Legal Resources | | T22 51309
Article 4. Scope and Duration of Benefits. Psychology, Physical Therapy, Occupational Therapy, Speech Pathology and Audiological Services
(a) Psychology, physical therapy, occupational therapy, speech pathology and audiological services are covered when provided by persons who meet the appropriate requirements specified in Article 2 and Article 3 of this Chapter.
The written prescription of a physician, dentist or podiatrist is required for physical therapy and occupational therapy services. Speech pathology and audiological services shall be provided only upon the written referral of a physician or dentist.
(b) Physical therapy services shall include physical therapy evaluation, treatment planning, treatment, instruction, consultative services, and application of topical medications. Services do not include the use of Roentgen rays or radioactive materials or the use of electricity for surgical purposes including cauterization. Services are limited to treatment immediately necessary to prevent or to reduce anticipated hospitalization or to continue a necessary plan of treatment after discharge from the hospital.
(c) Occupational therapy services shall include occupational therapy evaluation, treatment planning, treatment, instruction and consultative services.
(d) Such services, except physical therapy, are subject to the limitations set forth in Section 51304(a). Physical therapy services may be provided after prior authorization and approval of a treatment plan is obtained from the Medi-Cal consultant.
(1) The authorization request shall include diagnosis, modalities, frequency, therapeutic goals, duration of treatment and date of progress review where applicable. The physician's, dentist's or podiatrist's prescription shall be attached to the authorization request.
(2) Authorization for physical therapy services shall be contingent upon compliance with the following requirements:
(A) There is direct and specific relationship of the services to written treatment plan prescribed by the physician, dentist or podiatrist after consultation with a qualified physical therapist.
(B) The complexity and sophistication of the level of service or condition of the beneficiary requires the judgment, knowledge and skills of a physical therapist.
(C) Provision of the services is with the expectation that the beneficiary will improve significantly in a reasonable and generally predictable period of time or to establish an effective maintenance program in connection with a specific disease state.
(D) Service is to be performed by a qualified physical therapist who meets the standards set forth in Section 51201.1 of this chapter.
(E) The service is considered, under accepted standards of medical practice, to be a specific and effective treatment for the beneficiary's condition.
(F) The service is reasonable and medically necessary for the treatment of the beneficiary's condition.
(3) Professional physical therapy necessary to establish or periodically reevaluate a palliative or maintenance therapy program may be authorized. Services which do not require the skills of a physical therapist shall not be covered or authorized.
(4) Prior authorization shall not be granted for more than 30 treatments at any one time. Authorizations shall be valid for up to 120 days. A request for reauthorization shall include a statement describing the beneficiary's progress toward achieving the therapeutic goals included in the treatment plan.
Authority cited:
Welfare and Institutions Code 14105
Welfare and Institutions Code 14124.5
Section 57(c), Chapter 328, Statutes of 1982
Reference:
Welfare and Institutions Code 14132
Section 52, Chapter 328, Statutes of 1982
(Amended by Register 87, No. 27)