Wisconsin Administrative Code
Department of Health Services
DHS 101-109 - Medical Assistance
Chapter DHS 107 - Covered Services
Section DHS 107.19 - Audiology services
Universal Citation: WI Admin Code ยง DHS 107.19
Current through February 26, 2024
(1) COVERED SERVICES. Covered audiology services are those medically necessary diagnostic, screening, preventive or corrective audiology services prescribed by a physician and provided by an audiologist certified pursuant to s. DHS 105.31. These services include:
(a) Audiological evaluation;
(b) Hearing aid or other assistive listening
device evaluation;
(c) Hearing aid
or other assistive listening device performance check;
(d) Audiological tests;
(e) Audiometric techniques;
(f) Impedance audiometry;
(g) Aural rehabilitation; and
(h) Speech therapy.
(2) PRIOR AUTHORIZATION.
(a)
Services requiring prior
authorization. The following covered services require prior
authorization from the department:
1. Speech
therapy;
2. Aural rehabilitation:
a. Use of residual hearing;
b. Speech reading or lip reading;
c. Compensation techniques; and
d. Gestural communication techniques;
and
3. Dispensing of
hearing aids and other assistive listening devices.
(b)
Conditions for review of requests
for prior authorization. Requests for prior authorization of
audiological services shall be reviewed only if these requests contain the
following information:
1. The type of
treatment and number of treatment days requested;
2. The name, address and MA number of the
recipient;
3. The name of the
provider of the requested service;
4. The name of the person or agency making
the request;
5. The attending
physician's diagnosis, an indication of the degree of impairment and
justification for the requested service;
6. An accurate cost estimate if the request
is for the rental, purchase or repair of an item; and
7. If out-of-state non-emergency service is
requested, a justification for obtaining service outside of Wisconsin,
including an explanation of why the service cannot be obtained in the state.
Note: For more information on prior authorization, see s. DHS 107.02(3).
(3) OTHER LIMITATIONS.
(a)
Plan of care for therapy
services. Services shall be furnished to a recipient under a plan of
care established and periodically reviewed by a physician. The plan shall be
reduced to writing before the treatment is begun, either by the physician who
makes the plan available to the provider or by the provider of therapy when the
provider makes a written record of the physician's oral orders. The plan shall
be promptly signed by the ordering physician and incorporated into the
provider's permanent record for the recipient. The plan shall:
1. State the type, amount, frequency, and
duration of the therapy services that are to be furnished the recipient and
shall indicate the diagnosis and anticipated goals. Any changes shall be made
in writing and signed by the physician or by the provider of therapy services
or physician on the staff of the provider pursuant to the attending physician's
oral orders; and
2. Be reviewed by
the attending physician in consultation with the therapist providing services,
at whatever intervals the severity of the recipient's condition requires but at
least every 90 days. Each review of the plan shall contain the initials of the
physician and the date performed. The plan for the recipient shall be retained
in the provider's file.
(b)
Restorative therapy
services. Restorative therapy services shall be covered
services.
(c)
Maintenance
therapy services. Preventive or maintenance therapy services shall be
covered services only when one of the following conditions are met:
1. The skills and training of an audiologist
are required to execute the entire preventive or maintenance program;
2. The specialized knowledge and judgment of
an audiologist are required to establish and monitor the therapy program,
including the initial evaluation, the design of the program appropriate to the
individual recipient, the instruction of nursing personnel, family or
recipient, and the re-evaluations required; or
3. When, due to the severity or complexity of
the recipient's condition, nursing personnel cannot handle the recipient safely
and effectively.
(d)
Evaluations. Evaluations shall be covered services. The need
for an evaluation or a re-evaluation shall be documented in the plan of
care.
(e)
Extension of
therapy services. Extension of therapy services shall not be approved
in the following circumstances:
1. The
recipient has shown no progress toward meeting or maintaining established and
measurable treatment goals over a 6-month period, or the recipient has shown no
ability within 6 months to carry over abilities gained from treatment in a
facility to the recipient's home;
2. The recipient's chronological or
developmental age, way of life or home situation indicates that the stated
therapy goals are not appropriate for the recipient or serve no functional or
maintenance purpose;
3. The
recipient has achieved independence in daily activities or can be supervised
and assisted by restorative nursing personnel;
4. The evaluation indicates that the
recipient's abilities are functional for the person's present way of
life;
5. The recipient shows no
motivation, interest, or desire to participate in therapy, which may be for
reasons of an overriding severe emotional disturbance;
6. Other therapies are providing sufficient
services to meet the recipient's functioning needs; or
7. The procedures requested are not medical
in nature or are not covered services. Inappropriate diagnoses for therapy
services and procedures of questionable medical necessity may not receive
departmental authorization, depending upon the individual
circumstances.
(4) NON-COVERED SERVICES. The following services are not covered services:
(a)
Activities such as end-of-the-day clean-up time, transportation time,
consultations and required paper reports. These are considered components of
the provider's overhead costs and are not covered as separately reimbursable
items; and
(b) Services performed
by individuals not certified under s.
DHS
105.31.
For more information on non-covered services, see s. DHS 107.03.
Disclaimer: These regulations may not be the most recent version. Wisconsin may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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