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Conditions for Coverage

General Conditions

To be considered medically necessary, all of the following conditions must be met:

    • The services requested must be considered under the accepted standards of practice to be a specific and effective treatment for the patient’s condition.
    • The services requested must be of a level of complexity or the patient’s condition must be such that the services required can only be effectively performed by or under the supervision of a licensed occupational therapist, physical therapist, or speech-language pathologist, and requires the skills and judgment of the licensed therapist to perform education and training.
    • Functional goals refer to a series of behaviors or skills that allow the client to achieve an outcome relevant to his/her health, safety, or independence within the context of everyday environments. Functional goals must be specific to the client, objectively measurable within a specified time frame, attainable in relation to the client’s prognosis or developmental delay, relevant to client and family, and based on a medical need.

Coverage for Children

For clients who are 20 years of age and younger, the following conditions must be met:

    • The goals of the requested services to be provided are directed at improving, adapting, restoring, or maintaining functions which have been lost or impaired due to a recent illness, injury, loss of body part or congenital abnormality or as a result of developmental delay or the presence of a chronic medical condition.
    • Testing must establish a client with developmental delays meets the medical necessity criteria for chronic therapy services.
    •  Evidence of care coordination with the prescribed pediatric extended care center (PPECC) provider, when the client receives therapy services in a PPECC setting.

Coverage for Adults

For clients who are 21 years of age and older, the following conditions must be met:

    • The goals of the requested services to be provided are directed at improving, adapting or restoring functions which have been lost or impaired due to a recent illness, injury, loss of body part and restore client’s function to within normal activities of daily living (ADL).
    • There must be reasonable expectation that therapy will result in a meaningful or practical improvement in the client’s ability to function within a reasonable and predictable time period.

Developmental Delay Criteria

To establish a developmental delay, all of the following criteria must be met:

    • Tests used must be norm-referenced, standardized, and specific to the therapy provided.
    • Retesting with norm-referenced standardized test tools for re-evaluations must occur every 180 days. Tests must be age appropriate for the child being tested and providers must use the same testing instrument as used in the initial evaluation. If reuse of the initial testing instrument is not appropriate, i.e. due to change in client status or restricted age range of the testing tool, provider should explain the reason for the change.
    • Eligibility for therapy will be based upon a score that falls 1.5 standard deviations (SD) or more below the mean in at least one subtest area of composite score on a norm-referenced, standardized test. Raw scores must be reported along with score reflecting SD from mean.
    • When the client’s test score is less than 1.5 SD below the mean, a criterion-referenced test along with informed evidenced-based clinical opinion must be included to support the medical necessity of services and will be sent to physician review to determine medical necessity.
    • If a child cannot complete norm-referenced standardized assessments, then a functional description of the child’s abilities and deficits must be included. Measurable functional short and long term goals will be considered along with test results. Documentation of the reason a standardized test could not be used must be included in the evaluation.

Specific developmental delay criteria requirements for speech diagnoses are as follows:

    •  Language—at least one norm-referenced, standardized test with good reliability and validity, a score that falls 1.5 SD or more below the mean, and clinical documentation of an informal assessment that supports the delay
    • Articulation—at least one norm-referenced, standardized test with good reliability and validity, a score that falls 1.5 SD or more below the mean, and clinical documentation of an informal assessment that supports the delay
    • Apraxia—at least one norm-referenced, standardized test with good reliability and validity, a score that falls 1.5 SD or more below the mean, and clinical documentation of an informal assessment that supports the delay
    • Fluency—at least one norm-referenced, standardized test with good reliability, a score that falls 1.5 SD or more below the mean, and clinical documentation of an informal assessment that supports the delay
    • Voice—a medical evaluation is required for eligibility and based on medical referral
    • Oral Motor/Swallowing/Feeding—an in-depth, functional profile of oral motor structures and function

If the client’s test score is less than 1.5 SD below the mean, additional documentation supporting the client’s medical need for therapy will be considered and the request will be sent to physician review to determine medical necessity.

Criteria for Discontinuation of Therapy

Discontinuation of therapy may be considered in one or more of the following situations:

    • Client no longer demonstrates functional impairment or has achieved goals set forth in the treatment plan or plan of care.
    • Client has returned to baseline function.
    • Client can continue therapy with a home treatment program and deficits no longer require a skilled therapy intervention and, for clients who are 20 years of age and younger only, maintain status.
    • Client has adapted to impairment with assistive equipment or devices.
    • Client is able to perform ADLs with minimal to no assistance from caregiver.
    • Client has achieved maximum functional benefit from therapy in progress or will no longer benefit from additional therapy.
    • Client is unable to participate in the treatment plan or plan of care due to medical, psychological, or social complications; and responsible adult has had instruction on the home treatment program and the skills of a therapist are not needed to provide or supervise the service.
    • Testing shows client no longer has a developmental delay.
    • Plateau in response to therapy/lack of progress towards therapy goals. Indication for therapeutic pause in treatments or, for those under age 21, transition to chronic status and maintenance therapy.
    • Non-compliance due to poor attendance and with client or responsible adult, non-compliance with therapy and home treatment program.

Reference

TMHP Physical Therapy, Occupational Therapy and Speech Therapy Handbook

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