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23.4 Authorization Requirements
PT and/or OT require authorization. Initial evaluations do not require authorization. Treatment plans require authorization; up to six months of treatment may be authorized. Authorization requests for an extension require documentation of medical necessity. If the client is of school age, the requesting provider must include a copy of the IEP or include a statement from the independent school district indicating that the child is not eligible for therapy services from the school district. Treatment plans are authorized using the OT and PT guidelines by age as stated above.
Refer to: Appendix B, "CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1)" or Appendix B, "CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2)". Note: Fax transmittal confirmations are not accepted as proof of timely authorization submission.
The GP or the GO modifier is required when requesting authorization for PT and OT services. PT should be requested using the GP modifier, and OT should be requested using the GO modifier.
PT and/or OT may be authorized when the child meets one of the following guidelines:
• The child is younger than 3 years of age, and measurable progress toward individual treatment goals can reasonably be expected (this may not always indicate physical improvement in the client's condition).
•The child is 3 years of age or older, not presently eligible for or receiving special education and/or special services during the school year, and has a disabling condition requiring therapy services where measurable progress toward individual treatment goals can reasonably be expected (this may not always indicate physical improvement in the client's condition). In addition, the child also must have at least one of the following conditions:
•The child has a developmental anomaly including, but not limited to: cerebral palsy, spina bifida, arthrogryposis, reduction deformities of a limb(s), hydrocephalus, Erb's palsy (brachial plexus palsy), or encephalocele.
•The child has an acute episode of a chronic condition that may include, but is not limited to: JRA, hemophilia, lupus erythematosus, sickle cell crisis (joint pain, swelling, and limited range of motion), or cancer.
•The child presents a new condition that may include, but is not limited to:
•Upper extremity trauma, median or radial nerve lesions, late effects of fractures, burns, spinal cord injury, traumatic brain injury, cerebral embolism, brain tumor, or Guillain-Barré Syndrome.
•The child is seen in a specialty clinic for periodic assessment or re-evaluations.
•The child needs short-term therapy related to surgery or casting.
•The child requires training on the use of equipment such as wheelchairs (powered or manual), orthotics or prosthetics, or other equipment such as ambulation aids like walkers or crutches).
•Short-term assistance is required to instruct the child/family in activities of daily living specific to the home or environment (bathing, toileting, or making equipment assessment for braces, wheelchairs, cushions, and so on).
PT/OT services may be authorized as follows:
•For children from birth to 3 years of age with a developmental anomaly, therapy services may be authorized up to two times a week for six months (may be extended up to school eligibility without medical review). Requests for a higher frequency of visits per week require the submission of documentation of medical necessity.
•Children 3 through 21 years of age with a developmental anomaly should be referred to the public school system for services unless they are ineligible or there is a medically related therapy issue to address.
•Presurgical therapy related to the reason for surgery may be approved up to three times a week for one month.
•Post-surgical therapy directly related to the reason for surgery or for cast removal may be authorized up to five times a week for two months and post rhizotomy for up to three times a week for one year. After these specified time periods, extensions require documentation of medical necessity.
•Therapy addressing an acute episode of a chronic condition (seldom eligible for therapy through the school system) may be authorized up to five times a week for three months. After three months, the physician's documentation of a continued acute episode is required. After the first six months are authorized, documentation of the specific rationale for the need of continued therapy based on the client's chronic diagnosis must be submitted.
•New conditions such as upper extremity trauma, median or radial nerve lesions, or late effects of fractures, may have therapy authorized up to five times a week for three months. Extensions after six months require additional documentation of medical necessity.
•New conditions (such as third-degree burns) may have therapy authorized up to five times a week for three months and may be extended up to one year. After one year, documentation of the specific rationale of the need for continued therapy must be submitted.
•New conditions such as spinal cord injury, traumatic brain injury, cerebral embolism, brain tumor, or Guillain-Barré Syndrome may have therapy authorized for up to five times a week for the initial three months. This may be extended up to one year.
•Home program monitoring for clients from birth to 3 years of age with cerebral palsy, spina bifida, arthrogryposis, reduction deformities of limbs, or hydrocephalus may have home program monitoring authorized for up to two times a month for six months.
•Home program monitoring for clients from birth to 21 years of age with JRA, hemophilia, lupus erythematosus, and sickle cell crisis (joint pain/swelling and limited range of motion) may have home program monitoring approved up to once a month for six months.
•Activities of daily living instructions to teach clients, parents, and caregivers for clients 3 years of age through 21 years of age may be authorized up to three times a week for one month.
•One equipment assessment before receiving the equipment and one assessment after receiving the equipment may be authorized.
•Training in the use of manual wheelchairs may be authorized for up to five times a week for one month.
•Training in the use of powered wheelchairs may be authorized for up to five times a week for one month and then three times a week for two months.
•Training in the use of orthotics/prosthetics (braces/artificial limbs) may be authorized for up to five times a week for one month and then three times a week for two months. Additional requests for additional training require documentation of the specific rationale for the medical need.
•Reciprocating gait orthoses (RGOs) may be provided for children with spina bifida or similar functional disability. The required documentation includes:
•A statement from the physician indicating the medical necessity.
•A coordinated PT treatment plan.
•Documentation that the client/family is expected to comply with the treatment plan.
•Dynamic splints are provided on a case-by-case basis using the following criteria submitted by the physician:
•The client's condition to be treated with the dynamic splint.
•The client's current course of therapy to date for the condition to be treated.
•The rationale for the use of the dynamic splint at this time.
•A therapy treatment plan related to the dynamic splint.
•Training for other equipment (such as walkers or crutches) may be authorized for up to five times a week for one month.
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