April 10, 2017
Tuality Health Alliance has been working to solidify our therapy policy and streamline the prior authorization
process. Beginning on April 10, 2017, referrals to Tuality Health Place do not require a prior authorization
if the following criteria are met:
This means no therapy for below line, or Non-Funded diagnoses. Providers should not request therapy for
members whose only diagnosis is on a Non-Funded Line.
Therapy is limited to 30 visits per calendar year. This is in keeping with OHA Prioritized
List Guideline Note 6.
The 2017 Therapy Policy is based on benefits available to THA members through the Oregon Health Authority.
Walter Hardin D.O.
Tuality Health Alliance
- No therapies for below line diagnoses will be approved.
- No Prior Authorization will be required for Tuality Health Place for the following therapy visits:
- Back and Spine diagnoses that fall on line 361 and 401: 1 evaluation and 4 visits
- All other funded diagnoses receive 1 evaluation and 2 visits
- Prior Authorization is required for all additional visits after the above limits are met for each specific
injury, surgery or issue being treated.
- Each new acute injury, surgery or significant change in functional statusthat occurs within the calendar
year will revert to the above process as outlined in point # 2.
- Maintenance Therapy is not a covered benefit. Maintenance therapy startswhen further clinical improvement cannot
be reasonably expected from continuous ongoing care.
Health Share/ Tuality Health Alliance
Subject: Physical Therapy, Occupational Therapy, Speech
Therapy, OMT/CMT, Acupuncture
I. To be compliant with Oregon Health Authority (OHA) Prioritized list Guideline Notes 6, 56, 60, and 92 and assist licensed
therapists with the ability to deliver health care services for the Medicaid population.
- Treatment provided with the intention of relieving or healing a physical or surgical condition.
I. As of July 1, 2016, most back and spine pain was changed to become payable diagnoses. The following protocols for low, medium or high risk patients have been established:
- For all low risk patients with an above line diagnosis for the back and spine: Patients may receive 1 evaluation and 4 TOTAL visits of any of the following therapy:
OMT/CMT, acupuncture and PT/OT. Massage may be considered.
- For all medium or high risk patients with an above line diagnosis for the back and spine: Patients may receive 1 evaluation and a TOTAL of 30 visits per year of
any of the following therapy: OMT/CMT, acupuncture and PT/OT.
II. For all Non-Back and Spine related diagnosis requiring some form of therapy:
- A total of 30 visits per year of PT, OT and Speech (rehab and /or Habilitative) when medically appropriate. The definition of Habilitative therapy is health care services that help you
keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical
and occupational therapy, speech-language pathology,and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
- Additional visits may be authorized in cases of a new acute injury, surgery or other significant change in functional status.
THA Procedure to align with State Guidelines/Protocols
- Appropriate above line diagnosis requests for therapy may receive 1 evaluation and 2 follow up visits to establish a Home Exercise Program (HEP) at Tuality Healthplace without a prior
- All above line diagnosis requests relating to the back or spine that are on lines 361 or 401, may receive 1 evaluation and 4 therapy visits to establish a HEP at Tuality Healthplace without
a prior authorization.
- All above line diagnosis requests relating to the back or spine that are on lines 361 or 401 for treatment by Chiropractic or Acupuncture require a prior authorization. An initial evaluation and
4 follow up visits can be approved by the referral coordinators if the request meets the guideline notes.
- All back and spine PA requests must include some form of validation tool from the referring provider and /or the provider performing the therapy.
- For any member that receives 4 visits (PT/OT, Speech, OMT/CMT, Acupuncture therapy) and the therapist would like additional visits, the therapist should send the request to be re-evaluated
by the Provider for the need for continued therapy and a new validation tool should be completed.
- Home Health may perform 1 therapy evaluation and 1 follow up visit without a prior authorization in place. A Retro PA must be obtained before any additional therapy is performed.
- All dual eligible member's requests for Chiropractic treatment will be covered by THA for diagnosis paired with therapy.
- No more than 2 modalities of therapy are allowed per day of treatment.
- Massage therapy may be considered, but is limited to 1 unit/day
- Transcutaneous electrical nerve stimulation (TENS; CPT 64550,97014 and 97032) is not included on the Prioritized List or the Fee Schedule for any condition due to lack of evidence of
effectiveness per Guideline Note 56.
GUIDELINE NOTE 6, REHABILITATIVE AND HABILITATIVE THERAPIES
A total of 30 visits per year of rehabilitative therapy and a total of 30 visits per year of habilitative therapy (physical, occupational and speech therapy) are included on these lines when medically appropriate. Additional visits, not to exceed 30 visits per year of rehabilitative therapy and 30 visits per year of habilitative therapy, may be authorized in cases of a new acute injury, surgery, or other significant change in functional status. Children under age 21 may have additional visits authorized beyond these limits if medically appropriate.
Physical, occupational and speech therapy are only included on these lines when the following criteria are met:
- therapy is provided by a licensed physical therapist, occupational therapist, speech language pathologist, physician, or other practitioner licensed to provide the therapy,
- there is objective, measurable documentation of clinically significant progress toward the therapy plan of care goals and objectives,
- the therapy plan of care requires the skills of a medical provider, and
- the client and/or caregiver cannot be taught to carry out the therapy regimen independently.
No limits apply while in a skilled nursing facility for the primary purpose of rehabilitation, an inpatient hospital or an inpatient rehabilitation unit.
Spinal cord injuries, traumatic brain injuries, or cerebral vascular accidents are not subject to the visit limitations during the first year after an acute injury.
GUIDELINE NOTE 37, SURGICAL INTERVENTIONS FOR CONDITIONS OF THE BACK AND SPINE OTHER THAN SCOLIOSIS
Spondylolisthesis (ICD-10-CM M43.1, Q76.2) is included on Line 351 only when it results in spinal stenosis with signs and symptoms of neurogenic claudication. Otherwise, these diagnoses are included on Line 532. Decompression and fusion surgeries are both included on these lines for spondylolisthesis.
Surgical correction of spinal stenosis (ICD-10-CM M48.0) is only included on Line 351 for patients with:
- MRI evidence of moderate to severe central or foraminal spinal stenosis AND
- A history of neurogenic claudication, or objective evidence of neurologic impairment consistent with MRI findings. Neurologic impairment is defined as objective evidence of one or more of the following:
- Markedly abnormal reflexes
- Segmental muscle weakness
- Segmental sensory loss
- EMG or NCV evidence of nerve root impingement
- Cauda equina syndrome
- Neurogenic bowel or bladder
- Long tract abnormalities
Otherwise, these diagnoses are included on Line 532. Only decompression surgery is included on these lines for spinal stenosis; spinal fusion procedures are not included on either line for spinal stenosis unless:
- the spinal stenosis is in the cervical spine OR
- spondylolisthesis is present as above OR
- there is pre-existing or expected post-surgical spinal instability (e.g. degenerative scoliosis >10 deg, >50% of foraminal joints expected to be resected)
The following interventions are not included on these lines due to lack of evidence of effectiveness for the treatment of conditions on these lines, including cervical, thoracic, lumbar, and sacral conditions:
- facet joint corticosteroid injection
- intradiscal corticosteroid injection
- local injections
- botulinum toxin injection
- intradiscal electrothermal therapy
- therapeutic medial branch block
- sacroiliac joint steroid injection
- coblation nucleoplasty
- percutaneous intradiscal radiofrequency thermocoagulation
- radiofrequency denervation
- epidural steroid injections
GUIDELINE NOTE 41, SCOLIOSIS
Non-surgical treatments of scoliosis (ICD-10-CM M41) are included on Line 361 when
- the scoliosis is considered clinically significant, defined as curvature greater than or equal to 25 degrees, or
- there is curvature with a documented rapid progression.
Surgical treatments of scoliosis are included on Line 361
- only for children and adolescents (age 20 and younger) with
- a spinal curvature of greater than 45 degrees
GUIDELINE NOTE 56, NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE
Lines 361, 401
Patients seeking care for back pain should be assessed for potentially serious conditions (“red flag” symptoms requiring immediate diagnostic testing) as defined in Diagnostic Guideline D4. Patients lacking red flag symptoms should be assessed using a validated assessment tool (e.g. STarT Back Assessment Tool) in order to determine their risk level for poor functional prognosis based on psychosocial indicators.
For patients who are determined to be low risk on the assessment tool, the following services are included on these lines:
- Office evaluation and education,
- Up to 4 total visits, consisting of the following treatments: OMT/CMT, acupuncture, and PT/OT. Massage, if available, may be considered.
- First line medications: NSAIDs, acetaminophen, and/or muscle relaxers.
- Opioids may be considered as a second line treatment, subject to the limitations on coverage of opioids in Guideline Note 60 OPIOID PRESCRIBING FOR CONDITIONS OF THE BACK AND SPINE. See evidence table.
For patients who are determined to be medium- or high risk on the validated assessment tool, as well as patient undergoing opioid tapers as in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE, the following treatments are included on these lines:
- Office evaluation, consultation and education
- Cognitive behavioral therapy. The necessity for cognitive behavioral therapy should be re-evaluated every 90 days and coverage will only be continued if there is documented evidence of decreasing depression or anxiety symptomatology, improved ability to work/function, increased self-efficacy, or other clinically significant, objective improvement.
- Prescription and over-the-counter medications; opioid medications subject to the limitations on coverage of opioids in Guideline Note 60 OPIOID PRESCRIBING FOR CONDITIONS OF THE BACK AND SPINE. See evidence table.
- The following evidence-based therapies, when available, are encouraged: yoga, massage, supervised exercise therapy, intensive interdisciplinary rehabilitation. HCPCS S9451 is only included on Line 401 for the provision of yoga or supervised exercise therapy.
- A total of 30 visits per year of any combination of the following evidence-based therapies when available and medically appropriate. These therapies are only included on these lines if provided by a provider licensed to provide the therapy and when there is documentation of measurable clinically significant prog ress toward the therapy plan of care goals and objectives using evidence based objective tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ).
- Rehabilitative therapy (physical and/or occupational therapy), if provided according to Guideline Note 6
- REHABILITATIVE AND HABILITATIVE THERAPIES. Rehabilitation services provided under this guideline also count towards visit totals in Guideline Note 6
- Chiropractic or osteopathic manipulation
Mechanical traction (CPT 97012) is not included on these lines, due to evidence of lack of effectiveness for treatment of back and neck conditions. Transcutaneous electrical nerve stimulation (TENS; CPT 64550, 97014 and 97032) is not included on the Prioritized List for any condition due to lack of evidence of effectiveness.
GUIDELINE NOTE 60, OPIOID PRESCRIBING FOR CONDITIONS OF THE BACK AND SPINE
Opioid medications are only included on these lines under the following criteria:
For acute injury, acute flare of chronic pain, or after surgery:
- During the first 6 weeks opioid treatment is included on these lines ONLY
- When each prescription is limited to 7 days of treatment, AND
- For short acting opioids only, AND
- When one or more alternative first line pharmacologic therapies such as NSAIDs, acetaminophen, and muscle relaxers have been tried and found not effective or are contraindicated, AND
- When prescribed with a plan to keep active (home or prescribed exercise regime) and with consideration of additional therapies such as spinal manipulation, physical therapy, yoga, or acupuncture, AND
- There is documented verification that the patient is not high risk of opioid misuse or abuse.
- Treatment with opioids after 6 weeks, up to 90 days after the initial injury/flare/surgery, is included on these lines ONLY:
- With documented evidence of improvement of function of at least thirty percent as compared to baseline based on a validated tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ).
- When prescribed in conjunction with therapies such as spinal manipulation, physical therapy, yoga, or acupuncture.
- With verification that the patient is not high risk for opioid misuse or abuse. Such verification may involve
- Documented verification from the state's prescription monitoring program database that the controlled substance history is consistent with the prescribing record
- Use of a validated screening instrument to verify the absence of a current substance use disorder (excluding nicotine) or a history of prior opioid misuse or abuse
- Administration of a baseline urine drug test to verify the absence of illicit drugs and non-prescribed opioids.
- Each prescription must be limited to 7 days of treatment and for short acting opioids only
- Chronic opioid treatment (>90 days) after the initial injury/flare/surgery is not included on these lines except for the taper process described below.
Transitional coverage for patients on long-term opioid therapy as of July 1, 2016:
For patients on covered chronic opioid therapy as of July 1, 2016, Opioid medication is included on these lines only from July 1, 2016 to December 31, 2016. During the period from January 1, 2017 to December 31, 2017, continued coverage of opioid medications requires an individual treatment plan developed by January 1, 2017 which includes a taper with an end to opioid therapy no later than January 1, 2018. Taper plans must include nonpharmacological treatment strategies for managing the patient’s pain based on Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE. If a patient has developed dependence and/or addiction related to their opioids, treatment is available on Line 4 SUBSTANCE USE DISORDER.
GUIDELINE NOTE 92, ACUPUNCTURE
Inclusion of acupuncture (CPT 97810-97814) on the Prioritized List has the following limitations:
Line 1 PREGNANCY
- Acupuncture pairs on Line 1 for the following conditions and codes.
- Hyperemesis gravidarum: ICD-10-CM: O21.0, O21.1
- Acupuncture pairs with hyperemesis gravidarum when a diagnosis is made by the maternity care provider and referred for acupuncture treatment for up to 12 sessions of acupressure/acupuncture per pregnancy.
- Breech presentation ICD-10-CM: O32.1
- Acupuncture (and moxibustion) is paired with breech presentation when a referral with a diagnosis of breech presentation is made by the maternity care provider, the patient is between 33 and 38 weeks gestation, for up to 6 session per pregnancy.
- Back and pelvic pain of pregnancy ICD-10-CM: O99.89
- Acupuncture is paired with back and pelvic pain of pregnancy when referred by maternity care provider/primary care provider for up to 12 sessions per pregnancy.
Line 5 TOBACCO DEPENDENCE
- Acupuncture is included on this line for a maximum of 12 sessions per quit attempt up to two quit attempts per year; additional sessions may be authorized if medically appropriate.
Line 208 DEPRESSION AND OTHER MOOD DISORDERS, MILD OR MODERATE
- Acupuncture is paired with the treatment of post-stroke depression only. Treatments may be billed to a maximum of 30 minutes face-to-face time and limited to 12 total sessions per year, with documentation of meaningful improvement.
Line 361 SCOLIOSIS
- Acupuncture is included on this line with visit limitations as in Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE.
Line 401 CONDITIONS OF THE BACK AND SPINE
- Acupuncture is included on this line with visit limitations as in Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE.
Line 415 MIGRAINE HEADACHES
- Acupuncture pairs on Line 415 for migraine (ICD-10-CM G43.0, G43.1, G43.5, G43.7, G43.8, G43.9), for up to 12 sessions per year.
Line 467 OSTEOARTHRITIS AND ALLIED DISORDERS
- Acupuncture pairs on Line 467 for osteoarthritis of the knee only (ICD-10-CM M17), for up to 12 sessions per year.
*Line 543 TENSION HEADACHES
- Acupuncture is included on Line 543 for treatment of tension headaches (ICD-10-CM G44.2), for up to 12 sessions per year.
Oregon Health Authority Guideline Note 60
Oregon Health Authority Guideline Note 56
Oregon Health Authority Guideline Note 6
Oregon Health Authority Guideline Note 92
CDC Guidelines for Prescribing Opioids for Chronic Pain-United States, 2016