 and 65;

DHS 107.21(1)(c)1.d. d. Bacterial smear or culture (gonorrhea, trichomonas, yeast, etc.) including VDRL — syphilis serology with positive gonorrhea cultures; and

DHS 107.21(1)(c)1.e. e. Serology;

DHS 107.21(1)(c)2. 2. Procedures covered if indicated by the recipient’s health history:

DHS 107.21(1)(c)2.a. a. Skin test for TB;

DHS 107.21(1)(c)2.b. b. Vaginal smears and wet mounts for suspected vaginal infection;

DHS 107.21(1)(c)2.c. c. Pregnancy test;

DHS 107.21(1)(c)2.d. d. Rubella titer;

DHS 107.21(1)(c)2.e. e. Sickle-cell screening;

DHS 107.21(1)(c)2.f. f. Post-prandial blood glucose; and

DHS 107.21(1)(c)2.g. g. Blood test for cholesterol, and triglycerides when related to oral contraceptive prescription;

DHS 107.21(1)(c)3. 3. Diagnostic and other procedures not for the purpose of enhancing the prospects of fertility in males or females;