DHS 107.18(1)(c)3. 3. Pre-speech skills:

DHS 107.18(1)(c)3.a. a. Oral and peri-oral structure;

DHS 107.18(1)(c)3.b. b. Vegetative function of the oral motor skills; and

DHS 107.18(1)(c)3.c. c. Volitional oral motor skills; and

DHS 107.18(1)(c)4. 4. Hearing/auditory training:

DHS 107.18(1)(c)4.a. a. Hearing screening and referral;

DHS 107.18(1)(c)4.b. b. Auditory training;

DHS 107.18(1)(c)4.c. c. Lip reading;

DHS 107.18(1)(c)4.d. d. Hearing aid orientation; and

DHS 107.18(1)(c)4.e. e. Non-verbal communication.

DHS 107.18(2) (2) Services requiring prior authorization.

DHS 107.18(2)(a) (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.

DHS 107.18(2)(b) (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.

DHS 107.18 Note Note: Speech and language pathology services provided by a home health agency are subject to prior authorization under s. DHS 107.11 (3).

DHS 107.18(2)(c) (c) Conditions justifying spell of illness designation. The following conditions may justify designation of a new spell of illness:

DHS 107.18(2)(c)1. 1. An acute onset of a new disease, injury or condition such as:

DHS 107.18(2)(c)1.a. a. Neuromuscular dysfunction, including stroke-hemiparesis, multiple sclerosis, Parkinson’s disease and diabetic neuropathy;

DHS 107.18(2)(c)1.b. b. Musculoskeletal dysfunction, including fracture, amputation, strains and sprains, and complications associated with surgical procedures; or

DHS 107.18(2)(c)1.c. c. Problems and complications associated with physiologic dysfunction, including severe pain, vascular conditions, and cardio-pulmonary conditions;

DHS 107.18(2)(c)2. 2. An exacerbation of a pre-existing condition including but not limited to the following, which requires speech therapy intervention on an intensive basis:

DHS 107.18(2)(c)2.a. a. Multiple sclerosis;

DHS 107.18(2)(c)2.b. b. Rheumatoid arthritis; or

DHS 107.18(2)(c)2.c. c. Parkinson’s disease; or

DHS 107.18(2)(c)3. 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.

DHS 107.18(2)(d) (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.

DHS 107.18(2)(e) (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.

DHS 107.18(2)(f) (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.

DHS 107.18(2)(g) (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.

DHS 107.18(2)(h) (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.