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C-700: Medical Services

Medical services, which are also referred to as "physical restoration," are available to eligible Vocational Rehabilitation (VR) customers through the Texas Workforce Commission's (TWC) Vocational Rehabilitation Services (VR) when these services are expected to decrease, help manage, or stabilize physical barriers so that eligible customers can secure, keep, advance in, or return to competitive integrated employment. These services include corrective surgery or physical therapeutic treatment, dentistry, various types of therapy, and other medically related rehabilitation services that are likely, within a reasonable time frame, to correct or substantially modify a stable or slowly progressing physical or mental impairment that constitutes a substantial impediment to employment.

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C-701: Legal Authority

The Code of Federal Regulations (CFR) states:

"(39) Physical and mental restoration services means—

(i) Corrective surgery or therapeutic treatment that is likely, within a reasonable period, to correct or modify substantially a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to employment;

(ii) Diagnosis of and treatment for mental or emotional disorders by qualified personnel in accordance with State licensure laws;

(iii) Dentistry;

(iv) Nursing services;

(v) Necessary hospitalization (either inpatient or outpatient care) in connection with surgery or treatment and clinic services;

(vi) Drugs and supplies;

(vii) Prosthetic and orthotic devices;

(viii) Eyeglasses and visual services, including visual training, and the examination and services necessary for the prescription and provision of eyeglasses, contact lenses, microscopic lenses, telescopic lenses, and other special visual aids prescribed by personnel who are qualified in accordance with State licensure laws;

(ix) Podiatry;

(x) Physical therapy;

(xi) Occupational therapy;

(xii) Speech or hearing therapy;

(xiii) Mental health services;

(xiv) Treatment of either acute or chronic medical complications and emergencies that are associated with or arise out of the provision of physical and mental restoration services, or that are inherent in the condition under treatment;

(xv) Special services for the treatment of individuals with end-stage renal disease, including transplantation, dialysis, artificial kidneys, and supplies; and

(xvi) Other medical or medically related rehabilitation services."

(Authority: 34 CFR 361.5(39) (40); §§12(c) and 103(a)(6) of the Rehabilitation Act of 1973, as amended; 29 USC. 709(c) and 723(a)(6))

C-701-1: Professional Medical Services

Policy

Federal law requires that medical services (including corrective surgery or treatment) that are sponsored or supported by Vocational Rehabilitation Services (VR) must:

  • have a direct effect on the customer's functional ability to perform the employment goal or the services must support other needed vocational rehabilitation services; and
  • be likely, within a reasonable period, to correct or modify substantially a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to employment.

34 CFR 361.5(39) (i)

VR is the payer of last resort.

Comparable benefits (B-310-5) and required customer participation in cost of services (B-310-6) must be applied before VR funds are expended.

Because VR uses tax revenue for case service expenditures, the division must purchase the least expensive services that meet the customer's vocational needs. For more information, see the requirements in D-203-1: Best Value Purchasing.

After the customer's primary and/or secondary benefit coverage has been applied and the customer's ability to pay has been determined, VR may pay to the provider an amount equal to the customer's co-payment, coinsurance, or deductible due. VR payment does not exceed the amount allowed by the insurance coverage or the allowable VR rate or VR contract rate, whichever is less.

Restrictions

When approval for any procedure, service, food, or device is required, the review and approval must be completed and documented in ReHabWorks (RHW) before including the services on the customer's IPE or IPE amendment.

The following medical services are not authorized:

  • ongoing general medical care for health maintenance;
  • emerging technology and temporary, experimental, or investigational medical services (terminology codes, also called T-codes);
  • maternity care; and
  • medical or surgical treatment associated with:
    • active tuberculosis;
    • sexually transmitted diseases;
    • cancer;
    • organ transplantation (except for the treatment of individuals with end-stage renal disease, subject to management review and approval, as set out below*); or
    • human immunodeficiency virus infection (HIV) or acquired immunodeficiency syndrome (AIDS).

Management exceptions to this list are not allowed.

*End-Stage Renal Disease

Federal guidelines at 34 CFR 361.5(39) (xv) mandate certain vocational rehabilitation services for customers with end-stage renal disease. These customers' cases must be reviewed by the:

  • local medical consultant (LMC);
  • manager;
  • central office program specialist; and
  • VR medical director.

C-701-2: Medical Services Required Review and Approvals Policy

Medical, dental, and ophthalmological consultants provide support to VR staff throughout the VR process.

For more information about the roles of various consultants, refer to VRSM A-100: Introduction to Vocational Rehabilitation.

Medical Director

The following require review and approval by the medical director:

  • Medical services with payments exceeding the Maximum Affordable Payment Schedule (MAPS);
  • Approval for medical services or devices with unlisted MAPS codes;
  • Payment for co-surgeons;
  • Actions contrary to the LMC's advice;
  • Hiring new consultants; and
  • Services, procedures, and programs with special requirements.

State Ophthalmology Consultants

The state ophthalmology consultants are ophthalmologists and retinal specialists and surgeons. Ophthalmological and surgical questions are directed to their attention.

State Optometric Consultants

State optometric consultants are optometrists and clinical low-vision specialists. Low-vision, vision therapy, and related optometric questions are directed to their attention.

Regional Dental Consultant

A regional dental consultant (RDC) is required for all dental services.

Local Medical Consultant

The following require review and approval by an LMC:

  • Surgical services with the exception of eye surgeries.
  • Procedures requiring local and general anesthesia
  • Services, procedures, and programs with special requirements

Eye surgeries with complex procedures may need more consultation, staff may contact State office program specialist for blind services.

Limitations on LMC Services

The LMC does not examine or treat VR customers, except when:

  • the customer is, or has been, the LMC's patient before becoming a VR customer;
  • the LMC is asked to provide ancillary services, such as assisting the principal surgeon, giving emergency treatment, etc.; or
  • the LMC is the only, or one of the few, specialists in the immediate area.

Other cases may be referred to the LMC for treatment only when

  • there is no apparent conflict of interest, and
  • the VR counselor has obtained an approval from the VR Supervisor.

Procedures

When medical services are being considered, the following procedures must be followed:

  1. The vocational rehabilitation counselor (VR counselor) documents in a case note how the customer's substantial impediments to employment will be addressed by the proposed medical services to allow the customer to return to, obtain, maintain, or advance in competitive integrated employment.
  2. The VR counselor or the designee submits all required documentation for required reviews and approvals to the appropriate source for review and approval.
  3. All required reviews and approvals are documented in RHW before VR commitment to VR sponsorship of a medical service by its inclusion in the IPE or an IPE amendment.
  4. After confirming documentation of all required reviews and approvals, medical services must be included in the customer's IPE or IPE amendment.
  5. The VR counselor provides counseling and guidance to ensure that the customer understands the recommended treatment and the customer's responsibilities throughout the physical restoration process.

For additional information about the customer's medical condition, treatment options, and potential employment impact, consult the Medical Disability Guidelines (PDF).

The VR counselor uses the following procedures when authorizing medical services.

  1. Review the customer's medical records related to the reported disability.
  2. Obtain a written recommendation for planned medical services.
  3. Obtain the current procedural terminology codes from the surgeon or physician for the recommended procedures.

If the recommendations include VR-sponsored surgeries or invasive medical procedures requiring general and or local anesthesia, VR staff:

  1. obtain a completed a DARS3110, Surgery and Treatment Recommendations;
  2. has the LMC review the DARS3110;
  3. has the LMC complete a DARS3101, Medical Consultant Review, before purchasing medical services;
  4. consult with the VR program specialist for physical restoration for medical services that:
    • are not listed in MAPS;
    • use codes listed as $0; or
    • use codes ending in "99" or the letter "T"; and
  5. documents the outcome of the LMC in a case note in RHW.

When dental services require review and approval, the VR counselor completes each of the steps that are listed above and asks the regional dental consultant to complete the DARS3108, Dental Report form before services are approved.

If the provider requests authorization for services that exceed the MAPS rates, the VR counselor must obtain approval from the VR medical director.

Justification of a payment rate that exceeds the MAPS rate must show that the:

  • customer is an established patient of the medical provider;
  • a limited number of medical providers exists in the geographical area where the customer resides;
  • surgery or procedure is complicated and requires the special expertise of the medical provider; or
  • rate is the best value to VR.

When needing a state ophthalmology or state optometric consultants review, the VR counselor:

  • completes DARS2351, Request for MAPS Consultation (PDF), that states the name of the appropriate consultant, explains the reason for the request, and lists all the codes and dollar amounts associated with the request;
  • includes all pertinent background materials (such as eye exams, other medical reports, and provider comments and recommendations) as well as invoices or other documentation submitted by the provider;
  • emails information to the program specialist for physical restoration at VR Medical Services (vr.medicalservices@twc.state.tx.us);
  • ensures that the program support specialist forwards the request to the consultant, coordinates with the consultant regarding any additional information that may be needed, receives the consultant's response, and provides a written response to the originator; and
  • takes responsibility for:
    • documenting the consultant's response in the customer's case records;
    • ensuring that the service is provided in accordance with the consultant's recommendations; and
    • processing payment for the completed service in accordance with all programmatic and purchasing requirements.

Local field office staff coordinates customer medical services that are not provided in a hospital, facility, or medical school. These include medical evaluation and treatment in a physician's office, including surgical and physical restoration procedures, therapy services, durable medical equipment, and prosthetic or orthotic services.

The designated medical services coordinator (MSC) coordinates all customer physical restoration services that will be provided in a hospital, ambulatory surgical center, post-acute brain injury facility, or medical school. The VR counselor sends a complete courtesy case to the MSC to assist with coordination of the services.

Exception: The local field office staff may coordinate a laboratory or radiology diagnostic test at a hospital or facility if the diagnostic test is ordered by a physician in conjunction with a medical evaluation and the laboratory or radiology order does not allow time for MSC coordination of the requested diagnostic test. In that case, the local field office staff obtains guidance from the MSC before issuing the service authorization.

The VR counselor contacts the customer at the time of hospital discharge to ensure that the customer understands postoperative instructions and is aware that he or she must notify the physician and the VR counselor if there are signs and/or symptoms of a potential medical complication. The VR counselor provides monitoring and support to the customer during rehabilitative treatment to assess progress and compliance with the treatment regimen.

Following the completion of services, the VR counselor obtains verbal or written information about changes in functional limitations or work capacity from the service provider. The VR counselor documents how the impediment to employment has changed because of the physical restoration service by using one of the following:

Exception: Intercurrent illness and dental treatment do not require assessment of residual functional limitations.

The VR counselor identifies the customer's long-term and ongoing medical needs after VR sponsorship of physical restoration services ends and discusses with the customer the plans for meeting those needs.

C-701-3: Role of the Medical Services Coordinator

The medical services coordinator (MSC) must coordinate:

  • all hospital inpatient and outpatient medical services;
  • ambulatory surgical center services;
  • residential and non-residential post-acute brain injury (PABI) services; and
  • treatment at medical schools.

The MSC coordinates all durable medical equipment for the first two weeks following discharge for in-region cases and the first 30 days for out-of-region cases. Medications for discharge must be coordinated between the rehabilitation services technician (RST) and VR counselor team and the MSC before the customer's discharge.

For MSC-coordinated services, the VR counselor sends a complete courtesy case of required information to the designated MSC. For out-of-region customer medical services, the VR counselor sends the courtesy case to the designated in-region MSC (Home MSC), who will:

  • manage out-of-region cases as per regional policy for coordination of the service; and
  • notify the counselor of the case assignment.

When out-of-region services are completed, the Service MSC notifies the Home MSC and the VR counselor that the services have been completed. The Service MSC then transfers the medical services coordination of the case back to the Home MSC for additional services that must be provided in the home region.

When coordinating medical services, the MSC must:

  • serve as the VR point of contact with the medical provider to coordinate the services;
  • review and verify comparable benefits and release of information forms submitted by RST and VR counselor team;
  • obtain a cost estimate for medical services and notify the counselor;
  • issue service authorizations for service and all anticipated ancillary services;
  • obtain admission or start dates for services and notify the customer as directed by the VR counselor;
  • verify customer admission, discharge, and completion of service;
  • notify the VR counselor of case-coordination issues or medical complications requiring authorization of additional services;
  • coordinate discharge durable medical equipment needs for the customer; and
  • coordinate medications for discharge between the RST and VR counselor team and the MSC before the customer's discharge.

The MSC also must:

  • pay medical provider bills and send paid bills to the VR counselor;
  • obtain customer treatment records and send records to the VR counselor; and
  • document in RHW the MSC case actions related to the coordination of medical services, including:
    • comparable benefit verification information with contact name and date;
    • specific medical service coordinated, including the provider name, admission or start date of service, and number of units or days authorized;
    • for surgery cases, the name of the surgery, surgeon, hospital or facility, and admission and surgery date;
    • verification of discharge date, end date of service, and customer completion of service;
    • a list of ancillary providers required for coordination of the primary medical service;
    • customer medical complications and requests for additional services or an extension of services;
    • the reason for delay in the coordination of medical services;
    • the VR counselor contact information to discuss medical coordination case issues; and
    • the medical provider contacts to coordinate and pay for medical services.

C-701-4: Necessary Unplanned Medical Services

The VR counselor or MSC must not authorize payment for any vocationally necessary medical service that has not been approved by means of a service authorization before the provision of the service. If additional medical services are necessary, the provider must ask the VR counselor or the MSC to request a service authorization before providing the additional services.

Exceptions: Invoices to VR for vocationally necessary medical services that were provided without prior VR approval should be infrequent and must be for immediate services that were required for a customer's safety and welfare. These invoices are submitted for review and approval of an after-the-fact service authorization for payment to:

  • the VR Supervisor for medical services that are coordinated at the local field office; or
  • the program support manager of the MSC for MSC-coordinated medical services.

The VR Supervisor or program support manager must document the review of the invoice and the decision regarding payment in RHW.

Refer to VRSM D-204: The Purchasing Process for more information about processing after-the-fact service authorizations.

C-701-5: Treatment of Medical Complications

Legal Authority

The definition of physical and mental restoration services as stated in the CFR is as follows:

"(39) Physical and mental restoration services means—

(xiv) Treatment of either acute or chronic medical complications and emergencies that are associated with or arise out of the provision of physical and mental restoration services, or that are inherent in the condition under treatment."

34 CFR §361.5(39) (xiv)

Policy

If the customer does not recover sufficiently from medical complications within a reasonable period, and the VR counselor concludes that the customer is no longer able to participate in VR services, the VR counselor must refer the customer to other comparable benefits for additional services and support.

After reviewing and documenting the circumstances of the case closure with the manager and the MSC, the VR counselor must notify the following individuals in writing if the decision is made to close the customer's case:

  • Customer
  • Customer's family
  • Hospital representative
  • Attending physician

If the closure reason is "disability too severe," the VR counselor refers to VRSM B-600: Closure and Post-Closure Services for required closure procedures for all closure reasons.

Procedure

The MSC is responsible for confirming that the customer is discharged from the hospital or facility as planned and in accordance with the number of days documented on the service authorization. If the customer is not discharged as planned because of medical complications, the MSC and the VR counselor follow the procedures in the Medical Services Required Practices Handbook (PDF).

The MSC is the point of contact with the hospital or facility with respect to the authorization of additional hospital days and medical treatment. The VR counselor assesses the prognosis for recovery within a time frame that will permit the customer to participate in VR services that lead to employment and, when necessary, consults the LMC.

C-701-6: Comparable Services and Benefits for Restoration Services

Legal Authority

Federal law requires state VR programs, when providing VR services, to determine whether comparable services and benefits exist and are available to the individual. Specifically, 34 CFR §361.53, entitled "Comparable services and benefits," states:

"(a) Determination of availability. The vocational rehabilitation services portion of the Unified or Combined State Plan must assure that prior to providing an accommodation or auxiliary aid or service or any vocational rehabilitation services, except those services listed in paragraph (b) of this section, to an eligible individual or to members of the individual's family, the State unit must determine whether comparable services and benefits, as defined in §361.5(c)(8), exist under any other program and whether those services and benefits are available to the individual unless such a determination would interrupt or delay—

(1) The progress of the individual toward achieving the employment outcome identified in the individualized plan for employment;

(2) An immediate job placement; or

(3) The provision of vocational rehabilitation services to any individual who is determined to be at extreme medical risk, based on medical evidence provided by an appropriate qualified medical professional."

Policy

When a customer is determined to be eligible for services, all available comparable services and benefits must be used for planned physical restoration before using VR funds.

The VR counselor:

  • assesses the availability of comparable services and benefits;
  • advises the customer to apply for them; and
  • assists the customer with the applications, as needed.

An identified comparable service or benefit is used unless:

  • the use of the comparable service or benefit would result in an interruption or delay in the provision of VR services to a customer who has been determined to be at medical risk, based on medical evidence provided by an appropriate qualified medical professional; and
  • the treating physician who has an established relationship with the customer does not have privileges to perform the service at the hospital or facility where the comparable benefit is available.

If comparable benefits are verified, VR may pay the customer's portion, to include the deductible, coinsurance, and/or co-pay amount, if the customer's portion does not exceed the maximum amount allowed by:

  • MAPS;
  • the contracted payment rate; or
  • the retail or negotiated lower price (for non-MAPS, noncontract items).

The VR counselor must ensure that consideration is given to the customer's participation in cost of services. Payment of the customer's portion by VR should be considered only when:

  • the customer demonstrates financial need; and
  • payment of the customer's portion is less than what VR would pay in the absence of a comparable benefit.

If the comparable benefit is:

  • major medical insurance, a health maintenance organization, or preferred provider organization, then VR may pay the customer's portion (co-payment, coinsurance, and unmet deductible) not to exceed the MAPS rate, contract rate, or retail price, as applicable;
  • Medicare, then VR may pay the customer's portion (co-payment, coinsurance, and any unmet deductible) not to exceed the MAPS rate, contract rate, or retail price, as applicable; or
  • Medicaid, then VR pays nothing. VR does not supplement a Medicaid payment for a specific service or procedure. However, if Medicaid does not cover a service that VR has determined is vocationally necessary, VR can cover the cost of the approved service.

Explanation of Benefits

When a customer has health insurance, Medicare, or Medicaid, the provider first submits a timely claim to these entities, as applicable, for payment of the provided medical services. An Explanation of Benefits (EOB) is sent to the medical provider to document the payment made per benefit coverage and the patient's payment responsibility (the customer's portion). The medical provider submits to VR a copy of the EOB with the provider's invoice so that the VR payment responsibility can be determined.

If the comparable benefit denies the service, then the VR counselor reviews the EOB to determine the reason for the denial. If the service was denied for insufficient documentation, the VR counselor contacts the medical provider and requests that the provider resubmit the claim with proper documentation. VR is not responsible for payment of services when a medical provider fails to file the claim with the comparable benefit in a timely manner.

C-701-7: Professional Medical Providers

Policy

Medical treatment must be provided, as appropriate, only by a Texas licensed and/or certified:

  • physician;
  • surgeon;
  • anesthesiologist;
  • assistant surgeon;
  • chiropractor;
  • radiologist;
  • pathologist;
  • physician's assistant;
  • nurse practitioner;
  • physical therapist;
  • occupational therapist;
  • speech therapist; and/or
  • registered nurse anesthetist.

A physician's assistant (PA) and a nurse practitioner provide medical services under the licensure and supervision of a physician. However, they may evaluate and treat a customer, as well as issue a report, without a physician's co-signature.

For additional information about required qualifications of health care providers, refer to VRSM D-200: Purchasing Goods and Services.

Procedure

The medical provider must send documentation along with the invoice for payment that the medical service was provided. Examples of acceptable documentation include:

  • medical report or office notes;
  • operative report;
  • therapy evaluations and progress notes; and
  • diagnostic test reports.

If a medical evaluation is purchased, the evaluation report must address the following:

  • Medical history
  • Reported symptoms
  • Review of body systems
  • Clinical examination findings
  • Diagnoses of medical conditions
  • Recommended treatment

C-701-8: Payment to Medical Providers

Policy

The following conditions apply to payment for professional medical services:

  • Payment for medical treatment must be the professional's usual fees or the MAPS maximum payment rate for the medical service, whichever is less.
  • If the medical professional's usual fee exceeds the MAPS maximum payment rate, the VR counselor verifies that the medical professional providing the service will agree to accept the VR allowance in MAPS as payment in full before coordinating services.
  • If the medical provider requests payment that exceeds the MAPS rate for the medical service, the VR counselor obtains approval from the VR medical director.
  • If the medical provider requests payment for travel costs, the VR counselor sends the request to state office program specialist for physical disabilities for approval before coordinating services.
  • The VR counselor consults with the VR program specialist for physical restoration if the VR counselor is requested to authorize medical services not listed in MAPS.
  • Medical providers are not paid maintenance or a per diem.

C-701-9: Professional Surgical Services Policies

Surgeon

The surgeon's fee usually includes postoperative office visits for a specified period. The period should be verified for each individual customer and surgery.

A medical complication that results from the surgery directly or is inherent in the condition under treatment is a part of the physical restoration service.

VR uses a multiple surgical procedure discount when calculating the surgeon's fee per MAPS. Refer to the Medical Services Required Practices Handbook (PDF) for the payment method.

Co-Surgeons

Two surgeons may not be paid as co-surgeons on the same case at the same time except when the surgery requires the collaboration of two or more surgical specialties.

For approval of co-surgeons, the VR counselor:

  • obtains a DARS3110, Surgery and Treatment Recommendations from both surgeons;
  • verifies that the identified surgeons have different specialties required by the proposed surgery;
  • verifies that the current procedural terminology (CPT) codes identifying the surgical procedures are different for each surgeon; and
  • obtains approval from the VR medical director to pay for co-surgeons.

Surgical Assistant

A licensed physician, licensed PA, licensed surgical assistant, or registered nurse first assistant may be paid as a surgical assistant. The VR counselor refers to the Medical Services Required Practices Handbook (PDF) for the payment method.

Anesthesiology Services

A fee for the administration of anesthesia during a surgical procedure is paid to an anesthesiologist or a certified registered nurse anesthetist (CRNA). When a CRNA administers anesthesia under the supervision of an anesthesiologist, the supervising anesthesiologist may be paid for supervising the CRNA. The VR counselor refers to the Medical Services Required Practices Handbook (PDF) for the payment method.

A fee for anesthesia may not be paid to a physician or surgeon who administers a local anesthetic agent when performing an office procedure.

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C-702: Clinical Settings Policies

Physical restoration services include a range of medical services provided in a variety of clinical settings such as hospitals, outpatient facilities, and doctors' offices.

VR is the payer of last resort.

Comparable benefits (B-310-5) and required customer participation in cost of services (B-310-6) must be applied before VR funds are expended.

Because VR uses tax revenue for case service expenditures, the division must purchase the least expensive services that meet the customer's vocational needs. For more information, see the requirements in D-203-1: Best Value Purchasing.

With respect to VR's responsibility for payment, after the customer's primary and/or secondary benefit coverage has been applied and the customer's ability to pay has been determined, VR may pay to the provider an amount equal to the customer's co-payment, coinsurance, or deductible due. VR payment does not exceed the amount allowed by the insurance or the allowable VR rate or VR contract rate, whichever is less.

Refer to VRSM D-220: Health Care Facilities - Required Qualifications for additional information about required qualifications of health care facilities.

C-702-1: Ambulatory Surgery Center Services

Generally, medical procedures performed in an ambulatory surgery center (ASC) are less complicated than procedures performed in a hospital and do not require an overnight stay. The MAPS codes that are used to pay the surgeon and the ASC are the same except for the code for the facility, which is "FAC" (for example, "69930 FAC"). The VR counselor obtains a copy of the operative report and/or the discharge summary before authorizing payment.

C-702-2: Hospital or Medical Facility Services

Hospitals or medical facilities must have a written contract with TWC to receive payment for provided services. The TWC Contract Management Unit (CMU) maintains all hospital and medical facility contracts. The hospital or medical facility contract defines the business relationship with VR as well as the rate of payment for services, which may include:

  • inpatient hospital services;
  • outpatient hospital services;
  • residential PABI services;
  • nonresidential PABI; and
  • medical records.

When hospital or medical facility services are necessary, the VR counselor selects a hospital or facility that has a TWC contract, if possible. If a physician selects a hospital or facility for a medical service that does not have a TWC contract, the medical services coordinator must contact the physician's office to determine whether the physician has hospital and facility privileges at a TWC-contracted hospital and if the surgery or procedure can be moved to the TWC-contracted hospital.

C-702-3: Necessary Medical Services at Non-Contracted Hospital or Medical Facility

If a customer needs a medical service at a hospital or medical facility that does not have a TWC contract, the assigned MSC must contact the CMU to develop a single-customer contract with a negotiated payment rate for the medical service before authorizing the service. A DARS3423, Exception to Contracted Hospital Purchase must be completed to initiate the approval process.

The VR Counselor may refer to VRSM D-200: Purchasing Goods and Services Process for Exceptions to Hospital Contracts for a list of required processes and procedures.

C-702-4: Selecting the Appropriate Facility

The customer's treating physician can provide guidance on whether a contracted hospital or noncontracted ASC will best meet the customer's needs. In either case, the VR counselor considers the:

  • availability of comparable services and benefits to pay for all or part of costs;
  • best value;
  • customer's informed choice; and
  • proximity of the facility to the customer's home and family.

If hospitalization is necessary, the VR counselor uses a hospital with which TWC has a contract. When selecting a hospital, the VR counselor and the customer must consider the:

  • specialized services available (for example, for traumatic brain or spinal cord injuries or ear, heart, brain, or orthopedic surgery);
  • composition of the patient population (for example, a comprehensive medical rehabilitation program primarily serving elderly stroke patients might not be appropriate for treating a young customer with a spinal cord injury);
  • availability of additional services (for example, driver's evaluation and training, vocational evaluation, specialized orthotics, rehabilitation engineering); and
  • availability and/or access to follow-up and aftercare.

C-702-5: Hospital or Medical Facility Payments

Hospital and medical facility services are paid at the current payment rate established by the TWC contract and may not exceed the contract rate. Hospital services are paid based on a percentage of the hospital's usual and customary billing. Before authorizing payment, the VR counselor:

  • consults the hospital contract comments in RHW to obtain the hospital's current payment rate; and
  • obtains appropriate documentation that a medical service was provided.

For more information, see C-703-32: Specialized Physical Restoration Programs.

The following documentation is required for payment of a hospital or medical facility bill:

  • Name of provider
  • Documentation of service
  • Record of hospital inpatient surgery or treatment
  • Record of hospital inpatient diagnostic tests (laboratory, radiology, pathology)
  • Record of hospital outpatient treatment, therapy, or diagnostic test
  • Treatment, therapy, or diagnostic test report
  • Information about PABI facility residential program progress (or staffing notes)
  • Information about PABI facility nonresidential program progress (or staffing notes)
  • Discharge summary and/or operative report

C-702-6: Reduced Payment Agreement

When the customer's circumstances warrant, hospital contracts allow for payments to be less than or more than the contracted rate. A special reduced-payment agreement may be negotiated with a hospital under the terms of the hospital contract when the customer:

  • is having a procedure with a projected high cost;
  • is undergoing a series of surgical procedures; or
  • has medical complications following surgery and is therefore having a hospital stay beyond the generally expected time frames associated with typical recovery.

DARS3422, Reduced Payment Agreement must be completed by the MSC and signed by the MSC and an authorized hospital representative. The MSC notifies State Office Program Specialist for Physical Disabilities and, a copy of the reduced-payment agreement is placed in the customer's case file.

C-702-7: Length of Hospital Stay—Required Review

If the treating physician expects the recommended hospitalization to exceed 14 days, excluding inpatient comprehensive rehabilitation services and PABI services, the VR Manager must review the medical treatment and consult with the program specialist for physical disabilities to ensure that the proposed treatment or surgery is an appropriate physical restoration service. The manager's review must be documented in the Texas Review, Oversight, and Coaching System (TxROCS). Refer to Standards for Providers Chapter 19: Technical Information and References, 19.5 Case Reviews, for additional information.

When a customer requires hospitalization beyond the length of time to which VR originally agreed and VR payment does not continue, the VR counselor makes other arrangements to pay for the additional hospitalization.

VR Manager approval of written notification of the change in payment authorization must be provided to:

  • the customer;
  • the hospital;
  • the attending physicians; and
  • all other parties concerned.

C-702-8: Other Hospital Services

Hospital services that are not covered include:

  • television rental;
  • telephone calls;
  • gourmet meals;
  • cots; and
  • guest trays and a private room, unless:
    • the physician orders it as medically necessary; and/or
    • no other room is available.

Blood

If a customer needs a blood transfusion, the VR counselor discusses with the customer donations from family and friends for replacement, if the physician has not done so. The VR counselor purchases blood when replacement from family and friends is not possible. When a medical procedure is scheduled, every effort should be made to obtain blood donations before the procedure.

Social Work Charges

VR pays hospital charges for social work services at the hospital contract rate when the services are prescribed by attending physicians.

These services are provided by contracts in either a residential or a nonresidential program.

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C-703: Policies for Services, Procedures, and Programs with Special Requirements

Listed below are physical restoration services or procedures that have special requirements. The VR counselor reviews the requirements throughout this chapter before including any of the services in the customer's IPE or IPE amendment.

The services are:

  • adaptive or assistive technology;
  • back surgery and steroid injections;
  • breast implant removal;
  • cardiac catheterization or angiography;
  • chiropractic treatment;
  • cochlear implant;
  • comprehensive medical treatment for spinal cord injury;
  • dental treatment;
  • discograms;
  • electrical bone stimulators;
  • eyeglasses and contact lenses;
  • functional capacity assessments (FCA);
  • functional electrical stimulation (FES) devices;
  • hearing aids;
  • home health and nursing-home care;
  • intercurrent illness;
  • low-vision aids
  • medical assistive devices and supplies;
  • nursing-home care;
  • occupational therapy;
  • orthoses and prostheses (see also FES devices, above);
  • osteomyelitis;
  • outpatient services;
  • pain treatment;
  • physical therapy;
  • prescription drugs and medical supplies;
  • procedures for pregnant customers;
  • severe (morbid) obesity surgery;
  • post bariatric surgery case management;
  • speech therapy and speech training;
  • spinal cord stimulator or dorsal column stimulator;
  • weight loss programs;
  • wheelchairs; and
  • wound care.

These services or procedures are purchased when it is likely that they will enhance a customer's employability or capability to perform activities of daily living that will facilitate employment.

VR is the payer of last resort.

Comparable benefits (B-310-5) and required customer participation in cost of services (B-310-6) must be applied before VR funds are expended.

Because VR uses tax revenue for case service expenditures, the division must purchase the least expensive services that meet the customer's vocational needs. For more information, see the requirements in D-203-1: Best Value Purchasing.

With respect to VR's responsibility for payment, after the customer's primary and/or secondary benefit coverage has been applied and the customer's ability to pay has been determined, VR may pay to the provider an amount equal to the customer's co-payment, coinsurance or deductible due. VR payment does not exceed the insurance allowed amount or the allowable VR rate or VR contract rate, whichever is less.

C-703-1: Back or Neck Injections or Neurotomy

The following procedures for back or neck pain require the review and approval of the LMC and the VR medical director:

  • Epidural steroid injections of the spine
  • Facet injections of the spine
  • Medial branch blocks
  • Radiofrequency neurotomy

C-703-2: Back or Neck Treatment

Back or neck surgery may be purchased for a customer who meets the following criteria:

  • The medical records must show evidence of:
    • abnormal radiographic imaging and clinical findings that correlate to the customer's symptoms;
    • a course of conservative treatment if the treating physician has determined that conservative treatment is a reasonable treatment option for the customer's medical condition; or
    • other potential causes of the customer's symptoms being ruled out;
  • The back or neck surgery is expected to remove the substantial impediment to employment by enhancing a customer's employability or capability to perform activities of daily living that will facilitate employment.
  • LMC review; and
  • VR Manager approval.

Note: The VR Manager and VR medical director review and approval is required for all spinal fusion surgeries involving three or more levels.

C-703-3: Breast Implant Removal

The VR Manager and VR medical director must approve sponsorship of breast implant removal. To request medical director approval, see VRSM E-200: Required Approvals and/or Consultations.

C-703-4: Breast Reduction Surgery

To be approved, macromastia must be determined to be a substantial impediment to employment. Before surgery can be considered, there must be documentation that less-invasive therapeutic measures were tried first, including proper brassiere support, prescription medication, and/or physical therapy. The VR Manager and VR medical director must approve sponsorship of breast reduction surgery. Symptoms must be shown to have persisted despite reasonable therapeutic efforts. Reduction mammoplasty for macromastia may be purchased for a customer meeting the following criteria:

  • Persistent functional impairment in two or more body areas, such as:
    • neck pain;
    • pain in the trapezius muscles (upper shoulder) and/or pain in the lateral cervical group of muscles (back of neck);
    • pain from brassiere straps cutting into shoulders;
    • upper back pain;
    • painful kyphosis documented by X-ray; and
    • chronic skin breakdown despite treatment;
  • Evaluation by an orthopedic or spine surgeon noting that the customer's symptoms are primarily due to macromastia.

The VR Manager and VR medical director must approve sponsorship of breast reduction surgery.

C-703-5: Cardiac Catheterization or Angiography

Cardiac catheterization may not be authorized as a diagnostic test before the IPE is written.

When stents are placed during a cardiac catheterization, the procedure is considered a medical service and is beyond the scope of a diagnostic procedure. All medical procedures, including cardiac catheterization that includes the placement of stents must be included as a planned service on the IPE.

Angiography should not be authorized before the IPE is written.

LMC review and VR Manager approval are required before authorizing cardiac catheterization and/or angiography.

C-703-6: Chiropractic Treatment

Chiropractic treatment may be purchased for a customer only under the following conditions:

  • A board-certified orthopedic or physical medicine and rehabilitation physician has submitted a written recommendation for chiropractic treatment and included the number of recommended sessions.
  • The number of sessions does not exceed 10 sessions for the life of the case. Additional sessions require medical director approval.
  • Only chiropractic manipulative treatment is purchased (MAPS 98940, 98941, or 98942).

C-703-7: Cochlear Implant and Bone Anchored Hearing Aid Surgery

Surgery for a cochlear implant or a bone anchored hearing aid (BAHA) may be authorized when it is expected to correct or substantially modify a stable or slowly progressive hearing impairment that constitutes a substantial impediment to employment and/or training that is required for a specific employment outcome.

Documentation must address how the surgery will correct or modify substantially, within a reasonable period, the hearing impairment that constitutes a substantial impediment to employment.

TWC must use comparable benefits when possible when planning services related to hearing aids, cochlear implants, and BAHA for customers aged 18 and younger. To this extent, TWC may pay for any deductible, co-payments, and/or coinsurance for the provision of these goods and services if the total cost (insurance paid amount plus VR funds paid toward cost) does not exceed allowable VR contract rates.

Additionally, before planning surgical services, the customer must have:

  • been diagnosed with a significant hearing loss and be unable to use a hearing aid effectively in the ear to be implanted;
  • a stable or slowly progressive hearing impairment;
  • good overall general health, as evaluated by a general history and physical examination;
  • no evidence of problems that would preclude surgery or the aural rehabilitation program, including middle ear infection;
  • for cochlear implant surgery:
    • an optimal inner ear structure, including an accessible cochlear lumen that is structurally suited to taking an implant; and
    • no evidence of lesions in the auditory nerve and acoustic areas of the central nervous system;
  • for BAHA surgery, good inner ear function; and
  • been evaluated by an otologic surgeon who is qualified to perform cochlear implant and BAHA surgeries.

The evaluation report completed by the otologic surgeon must include:

  • diagnosis;
  • recommendations for treatment; and
  • prognosis.

The VR counselor must ensure that:

  • the consultation with an LMC has occurred;
  • for cochlear implant candidates, an effective aural rehabilitation program following surgery is available; and
  • through counseling and guidance, the customer:
    • understands the prescribed treatment program and is willing and able to follow through;
    • acknowledges potential side effects; and
    • accepts that the device:
      • may be supplemented by a hearing aid in the other ear and/or use of other assistive listening devices; and
      • can create the perception of sound, but will not restore normal hearing.

The VR program specialist for the Deaf and hard of hearing (for customers accessing VR services) or the Blind services manager of field support (for customers accessing deafblind services) must review a courtesy case packet before planning the surgery.

The courtesy case packet includes the:

  • medical, audiological, speech, and language evaluations and other reports as specified;
  • justification of how the surgery will correct or substantially modify the substantial vocational impediment within a reasonable period;
  • DARS3101, Consultant Review (completed by the local medical consultant); and
  • DARS3110, Surgery and Treatment Recommendations (completed by the otologist performing the surgery).

After the VR program specialist for the Deaf and hard of hearing or the VR Manager of field support reviews the courtesy packet, a case note granting approval of the procedure is entered in RHW.

All medical services related to the provision of cochlear implants and BAHA must be performed by licensed and/or certified:

  • otologists; and
  • audiologists.

C-703-8: Dental Surgery and Treatment

To be allowable, dental corrective surgery or therapeutic treatment must be likely, within a reasonable period, to correct or modify substantially a stable or slowly progressive physical impairment that constitutes a substantial impediment to employment.

Dental treatment may be provided as:

  • a means to address an intercurrent illness (for example, abscess or infection);
  • a component of maxillofacial surgery; or
  • needed treatment, as determined by the regional dental consultant, that allows the customer to participate in planned services within a reasonable period.

Dental treatment outlined above requires:

  • regional dental consultant review; and
  • VR Manager approval.

Routine dental care is not covered under VR. To be allowable, expenses for dental treatments must be shown to be directly related to a customer's employment goals as outlined in the IPE. The VR counselor must consider comparable benefits and ensure that least-cost, least-invasive procedures are considered first.

C-703-9: Diabetes Insulin Pumps

VR does not purchase insulin pumps for the medical management of diabetes.

C-703-10: Discograms

VR usually does not pay for a discogram, because the test has been found to be of limited diagnostic value. To obtain approval for a discogram, the VR counselor:

  • obtains written justification for the discogram for the requesting physician; and
  • submits the written justification along with the pertinent medical records to the medical director for review and approval.

C-703-11: Dynamic Splinting Devices

Dynamic splinting devices may be prescribed for joint stiffness or contracture of the knee, elbow, wrist, finger, or toe. These devices are spring-loaded and adjustable to provide a low-load prolonged stretch while the customer is asleep or at rest. Dynamic splinting devices include, but are not limited to, such products as Dynasplint, EMPI Advance, LBM Pro-Glide, SaboFlex and Ultraflex. Consult with the program specialist for physical disabilities for the current clinical criteria and best value considerations.

C-703-12: Electrical Bone Stimulators

An electrical bone stimulator may be authorized for a customer only when:

  • the customer has:
    • a previous failed spinal fusion;
    • a multilevel spinal fusion; or
    • nonunion of a fracture six months or more from the initial fracture date;
  • the customer has a prescription from the treating physician;
  • the LMC determines that the request meets medical criteria for sponsorship; and
  • best-value principles have been applied (that is, rent or purchase).

C-703-13: Eyeglasses and Contact Lenses

To purchase single vision, bifocal, or trifocal glasses or contact lenses, the counselor obtains a prescription from an ophthalmologist or optometrist.

Frames must be the least expensive serviceable type available. The customer may supplement the additional cost for frames if their cost exceeds the MAPS maximum.

Lenses may have tint and/or be impact-resistant only when specified in the prescription.

Note: Irlen lenses may not be purchased without review and approval of the VR state optometric consultant.

Glasses may be purchased if needed to complete diagnostic studies.

Before purchasing contact lenses, the VR counselor:

C-703-14: Low-Vision Services

A potential candidate for low-vision services is a customer whose vision cannot be normalized by conventional prescription glasses or contacts. Because expanding the provider base of low-vision specialists statewide is an ongoing need, the VR counselor contacts the Central Office physical restoration program specialist if he or she learns of a new potential service provider. The VR counselor contacts the physical restoration program specialist also for information about how VR purchases low-vision services.

The primary goal for low-vision specialists and for VR is to ensure that customers have the opportunity for optimum visual functioning for vocational, educational, and independent living goals. However, because VR uses tax revenue for case service expenditures, the division must purchase the least expensive optical low-vision devices that meet the vocational needs of the customer. However, in some cases, the most expensive device might be the only one that meets the needs of the customer.

Note: The visual acuity to be used is the best corrected distance acuity. Best correction is the best visual acuity with a simple refraction (glasses or contact lenses), not with a low vision aid, such as a telescopic aid. An ophthalmologist or optometrist must:

  • measure the visual acuity using the distance Snellen chart; or
  • measure and then convert the measurement in writing to the distance Snellen equivalent.

Low-Vision Provider Base

Procedure

While no licensure or certification for low-vision specialists exists, a growing network of service providers in the state exists who are well-trained, experienced, and provide excellent services. Some ophthalmological practices have a low-vision specialist on staff, but most low-vision specialists are licensed optometrists. Many are active members of the low-vision section of the Texas Optometric Association and have collaborated with VR via the state optometric consultant in the development of these guidelines.

Optical and Nonoptical Low-Vision Devices

Policy

A wide range of services and items is available for people with low vision, from low-tech and low-cost approaches (for example, modifications in lighting, magnification, and contrast) to high-tech optical devices with higher costs (for example, single and compound optical systems). Only the optical devices are purchased through MAPS.

Other nonoptical items such as independent living aids, magnifiers, closed-circuit televisions (CCTV), and adaptive computer hardware and software are acquired and/or purchased as a non-MAPS specification in RHW (that is, warehouse supply, commercial requisitions, or contract purchases). The VR counselor contacts Customer Procurement and Client Services Contracting (CPCSC) to determine which purchasing mechanism to use.

Specific Referral Information for the Low-Vision Specialist

VR counselor can maximize the effectiveness of services by providing the low-vision clinician with information about the customer's:

  • level of visual functioning for specific tasks and activities;
  • specific visual problem areas as experienced in school, independent living, and/or on a job; and
  • goals for greater independence in these areas.

Specificity of information is critical for the low-vision specialist to be able to direct the examination in terms of activities related to the customer's IPE goals. General referral information typically results in only general recommendations; specific referral information can produce pertinent recommendations related to the customer's IPE goals. It is recommended that a customer bring samples of materials that he or she wants to access visually to his or her meeting with the specialist.

The Low-Vision Evaluation

The CCS provides customer information to the low-vision provider before scheduling a low-vision evaluation. This preliminary step is critical in helping the provider to give VR information about how the customer's visual functioning relates to his or her planned goal.

Once the referral information has been provided and the customer's visual needs have been communicated, an initial low-vision evaluation is scheduled for the customer using MAPS Code DBS01 (low-vision evaluation—diagnostic/medical and functional components).

The DBS01 evaluation is a combination of:

  • a diagnostic and medical component that must include a comprehensive medical history and eye examination (92014) with automated visual fields measurements (92083); and
  • a low-vision refraction and magnification assessment with an individualized evaluation of the customer's functional use of residual vision in relation to the rehabilitation goal.

The second component is the unique component of the DBS01 low-vision evaluation. Because VR pays for this service, the information must be detailed in the provider's written report.

Note: The costs for the medical services component of the DBS01 evaluation are often covered by comparable benefits resources such as health insurance policies and Medicare. However, the functional component is rarely a covered service by any comparable benefits resource, and VR is the only financial participant to assist the customer with the costs. Comparable benefits for evaluations, if available, can be considered after the IPE is written.

From the evaluation, the low-vision clinician provides answers to the following questions about the customer's visual functioning:

  • Is the current diagnosis consistent with the clinical findings?
  • Can vision be improved with conventional corrective lenses?
  • If so, what is the best corrected distance acuity in both eyes, with conventional lenses?
  • What is the customer's near acuity, both single-letter identification and reading?
  • Is this customer monocular or binocular?
  • Does this customer have a problem with contrast sensitivity, and if so, how does this affect visual functioning and reaching rehabilitation and/or habilitation goals?
  • Are there significant peripheral or central visual field losses?
  • If so, how do these affect visual functioning and reaching rehabilitation and/or habilitation goals?
  • Can distance vision be improved with telescopes, and if so, is a telescopic correction practical for this customer's vocational and/or daily living goals?

Subsequent Low-Vision Evaluation Visits

Procedure

As rehabilitation and habilitation goals are refined, low-vision revisits may be indicated to determine further the types of nonprescription and/or prescription optical devices that could help the customer perform desired tasks and activities. The level of service required depends on the amount of time needed to accomplish subsequent evaluations.

It is important that the customer demonstrate the ability to use recommended optical devices at an acceptable level of efficiency. Unless the customer finds using the optics to be more efficient than not using them, it is unlikely that the devices will be used.

Examples include the following:

  • Brief low-vision office visit—15 minutes (use MAPS 97535 x one unit). Usually, this visit is included in dispensing an optical device and is indicated for training a customer with a stock low-vision prescription.
  • Intermediate low-vision office visit—30 minutes (use MAPS 97535 x two units). This level of service is mainly for working with the customer and a device that may be considered as a recommended prescription.
  • Extended low-vision office visit—45 minutes (use MAPS 97535 x three units). An additional clinical evaluation after the first or subsequent visit may be indicated. Typically, the purpose is to finalize a prescription for an optical device, to continue the low-vision assessment because of complicating medical conditions or poor responses by the customer, or to provide a supplemental evaluation related to specific vocational, educational, or independent living tasks being addressed.

MAPS Codes for Reimbursement for Optical Devices and Professional Services

Reimbursement to the low-vision specialist for prescribing, dispensing, and training for an optical low-vision device is based on the wholesale supplier's price apart from the specialist's professional service with the customer. A minimum processing fee (calculated as a designated percentage of the device's base cost) is added to the cost of the device to cover the low-vision specialist's costs, such as handling the prescription-ordering, verifying, shipping, and stocking.

VR reimburses the provider for professional time spent with the customer in designing a system of optical devices and in training the customer to use the system. This reimbursement method reflects the time and effort spent the low-vision clinician spent in developing an effective treatment for the VR customer.

Categories of Optical Devices and Price Ranges

The Low-Vision Packet for Eye Glasses and Low-Vision Recommendations is available by request from the physical restoration program specialist. The electronic version is in a printable format that may be shared with low-vision providers that recommend specific eyeglasses prescriptions and low-vision aids to ensure that both VR staff members and providers are sharing a common terminology and fee structure.

Handheld, Stand, and Other Stock Nonspectacle-Mounted Optical Devices

Handheld, stand, and other nonspectacle-mounted optical devices, known as V2600 devices, are nonprescription devices that can be purchased directly from a supplier as non-MAPS rehabilitation supplies or as a MAPS purchase through a low-vision specialist at the wholesale supplier's price plus 25 percent to the low-vision specialist.

These items are readily available and can be purchased over the counter by the public. VR staff may purchase these directly from a wholesale supplier as the least costly option. When purchased through a low-vision specialist, an additional 25 percent processing fee is paid on all stock items (including handheld magnifiers, handheld telescopes, stand magnifiers, and fit over filters for glare control and contrast enhancement). The base price is the cost that appears in the price list of a national supplier. Local VR offices have supplier price lists that can be used to verify that the service provider's charges do not exceed the MAPS maximum allowable payment.

A minimum of professional time is needed to train a customer to use these devices. For each classification of devices in the V2600 category, one DBS05 fitting fee can be authorized. For example, if the VR counselor approves one magnifier and one illuminated magnifier on the same date for the same customer, the VR counselor may authorize a total of two DBS05 fees (one for the non-illuminated magnifier and one for the illuminated magnifier).

Examples of devices include the following:

  • V2600, illuminated stand magnifier (supplier's price + 25 percent)
  • DBS05, dispensing fee
  • V2600, handheld illuminated magnifier for home use (supplier's price + 25 percent)
  • V2600, illuminated stand magnifier for workplace use (supplier's price + 25 percent)
  • VR05, dispensing fee
  • V2600, non-illuminated handheld magnifier (supplier's price + 25 percent)
  • V2600, handheld telescope (supplier's price + 25 percent)
  • DBS05, dispensing fee x 2

Single Lens, Spectacle-Mounted Low-Vision Devices

V2610 devices are prescribed and include all spectacle microscopes, microscopic bifocals (+5 diopters and over), doublet and triplet microscopes, Unilens, and prismatic half eyes. These devices are reimbursed at the supplier's price plus a 30 percent prescriptive service fee. Additionally, the low-vision specialist is reimbursed for a 92354 fitting fee for each single element low-vision device to cover the design, evaluation, and training costs involved. The VR counselor does not authorize an exam or evaluation, because the fitting fee covers the office visit and training. An additional exam may be provided and billed only if there is an additional goal that is being pursued and another prescription that is being considered.

Examples of these devices include the following:

  • V2610, single element low-vision prescription (supplier's price + 30 percent); and
  • 92354, fitting fee.

Spherical and Cylindrical Bifocal Microscopes

The low-vision clinician often must design and special order a prescription for the customer in bifocal or trifocal form, which includes cylinder, prism, and other special optics parameters. The reimbursement for these devices is per the V-codes as listed in MAPS.

Note: The 30 percent prescription service fee applies to V2610 items only.

Examples of these devices include the following:

  • Monocular microscope with cylinder
    • V2025, deluxe frame for microscope
    • V2114, over +12D with cyl, per lens
    • V2100, plano lens/balance
    • V2699, polycarbonate lenses/pair
    • V2741, yellow contrast tint/per lens
    • 92354, single element fitting fee
  • High add microscopic bifocal with cylinder
    • V2025, deluxe frame for microscopic bifocal
    • V2208, OD lens (-7 with -3 cyl)
    • V2211, OS lens (-10 with -4 cyl)
    • V2220, OD bifocal over +5D or greater
    • V2220, OS bifocal over +5D or greater
    • 92354, single element fitting fee

Telescopic and Other Compound Lens Systems

The more sophisticated and complex low-vision prescriptions are the bioptic, telemicroscopic, and reversed telescopic optical systems. These are spectacle mounted, include the customer's prescription, and often must include the use of filters. Advanced clinical skills and extended time are required for correct fitting. Extensive training is required for effective and efficient use of these prescriptive optical devices. Prisms for field awareness are also included in this category.

A fitting fee (92355) plus a 40 percent prescription service fee above the supplier's price are allowed for this category of devices. The VR counselor does not authorize an exam, because the fitting fee covers the office visit and training.

Note: The 40 percent prescription service fee applies to V2615 items only.

Examples of these devices include the following:

  • V2615, bioptic 3x/monocular telescope (supplier's price + 40 percent)
  • 92355, fitting fee for bioptic

Prism Awareness Systems

Custom prism awareness systems are unique ophthalmic prism designs. The low-vision specialist must provide the invoice from the lab that created the optics.

One example of this coding is an invoice for $400 for the prism, a $160 (40 percent) processing fee, $100 for the deluxe frame, and a $240 fitting fee. This allows for a maximum reimbursement of $900 for this system.

For prism (visual fields) awareness systems using Fresnel prisms (pronounced fre-NEL), V codes are used for the distance correction. Examples of the codes are as follows:

  • V2101, right eye single vision
  • V2101, left eye single vision
  • V2025, deluxe frame
  • V2784, polycarbonate lens (per lens)
  • V2718, Fresnel prism / OS (per lens)
  • V2718, Fresnel prism / OD (per lens)
  • V2714, tint (both lenses)
  • 92354, fitting fee

Additional Guidance: Team Effort Leads to Successful Low-Vision Services

Discovering what works visually for a customer is a collaborative undertaking of multiple parties: the customer, the low-vision specialist, the customer's regular eye doctor, and VR staff. Shared communication is particularly important with low-vision services because the desired outcome of enhanced visual functioning is subjective in nature, and ultimately, success relies on the feedback from each customer.

If a customer is being followed by an ophthalmologist, the VR counselor confirms that no medical factors exist that might negate referral for low-vision services. The VR counselor links the low-vision specialist with the customer's ophthalmologist and requests that reports and recommendations be shared with the medical doctor.

Visual deficits such as progressive conditions and fluctuating loss of vision (for example, caused by diabetic retinopathy), diplopia (double vision), hemianopsia (visual field losses), and severe photophobia (light sensitivity) can complicate visual functioning and the customer's success with optical devices. However, these factors do not negate the need for low-vision services relevant to the customer's functional problems.

C-703-15: Functional Capacity Assessment

A functional capacity assessment (FCA) is a comprehensive series of physical tests to determine a customer's ability to perform such functional tasks as walking, lifting, and stooping.

In most cases, an FCA is not required to determine the presence of an impairment and eligibility for services. Existing medical records should be used when possible. An FCA may be necessary at the completion of a physical restoration service to determine objectively a customer's physical capability to return to a specific job or achieve a specific employment goal.

To purchase a FCA, the VR counselor:

  • obtains a prescription from the customer's physician or evaluating specialist; and
  • verifies that the physician has provided medical care or evaluation of the customer within the past three months.

A licensed physical therapist, occupational therapist, or chiropractor must supervise the assessment directly. The assessment must include:

  • a range of motion evaluation;
  • a strength evaluation; and
  • an endurance evaluation.

The licensed physical therapist, occupational therapist, or chiropractor completing the assessment must report the results of the FCA to the prescribing physician or evaluating specialist and the VR counselor. If needed, the VR counselor consults with the prescribing physician if the customer's safe work-capacity and work restrictions are unclear. The treating doctor who prescribed the FCA can review FCA report and communicate a release to work for final work restrictions. An FCA evaluation report is not a release to work.

C-703-16: Gym Memberships and Home Exercise Equipment

Because of the potential risk of injury during unsupervised exercise, VR does not purchase gym memberships or home exercise equipment, including home equipment for water therapy or strengthening.

C-703-17: Home Health Care Services

Providers of home health care must be licensed by the Texas Department of State Health Services.

Home health care that exceeds 30 sessions requires VR Supervisor approval.

Note: This policy does not apply to rehabilitation technology education services provided in the home.

Home health care services may be provided following VR-sponsored surgery if the following criteria are met:

  • The customer is homebound or finds that leaving home requires considerable effort to go to the postoperative office visits and/or rehabilitative therapy.
  • A physician order identifies the need for home health care.
  • Home health care services are the best value to VR.

C-703-26: Rehabilitative Therapies, Outpatient Services has information about limitations.

C-703-18: Intercurrent Illness

When a short-term illness or condition hinders VR services, the VR counselor provides acute medical care as necessary. This supplemental service is limited to such acute conditions as:

  • infections or abscesses;
  • pneumonia;
  • appendicitis;
  • ectopic (tubal) pregnancy;
  • simple fractures; or
  • minor injuries.

These conditions usually are short-term and do not alter the existing IPE. They may be documented as supplemental services with a service justification case note.

C-703-19: Mammograms, Pap Tests, and Colonoscopy

VR does not purchase mammograms, Pap tests, and colonoscopies for general cancer screening. Mammograms may be purchased if required by the surgeon for VR-sponsored breast reduction surgery. A Pap test may be purchased if it is required by the surgeon for VR-sponsored gynecological surgery. A colonoscopy may be purchased if it is required by the surgeon for a related VR-sponsored surgery. In each instance, the sponsored corrective surgery must be likely, within a reasonable period, to correct or modify substantially a stable or slowly progressive impairment that constitutes a substantial impediment to employment.

C-703-20: Medical Assistive Devices and Supplies

Medically assistive devices and supplies may be purchased for a customer if the device or supplies are needed to meet the goals of the customer's VR program as set out in the IPE.

Before purchase, the VR counselor assesses and documents the following:

  • Functional need in line with VR goals
  • Expected functional improvement with device or technology
  • Duration of use
  • Issues related to use, such as compliance monitoring and maintenance
  • Best value option has resulted in the following:
    • A less expensive option has been ruled out
    • Rental versus purchase has been evaluated

Medical Devices with Unlisted MAPS

New medical devices are usually designated as "investigational" or "experimental" because of nonexistent or limited independent research showing that the device is safe and effective for its designated purpose. These items usually have unlisted MAPS codes. TWC does not authorize the use of investigational or experimental medical devices.

See VRSM D-200: Purchasing Goods and Services, D-210: Medical and Psychological Services (MAPS).

C-703-21: Orthoses and Prostheses

The VR counselor provides an orthosis or prosthesis to enhance a customer's employability or capability to perform activities of daily living that will facilitate employment.

Required Medical Examinations for Orthoses and Prostheses

For orthoses, a physician's examination is required before the purchase of an initial orthosis or if there is difficulty using the current orthosis.

For prostheses, an examination by a physician with a specialty in orthopedics or physical medicine and rehabilitation is required before the purchase of the first prosthesis.

If the customer has difficulty using his or her current prosthesis because of medical issues or problems with the residual limb, an orthopedic or physical medicine and rehabilitation specialist evaluation is required before planning the purchase of a second prosthesis. This specialty evaluation requirement for a prosthesis replacement does not apply to the following situations:

  • The fit and use of the current prosthesis is compromised by damaged prosthetic components.
  • A poor socket fit exists because of changes in weight or the normal physiologic changes that occur to the residual limb because of ambulation and activity with an initial prosthesis.

All providers of orthoses and prostheses must:

  • be currently licensed by the Texas Board of Orthotics and Prosthetics;
  • perform all measurements, fittings, alignments, and final checkouts;
  • fabricate or directly supervise the fabrication of these devices; and
  • provide final delivery and instructions for use.

Payments for orthoses or prostheses may not exceed MAPS.

If cost to VR for the prosthesis equals or exceeds $12,500 and the letter of specification contains no unlisted MAPS codes, then a University of Texas Southwestern (UTSW) technical review of the letter of specification is required.

If the letter of specification contains a prosthetic component with an unlisted MAPS code, then the component must be approved for purchase by the Central Office's Orthotic and Prosthetic Review Committee (OPRC) regardless of the cost.

An OPRC review is required even when the customer's comparable benefit is expected to pay for the major portion of the cost of the prosthesis or orthosis.

A letter of specification for a prosthetic that has an unlisted MAPS code does not require a secondary technical UTSW review.

If the L-code for a device or component is not listed in MAPS when the service record is generated, the OPRC must approve the purchase of the specialized device or component regardless of cost. OPRC approval for the purchase of a specialized device or component does not require an additional technical review by UTSW. Use the following procedures to submit a case to the OPRC for approval.

Procedure

Purchasing Orthoses and Prostheses

The VR counselor purchases the most basic orthotic or prosthetic device that allows a customer to meet his or her vocational needs. More technologically advanced devices or components may be purchased only if required by the customer's vocational needs as stated in the IPE. An orthosis or prosthesis is a medically prescribed item. The VR counselor is not required to obtain competitive bids. Payments for orthoses or prosthesis may not exceed MAPS.

See the Counselor Desk Reference, Purchasing Prostheses for guidance.

Orthoses include:

  • corsets;
  • orthopedic shoes;
  • braces; and
  • splints.

Prostheses include:

  • transhumeral (above elbow);
  • transradial (below elbow);
  • hand or fingers;
  • hip disarticulation (full leg);
  • transfemoral (above knee);
  • transtibial (below knee); and
  • foot or toes.

To purchase an orthosis or prosthesis for a customer, the VR counselor:

  • obtains a physician's written prescription (a prescription is not required for the repair or replacement of a prosthetic or orthotic component);
  • if purchasing a prosthesis, completes the DARS3601, Upper Extremity Amputation Checklist or the DARS3602, Lower Extremity Amputation Checklist and sends the identified section of the Checklist to the prosthetist for completion;
  • obtains a letter of specification from the orthotist/prosthetist that includes:
    • Healthcare Common Procedure Coding System (HCPCS) codes;
    • the number of units;
    • item descriptions; and
    • itemized charges;
  • obtains from the prosthetist or orthotist the medical or vocational justification for the components or devices selected. For a replacement, the VR counselor requests from the prosthetist or orthotist an identification of problems with the customer's current prosthesis or orthosis. The letter must describe the design and components of the current device fully. The letter must also:
    • identify problems that have limited the customer's ability to use the current device; and
    • explain the necessity and rationale of the proposed device;
  • develops a service record for a recommended orthosis or prosthesis using the letter of specification;
  • determines the need for a technical review of the letter of specification by the UTSW Medical Center Prosthetics—Orthotics Program or an approval by the VR OPRC for a specific component with an unlisted MAPS code; and
  • determines whether the cost to VR for the prosthesis equals or exceeds $12,500 and the letter of specification contains no unlisted MAPS codes. If both of those circumstances exist, a UTSW technical review of the letter of specification is required.

If the letter of specification contains a prosthetic component with an unlisted MAPS code, then the component must be approved for purchase by the OPRC, regardless of cost. An OPRC review is required even when the customer's comparable benefit is expected to pay for the major portion of the cost of the prosthesis or orthosis.

A letter of specification prosthetic that has an unlisted MAPS code does not require a secondary technical UTSW review.

Procedure for UTSW Technical Review

To submit a letter of specification for a prosthetic for UTSW review, the VR counselor:

  • uses the UTSW cover sheet, follows the instructions, and attaches required information; and
  • documents in RHW the need for the required review and the submission date of the cover sheet and required information.

Upon receipt of the UTSW technical review report, the VR counselor shares the report with the prescribing prosthetist.

The VR counselor:

  • discusses with the prosthetist the recommended changes to the letter of specification as identified by the UTSW review;
  • requests a revised letter of specification if the prosthetist agrees with the changes; and
  • states the reason in RHW if the UTSW recommendations are not followed.

The VR counselor issues a service authorization for fabrication of the orthosis or prosthesis and verifies receipt before payment.

If an amended letter of specification cannot be negotiated, the prosthetist may submit additional information and the VR counselor may request a UTSW follow-up review of the case. The additional information must be substantive and pertain specifically to the customer. It should not be generic information or the same information provided in the original documents. The VR counselor requests the UTSW follow-up review using the procedure outlined above at an additional cost. Only one follow-up review is allowed. Questions about the UTSW report should be directed to the program specialist for physical disability.

Procedure for Purchasing an Orthosis or Prosthesis with an Unlisted MAPS Code

If the L-code for a device or component is not listed in MAPS when the service record is generated, the OPRC must approve the purchase of the specialized device or component regardless of cost. OPRC approval for purchase of a specialized device or component does not require an additional technical review by UTSW. The VRC uses the following procedures to submit a case to the OPRC for approval.

The VR counselor:

  • prepares a packet using the OPRC cover sheet, follows the instructions, and attaches all required information;
  • documents in RHW the need for the required review and the submission date of the cover sheet and required information;
  • reviews the OPRC decision entered in a case note in RHW (The decision includes a review and report of the state prosthetic consultant and is based on the medical and/or vocational necessity of the component.);
  • gives the prosthetist a copy of the TWC state prosthetic consultant's report for review;
  • submits a request for another review if the VR counselor, prosthetist, or orthotist has additional pertinent information that might affect the OPRC decision;
  • contacts Medical Services to issue a service authorization for the fabrication of the orthosis or prosthesis if the component is approved by OPRC; and
  • verifies the receipt of orthosis or prosthesis before payment.

Functional Electrical Stimulation Devices

Purchase of functional electrical stimulation (FES) for walking is limited to customers with spinal cord injury who have met the clinical criteria and have received approval of the medical director.

The VR counselor selects the most basic orthotic device that allows the customer to perform his or her tasks in the work environment. VR may consider the purchase of lower extremity FES devices (for example, the Bioness L300 or the WalkAide) only for customers:

  • who have spinal cord injuries that meet specific clinical criteria in accordance with Centers for Medicare and Medicaid Services guidelines and who have had their cases reviewed and approved by the VR medical director;
  • who can demonstrate a clear vocational need for the FES devices as compared to ambulation with an ankle foot orthosis or a knee ankle foot orthosis;
  • who can demonstrate the ability to provide for the monthly maintenance and needed supplies; and
  • whose case favors best value purchasing.

To request approval of an FES device for a VR customer with spinal cord injury, the VR counselor:

  • consults with the Central Office program specialist for physical disabilities about the clinical criteria; and
  • submits a courtesy case to vr.medicalservices@twc.state.tx.us for the medical director to review.

Managers may not make exceptions to any part of the FES devices policy.

Warranties, Repair, and Maintenance of Orthoses and Prostheses

The provider agrees to replace, without cost to VR, defective parts and materials within 90 days of the customer's receiving the completed orthosis or prosthesis, excluding:

  • evidence that the device or component has been altered by anyone other than the provider; or
  • changes in the customer's condition that affect use of the device.

Manufacture Warranty

Policy

When an orthosis or prosthesis requires repair, the VR counselor determines whether any of the repair cost and/or component replacement cost is covered by warranty before using VR funds. The provider must honor the manufacturer warranties and pay all costs associated with warranty replacement.

Extended Warranty

The customer must pay all costs associated with extended warranties.

Maintenance

Policy

Before the purchase of an orthosis or prosthesis, the VR counselor discusses with the customer his or her responsibility to maintain, repair, and/or replace the orthosis or prosthesis. The VR counselor must discuss with the customer issues pertaining to specific maintenance costs of advanced technological components, such as the microprocessor knee unit.

Repair

Policy

The VR counselor authorizes repair of the current orthosis or prosthesis unless the repair cost is more than 60 percent of the replacement cost. A prosthetist must submit the manufacturer's written repair estimate for advanced technological components, such as a microprocessor knee unit.

Labor charges are calculated at prevailing hourly rates for individual providers and must not exceed $50 per hour.

Gait Training

Policy

The VR counselor purchases gait training for a customer with an above-knee prosthesis if the customer:

  • has not used a prosthesis previously;
  • will have a prosthesis that is different from the customer's previous prosthesis; or
  • has not used a prosthesis for a prolonged period.

A prosthetist may provide training in the use of a below-knee prosthesis. If the prosthetist recommends additional training, the VR counselor arranges for prosthetic training from a qualified physical or occupational therapist.

A qualified physical or occupational therapist also may provide training in the use of an upper-extremity prosthesis.

C-703-22: Osteomyelitis of the Extremities

Policy

Osteomyelitis is a bone infection that can cause an unstable medical condition with an uncertain prognosis. This condition may require complicated and extensive medical treatment.

VR considers sponsoring medical treatment for osteomyelitis only when:

  • amputation of an extremity is recommended as a curative treatment; or
  • the osteomyelitis condition occurs as a complication of a VR-sponsored surgery and the treatment is approved by the VR Supervisor and VR medical director.

Exceptions require review by the medical director and approval by the VR Supervisor before VR-sponsored treatment for osteomyelitis is included in a customer's IPE.

C-703-23: Pain Treatment

Pain treatment may be purchased on a short-term basis only to improve a customer's functional ability that is necessary to achieve a well-defined employment goal set out in the customer's IPE. Since VR does not sponsor long-term medical treatment for chronic medical conditions, the VR counselor informs the customer that long-term pain treatment must be provided by comparable benefits or by the customer.

When a customer reports functional limitations related to chronic pain, the VR counselor:

  • considers an orthopedic, neurological, or physical medicine and rehabilitation evaluation to determine whether the pain source can be treated with conventional physical restoration services;
  • considers a functional capacity assessment followed by job placement services if no physical restoration treatment options exist and the customer wants to work despite the pain;
  • screens for and coordinates treatment for comorbid psychological diagnoses; and
  • obtains information from the physician about pain medication use and potential safety risks.

The VR counselor refers the customer to available comparable benefits to meet long-term treatment needs.

C-703-24: Prescription Drugs and Medical Supplies

VR purchases medication that is prescribed to treat a specific diagnosis or condition for no more than three months. For any additional medication purchases an approval of the VR Supervisor must be entered into RHW. VR is the payer of last resort.

Comparable benefits (B-310-5) and required customer participation in cost of services (B-310-6) must be applied before VR funds are expended.

Because VR uses tax revenue for case service expenditures, the division must purchase the least expensive services that meet the customer's vocational needs. For more information, see the requirements in D-203-1: Best Value Purchasing.

Customers must be referred to a comparable benefit program that includes prescription assistance at the time the purchase of the prescription is authorized.

Documentation of the referral must be included in the case file.

The customer's status and progress towards accessing comparable benefits to meet ongoing medication needs must be monitored.

Note: When a customer is discharged from a medical rehabilitation facility or hospital that has an in-house pharmacy, VR may pay for a 30-day supply of the prescription drugs and medical supplies provided to the customer.

C-703-25: Procedures for Pregnant Customers

VR does not pay for medical services related to pregnancy.

The VR counselor assists the customer with child care planning to ensure her successful participation in the VR program.

C-703-26: Rehabilitative Therapies

Rehabilitative therapies are physical restoration services that may be provided as a primary service or following other physical restoration services, such as surgery or injections.

To purchase a rehabilitative therapy, the VR counselor:

  • obtains a prescription from the treating physician;
  • provides the therapist with the vocational goal;
  • monitors the customer's attendance and compliance with therapy; and
  • assesses the functional improvement for the customer at the completion of the prescribed period of therapy.

If an extension of treatment is requested, the VR counselor:

  • assesses and documents the customer's progress to date and potential for continued progress;
  • documents how the additional requested therapy sessions are expected to contribute to achieving the employment goal; and
  • obtains VR Supervisor approval for therapy exceeding 30 sessions or charges exceeding four units per session

Note: The 30-session limit for the life of the case applies to each individual therapy and not a combined number of therapies.

Outpatient Services

Outpatient services may include:

  • physician visits; and
  • nutritional services, when prescribed by a physician.

If the service provider requests an extension of treatment beyond the initial recommendation, the VR counselor assesses the customer's potential for continued progress. The assessment might involve reviewing treatment progress notes and/or contacting the physician, LMC, and/or provider. If continuing treatment is appropriate, the VR counselor:

  • documents in the case file how continued services are expected to contribute to achieving the employment goal;
  • may approve up to 30 visits or therapy sessions; and
  • obtains the manager's approval for extending treatment beyond 30 visits or therapy sessions.

Physical Therapy

Physical therapy is used to improve coordination, strength, and range of motion. This type of therapy:

  • may be provided as work hardening and conditioning;
  • is provided in 15-minute units of service (Multiple units make up one session.); and
  • must be provided by a licensed physical therapist.

Note: A licensed physical therapist must evaluate the customer and develop the treatment plan. However, a licensed physical therapy assistant may work with a customer under the supervision of a licensed physical therapist.

Occupational Therapy

Occupational therapy improves the ability to perform activities of daily living, independent living, and work to achieve the goals of the IPE. This type of therapy:

  • is provided in 15-minute units of service;
  • has a single session comprising multiple units; and
  • must be provided by a licensed occupational therapist.

Note: A licensed occupational therapist must evaluate the customer and develop the treatment plan; however, a licensed occupational therapy assistant may work with a customer under the supervision of a licensed occupational therapist.

Speech Therapy

Speech therapy improves expressive and receptive speech, auditory processing, and evaluation and training in the use of speech amplification devices. Speech therapy:

  • is provided as one unit of the service per session (No time limit exists for a session.); and
  • must be provided by a licensed speech and language pathologist.

Cognitive Therapy

Cognitive therapy improves memory, attention, social interaction, executive functions, visuospatial deficits, aphasia, and apraxia. Each therapy bills separately. Cognitive therapy must be provided by the following licensed providers:

  • licensed psychiatrist or neuropsychiatrist;
  • licensed psychologist or neuropsychologist;
  • licensed occupational therapist; and/or
  • licensed speech and language pathologist.

C-703-27: Surgery for Morbid Obesity

A customer is considered morbidly (severely) obese when his or her body mass index (BMI) is 40 or more. Morbid obesity is a disability if it results in an impediment to employment. Before considering bariatric surgery as a service for a morbidly obese customer, identify and document the customer's specific and substantial impediment to employment.

Procedure for Determining whether Morbid Obesity Results in a Substantial Impediment to Employment

To determine whether a customer has a substantial impediment to employment related to morbid obesity, the VR counselor uses the following assessment procedure:

  1. Obtain documentation from a physician that shows the customer's height and weight and verify that the customer has a BMI of 40 or more;
  2. Purchase an FCA to evaluate the customer's functional capabilities and accurately measure the customer's work capacity;
  3. If the customer is employed, purchase a job analysis to determine the functional requirements of the customer's job and review the FCA and job analysis to determine whether the customer can perform the critical tasks of the job. If the customer can perform the critical tasks of the job, with or without a reasonable accommodation, there is no substantial impediment to employment related to severe obesity; and
  4. If the customer is unemployed, use the results of the FCA to determine whether the customer can meet the physical demands of the job goal as defined in O*NET or an equivalent resource. If the customer can perform the critical job tasks of the chosen realistic job goal, there is no substantial impediment to employment related to morbid obesity.

Nonsurgical Alternatives to Bariatric Surgery

Because VR uses tax revenue for case service expenditures, the division must purchase the least expensive alternative that meets the functional needs of the customer.

If a customer has a substantial impediment to employment related to morbid obesity, the VR counselor first determines whether any of the following nonsurgical options will remove the customer's substantial impediment to employment:

  • Workplace modification
  • Reasonable accommodation
  • Assistive device
  • Nutritional counseling
  • Weight loss treatment (50–60 pounds in a six-month program)

Note: Before the VR counselor considers corrective surgery or therapeutic treatment, he or she must document that the surgery or treatment is likely, within a reasonable period, to correct or modify substantially the customer's impairment that is a substantial impediment to employment.

Procedure for Requesting Approval for Bariatric Surgery

If nonsurgical services will not remove the substantial impediment to employment, the VR counselor uses the following procedure to request approval to purchase bariatric surgery for a customer:

  1. Obtains clearance for bariatric surgery and documentation of the medical stability of the customer's other conditions from a primary care physician or internal medicine specialist.
  2. Arranges for a psychological or psychiatric evaluation with a bariatric focus that includes:
    • the Minnesota Multiphasic Personality Inventory (MMPI);
    • questions to the psychologist to determine the customer's motivation, family support, life stressors, coping ability, realistic expectations, and the presence of mental health diagnoses that may interfere with successful dietary compliance and weight loss; and
    • the need for medication management or psychological counseling to treat the underlying mental health condition (for example, anxiety or depression) that may interfere with successful dietary compliance and healthy lifestyle changes.
  3. Refers the customer to an experienced bariatric surgeon for evaluation. Uses a bariatric surgeon affiliated with a bariatric center accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program if available. https://www.facs.org/search/bariatric-surgery-centers.
  4. Instructs the LMC to review the customer's case.
  5. If the bariatric surgeon and the LMC determine that the customer is an appropriate candidate for surgery, provides documentation for the customer's file that the customer successfully participated in a prebariatric surgery multidisciplinary program for at least three months.

Prebariatric Surgery Multidisciplinary Program

The purpose of a prebariatric surgery multidisciplinary program is to evaluate the customer's motivation to make lifestyle changes and comply with necessary dietary restrictions. The multidisciplinary program must have these four components: medical management, nutrition, behavioral modification counseling, and exercise components. If the bariatric surgeon has a prebariatric surgery program, the VR counselor verifies that the program has the four required components. The VR counselor coordinates and purchases missing components or creates a multidisciplinary program that uses independent providers. Refer to Tips for Creating a Multidisciplinary Prebariatric or Weight-Loss Program with Independent Providers (DOC). If the customer participates in a prebariatric surgery multidisciplinary program, the VR counselor must:

  • monitor the customer's progress in the program;
  • set appropriate expectations with the customer for participation, responsibilities, attendance, and goal attainment;
  • discuss with the customer the consequences for noncompliance with the program;
  • obtain monthly progress reports from providers or use the Prebariatric Surgery Program Progress Report; and
  • if the customer successfully completes the prebariatric surgery multidisciplinary program, obtain final approval for the bariatric surgery from the VR Manager and  medical director.

Postbariatric Surgery Case Management

Following bariatric surgery, the VR counselor:

  • identifies the medical provider that is responsible for monitoring the customer's nutritional status and weight loss after surgery;
  • verifies that the customer understands and accepts responsibility for complying with the postsurgical treatment plan; and
  • monitors the customer's compliance with postsurgical instructions, dietary restrictions, and progress with weight loss.

Panniculectomy

Surgery to remove excess skin following weight loss (panniculectomy) is not a part of bariatric surgery services. A specific and separate impediment to employment must be established for VR to pay for a panniculectomy.

C-703-28: Skilled Nursing Facility Services

Skilled nursing facilities services may be provided following VR-sponsored surgery if the following criteria are met:

  • The customer's medical condition or lack of home care resources do not allow the customer to be discharged home.
  • The physician's order identifies the need and that medical services cannot be provided by home health care services.
  • Skilled nursing facility services are the best value to VR.

Skilled nursing facilities must meet the provider qualifications stated in VRSM D-200: Purchasing Goods and Services.

The VR counselor alerts the medical services coordinator at the time of physical restoration service coordination if the customer does not have adequate care resources following hospital or facility discharge.

C-703-29: Spinal Cord Stimulator or Dorsal Column Stimulator

A spinal cord or dorsal column stimulator should be considered for chronic intractable pain when other treatment options have failed to provide adequate pain relief. If a spinal cord or dorsal column stimulator is recommended by the customer's treating physician, the VR counselor:

  • obtains a psychological evaluation and has the report reviewed by the treating physician;
  • obtains medical director approval to proceed with trial placement; and
  • if the trial placement is successful in reducing the customer's pain, proceeds with the permanent placement of the spinal cord or dorsal column stimulator.

C-703-30: Weight-Loss Treatment

VR sponsors weight-loss treatment for a customer under the following conditions:

  • The customer has a BMI of 30 or more.
  • The customer must lose 50 to 60 pounds in a six-month period.
  • The reason for the recommended weight loss is:
    • to improve function or lessen the substantial vocational impediment caused by the primary disability;
    • to meet the surgeon's weight-loss requirement before surgery; or
    • to remove the substantial impediment to employment for a customer with severe (morbid) obesity when the loss of 50 to 60 pounds will remove the impediment.

Note: Obesity is not considered a primary disability unless the customer has a BMI of 40 or more, which meets the definition of morbid obesity.

To purchase weight-loss treatment for a customer, the VR counselor:

  • verifies that the customer's BMI is 30 or greater;
  • documents in RHW the reason that a weight-loss program is necessary;
  • obtains a referral for weight-loss treatment from the customer's primary physician;
  • obtains a psychological evaluation assessing motivation, family support, life stressors, coping ability, and realistic expectations to achieve and maintain weight loss. The psychological battery should include an MMPI;
  • if the customer has underlying psychological diagnoses, such as anxiety and/or depression, ensure that the customer's psychological issues are being addressed through treatment before the start of the weight-loss program.

Weight-loss treatment must be multidisciplinary and include:

  • medical supervision;
  • nutritional education;
  • psychological support and behavior modification; and
  • an exercise program.

Weight-loss treatment can be provided by an established weight-loss program or by independent providers forming a multidisciplinary team. If an established weight-loss program does not have the four required components, the VR counselor provides the missing component services by using independent service providers.

Note: If the customer is participating in a fasting program, a physician must see the customer weekly, and regular laboratory studies are required.

Refer to Tips for Creating a Multidisciplinary Pre-Bariatric or Weight Loss Program with Independent Providers (DOC).

The LMC must review all weight loss plans. The VR medical director must approve all weight-loss treatments before the service begins.

For more information, see RPM Chapter 19: Technical Information and References, Required Approvals and/or Consultations.

The VR counselor contacts the VR Central Office program specialist for physical restoration for services not listed in MAPS.

The VR counselor provides counseling and guidance on the following issues and documents the conversations in RHW:

  • The expectation of customer attendance and participation in weight-loss treatment
  • The expectation that the customer will meet realistic weight-loss goals during treatment
  • The consequences for noncompliance and the possible termination of treatment

The VR counselor must:

  • monitor the customer's progress in treatment closely by getting monthly progress reports (the service provider may submit a report or use the DARS3510, Weight-Loss Progress Report); and
  • provide counseling as needed to promote a positive weight-loss outcome.

C-703-31: Wound Care

The VR counselor considers services for wound care that is a result of a surgery only when it is directly associated with a VR-sponsored surgery. The VR counselor discusses with the treating surgeon whether intervention is needed urgently. If it is not, the VR counselor requests that the LMC review the case on a priority basis. The VR counselor informs the LMC, the VR Supervisor, the medical services coordinator, and the program specialist for physical disabilities of the status of the case, but does not delay services needed to promote the healing of the wound.

C-703-32: Specialized Physical Restoration Programs

Fees for Specialized Programs

For review and consideration of potential sponsorship and subsequent fee negotiation, the VR counselor provides information on specific services not otherwise described below to the TWC-VR Central Office program specialist for physical restoration.

Cardiac Rehabilitation Facilities

For VR to sponsor services in a cardiac rehabilitation facility, the customer's physician must refer the customer to that facility.

A cardiac rehabilitation facility must meet the following criteria:

  • Supervision by a cardiologist
  • For each participant, an individualized, structured, progressive exercise program defined by a physician
  • Continuous customer monitoring during exercise
  • A physician must be available during exercise sessions
  • A summary report with recommendations to the referring physician and to the VR counselor

Rehabilitation Hospital Programs Procedure

Rehabilitation hospital programs provide a coordinated and integrated service package that can include:

  • medical supervision and treatment;
  • physical and occupational therapy;
  • prescription of prosthetic and/or orthotic appliances;
  • psychological, social, and other services; and
  • patient education.

Some programs also offer the following services:

  • Driver education and training
  • Vocational evaluation and/or vocational counseling
  • Rehabilitation engineering

These are appropriate prevocational services for many customers with the most significant disabilities (for example, spinal cord injuries). For information on providing these services, see Back Disorders in B-308-1: Required Assessments and Policies for Selected Conditions.

The VR counselor confirms through a review of medical documentation that the customer is medically stable and that such medical complications as substantial decubitus ulcers, severe respiratory infection, and severe urinary tract infections have been treated successfully to allow the customer to participate fully in a comprehensive rehabilitation program. Refer to VRSM D-221: Health Care Professionals — Required Qualifications for criteria that apply to inpatient rehabilitation facilities.

C-703-33: Post-Acute Brain Injury Rehabilitation

Post-Acute Brain Injury (PABI) services are provided as recommended by an interdisciplinary team to address deficits in functional and cognitive skills based on individualized assessed needs. Services may include behavior management, the development of coping skills, and compensatory strategies. These services may be provided in a residential or nonresidential setting.

Services are based on an assessment of the individual's assessed deficits. The goal of PABI services for VR customers is to establish new patterns of cognitive activity as well as compensatory mechanisms to achieve a specific employment outcome.

Duration of Post-Acute Brain Injury Services

PABI services are not limited by the time that has passed since the traumatic brain injury (TBI) occurred.

The 180-day limit on post-acute rehabilitation services is measured from the first day of services sponsored. Post-acute rehabilitation services are indicated on the IPE "up to 30 days of service" and may be extended to a maximum of 180 days without an IPE amendment when recommended by the interdisciplinary team.

When a post-acute rehabilitation facility divides its program into two phases and releases the customer for a period before bringing the customer back to complete the program, VR may sponsor both periods of PABI services up to a cumulative total of 180 days.

When considering residential PABI services, the VR counselor must consult with the Central Office program specialist for physical disabilities. The VR counselor must have approval from the Central Office program specialist for physical disabilities before including residential PABI as a purchased service on an IPE or IPE amendment.

The MSC or medical services technician (MST) must issue all service authorizations for residential PABI services.

Procedure

When referring a customer to PABI, the VR counselor sends a packet to the MSC. The procedure for the MSC or MST to coordinate residential or nonresidential PABI services for eligible VR customers is as follows.

MSC or MST Contacts the PABI Facility

  • The MSC or MST verifies receipt of required physician orders for residential or nonresidential services and verifies that the facility has completed an assessment confirming that the customer is appropriate for facility services.
  • The MSC or MST verifies comparable benefits, if applicable, with the PABI facility representative to include the specific benefit coverage for PABI services and the expected customer portion of the cost and documents information and the source of information in a contact note.
  • If the comparable benefit requires preauthorization for PABI services, the MSC or MST verifies that the PABI services were approved and places documentation of approval in the case file.
  • The MSC or MST reviews TWC-VR payment policies and limitations, and determines whether customer medical records must be faxed or mailed to the facility and prescriptions updated.

The MSC or MST Creates Service Records

Residential PABI services are paid using a daily contract rate. Nonresidential services are paid using an hourly rate. The MSC or MST refers to the specific PABI facility contract for the payment rate and creates service records for all anticipated services, such as:

  • PABI facility services (per contract); and
  • physician consultations (MAPS);

    Note: Routine medical management is included in the daily contract rate. The VR counselor refers to the VR Standards for Providers Manual.

  • Medications (at cost if purchased from an outside pharmacy—prescription is required);
  • Individual therapies at a PABI facility (MAPS); and
  • Neuropsychological evaluation (MAPS).

    Note: If the facility is also a hospital and has a pharmacy, medications should be purchased through the hospital contract rate.

When the Customer Has Verified Comparable Benefits

If the customer has comparable benefits that have been verified, the MSC or MST creates service records using the customer portion not covered by the comparable benefit as the cost for the service. The customer portion amount cannot exceed the hospital contract rate or the MAPS rate for the ancillary service, whichever is applicable.

If the customer's comparable benefits have not been verified, the MSC or MST creates service records as if the customer does not have any comparable benefits.

  1. The MSC or MST contacts the counselor.
    • The MSC or MST provides an estimate of the total cost for requested service(s) and anticipated ancillary services.
    • The MSC or MST obtain counselor approval of encumbrance and documents contact and approval in a case note
  2. The MSC or MST contacts a PABI facility representative.
    • The MSC or MST obtains the admission or start date and advises the PABI facility representative that purchase order(s) will be mailed or faxed.
    • The MSC or MST obtains preadmission instructions for the customer and documents the contact in a case note.
  3. The MSC or MST issues purchase orders and sends a copy of the purchase orders to the PABI facility and ancillary service providers.
    • The MSC or MST reviews the service records to confirm that information is correct and to ensure that accurate purchase orders will be generated.
    • The MSC or MST issues purchase orders for planned service and all anticipated ancillary services. If comparable benefits are verified, the MSC or MST notes the specific comparable benefit in the Payment or Special Instructions section of the purchase order and requests a copy of the Explanation of Benefits with the invoice for payment. If comparable benefit coverage cannot be established before issuing the purchase order, the MSC or MST notes the reported comparable benefit in the Payment or Special Instructions section of the purchase order and alerts the provider of possible benefit coverage.
    • The MSC or MST issues a purchase order for an initial period of 90 days and extends PABI services in 30-day increments (or less if fewer than 30 days are needed to complete the program). Because of the length of the program, the purchase order has multiple line items corresponding to the facility's billing cycle and interim invoices.
    • The MSC or MST faxes or mails the purchase orders to the PABI facility and ancillary service providers, if applicable.
  4. The MSC or MST contacts the customer to coordinate the admission or start date of PABI services.
    1. The MSC or MST contacts the customer and/or family by phone or letter to notify the customer of the admission or start date or to request that the customer and/or family schedule the admission and/or start date and notify the MSC or MST.
    2. The MSC or MST verifies whether the customer has received special instructions from the PABI facility.
    3. The MSC or MST notifies the VR counselor of the customer's PABI admission or start date and of special instructions from the PABI facility.
    4. The MSC or MST sends a letter to the customer and/or family (if needed) with the facility admission or start date and includes additional instructions.
    5. The MSC or MST documents the information in a case note.
  5. The MSC or MST contacts the PABI facility.
    • The MSC or MST contacts the PABI facility representative within two days after the scheduled admission or start date to confirm that the customer started services.
    • The MSC or MST ensures that the PABI facility representative knows to contact the MSC or MST if the customer misses more than two days of PABI services.
    • The MSC or MST follows up with the PABI facility to obtain the treatment plan and monthly staffing progress reports.
    • The MSC or MST contacts the hospital case manager before the date of expected discharge to identify medical needs for the customer: supplies, durable medical equipment, and medication for the first two weeks following facility discharge for an in-region case or for the first 30 days if an out-of-region case.
  6. The MSC or MST contacts the VR counselor.
    • The MSC or MST notifies the VR counselor when the customer is discharged and of medical needs that the MSC or MST will coordinate. The MSC or MST obtains approval for encumbrances and documents the approval in a case note.
    • When medical records are received, the MSC or MST forwards them to the VR counselor.
    • The MSC or MST notifies the VR counselor and the home MSC, if applicable, when the case is returned to the VR counselor and/or rehabilitation services technician or home MSC. The VR counselor discusses additional case coordination needs with the MSC or MST.

For more information about PABI services, see the VR Standards for Providers Chapter 21: Standards for Post-acute Brain Injury (PABI) Service Providers. Providers of PABI services must adhere to all details stated in that chapter.

Post-Acute Brain Injury Service Array

Post-Acute Brain Injury Residential Services

A detailed list of post-acute brain injury residential services includes:

Residential Core Services

Service Delivery Modality

Provider Qualifications

Aquatic Therapy

Individual and Group

LP

Art Therapy

Individual and Group

LP

Behavior Management

Individual

LP or CP

Case Management

Individual

CP

Chemical Dependency

Individual and Group

LP

Cognitive Rehabilitation Therapy (CRT)

Individual and Group

LP

Dietary Nutritional Services

Individual and Group

LP

Massage Therapy

Individual

LP

Medical Services

Individual

LP

Mental Restoration

Individual and Group

LP

Music Therapy

Individual and Group

CP

Neuropsychiatric Services

Individual and Group

LP

Neuropsychological Services

Individual and Group

LP

Occupational Therapy

Individual and Group

LP or CP

Personal Assistance

Individual and Group

PP

Physical Therapy

Individual and Group

LP or CP

Recreational Therapy

Individual and Group

CP

Room and Board

Individual

Qualifications not stipulated

Speech and Language Pathology

Individual and Group

LP or CP

 

Residential Ancillary Services

Service Delivery Modality

Provider Qualifications

Audiology

Individual

LP

Durable Medical Equipment and Supplies

Individual

Qualifications not stipulated

Family Therapy

Individual and Group

LP

Family and/or Caregiver Education and Training

Individual and Group

LP or CP

Home Modification

Individual

LP

Limited Skilled Nursing

Individual

LP

Orthosis/Prosthesis

Individual

LP

Over-the-Counter Medications

Individual

Qualifications not stipulated

Physical Restoration

Individual

LP

Prescription Medications

Individual

LP

Rehabilitation Technology

Individual

LP, other professionals

Transportation

Individual

Qualifications not stipulated

Post-Acute Brain Injury Nonresidential Services

A detailed list of post-acute brain injury nonresidential services includes:

Nonresidential Core Services

Service Delivery Modality

Provider Qualifications

Aquatic Therapy

Individual and Group

LP

Art Therapy

Individual and Group

LP

Behavior Management

Individual

LP or CP

Case Management

Individual

CP

Chemical Dependency

Individual and Group

LP

Cognitive Rehabilitation Therapy (CRT)

Individual and Group

LP

Dietary Nutritional Services

Individual and Group

LP

Massage Therapy

Individual

LP

Mental Restoration

Individual and Group

LP

Music Therapy

Individual and Group

CP

Neuropsychiatric Services

Individual and Group

LP

Neuropsychological Services

Individual and Group

LP

Occupational Therapy

Individual and Group

LP or CP

Physical Therapy

Individual and Group

LP or CP

Recreational Therapy

Individual and Group

CP

Speech and Language Pathology

Individual and Group

LP or CP

 

Nonresidential Ancillary Services

Service Delivery Modality

Provider Qualifications

Audiology

Individual

LP

Durable Medical Equipment and Supplies

Individual

LP or CP

Family Therapy

Individual and Group

LP

Family and/or Caregiver Education and Training

Individual and Group

LP or CP

Home Modification

Individual

LP

Limited Skilled Nursing

Individual

LP

Orthosis and Prosthesis

Individual

LP

Over-the-Counter Medications

Individual

Qualifications not stipulated

Personal Attendant Care

Individual

PP

Physical Restoration

Individual

LP

Prescription Medications

Individual

LP

Rehabilitation Technology

Individual

LP, other professionals

Transportation

Individual

Qualifications not stipulated

Vision Services

Individual

LP

Exceptions to Service Array

Should services be medically necessary for rehabilitation purposes (that is, not for medical emergencies) but are not included as a core or ancillary service, a formal request process must be followed before services may be provided to VR customers.

Step

Issue

Notes

1

The Interdisciplinary Team (IDT) or medical expert identifies a need for a service and/or therapy that is not offered in the service array.

Identification of service and/or therapy needed for rehabilitation purposes is based on the medical assessment.

2

The IDT or medical expert sends a request for the service to the VR counselor.

The request for service must include supporting medical documentation and assessments to explain the necessity of the service and/or therapy and the proposed billing codes (for example, CPT or HCPCS rates) that will be used for billing purposes.

If additional information is needed for decision making purposes, the VR counselor contacts the facility.

3

The VR counselor sends an email to his or her chain of command and Central Office with the following information:

  • Customer name
  • Customer ID
  • Customer injury
  • Recommended therapy
  • Medical needs
  • Associated CPT, MAPS, or HCPCS codes

The Central Office includes the program specialist for physical disabilities, the program manager, and the administrative assistant.

The chain of command includes the VR Manager or staff acting on behalf of The VR Manager.

4

The VR counselor and the manager determine whether the service is appropriate and medically necessary.

The VR counselor and the VR Manager consider all information related to the customer to determine whether the service is necessary.

If the service is not appropriate or medically necessary, the service is denied by the VR counselor and manager. The VR counselor communicates this decision to the facility and central office. A case note must be entered to document the reason for denial.

If the service is appropriate and medically necessary, the VR counselor and the manager seek approval from chain of command.

5

The VR counselor sends a request to review and approve the proposed service to regional management.

 

6

Regional management reviews the request and determines whether the service is appropriate.

If the service is determined appropriate and medically necessary, an email indicating approval by the manager and regional management is sent to the Central Office requesting final review and approval.
If the service is not appropriate or medically necessary, the VR counselor and VR Manager deny the service. The VR counselor communicates this decision to the facility and Central Office.

7

Central Office reviews the service and determines whether it is appropriate to provide the service to the customer.

Note: If more information is needed to decide, the VR counselor must obtain the information at the request of Central Office.

8

Upon determining whether the service is approved or not approved, the VR counselor communicates the decision to the facility.

The VR counselor provides answers to questions about the decision. If the facility disagrees with the decision, the appeals process must be implemented.

9

An approved service requires a completed DARS3472, Contracted Service Modification.

The DARS3472 must be signed by the Regional Director or VR Division Director.

10

The VR counselor issues a service authorization for services.

All the steps above must be completed before issuing a service authorization.

C-703-34: Diabetes Self-Management Services

Considerations in Vocational Rehabilitation

When writing a plan for someone with diabetes, the VR counselor should consider several factors. First, it is important to maintain medical control of the diabetes through healthful diet, exercise, weight management, and use of medications. Therefore, these factors are key pieces of the rehabilitation plan.

A customer might need a flexible work schedule with frequent breaks to accommodate snacks and meals as well as insulin injections that are necessary to maintain proper blood sugar levels. Frequent breaks also may be needed to accommodate common functional limitations, such as low stamina. When discussing job options, the VR counselor and customer should not consider jobs with irregular hours, long hours of work without breaks, and irregular physical exertion. Also, when discussing possible jobs, the VR counselor and customer should remember that the long-term complications of diabetes might not be visible for many years. A good rehabilitation plan takes these factors into consideration.

When the customer is deciding on an employment goal, the VR counselor should ask him or her to answer the following questions:

  • Am I able to do the job with my current functional limitations?
  • How will potential problems such as loss of vision, amputation, and kidney dysfunction affect my ability to perform on the job?
  • Are there ways to accommodate these problems to allow me to do my job?
  • Are there other jobs with the same employer that could be accommodated for my limitations?
  • Will this job give me transferable skills that I need to find a closely related job that will accommodate my limitations?
  • Does my employer know about long-term complications related to diabetes?
  • Am I prepared for future complications? (Being prepared for future complications and how they might affect employment will help customers to select appropriate vocational goals as well as prepare them to develop confidence, competence, and independence.)

Customers with diabetes may have functional limitations in the areas of:

  • physical stamina and endurance;
  • standing and walking;
  • motor coordination;
  • manual and finger dexterity; and
  • concentration.

Treatment and Management Options

The goal of treatment is to keep blood glucose near normal levels. Treatment may include following a carefully calculated diet, exercising, testing blood glucose levels, and having daily insulin injections.

Complications of Diabetes

Diabetes can have several complications, including:

  • blindness;
  • heart disease;
  • high blood pressure and stroke;
  • kidney disease;
  • nervous system disease;
  • amputations; and
  • dental disease.

Adaptive Diabetes Equipment and Supplies

Policy

To maintain consistency and to ensure that the VR counselor has a thorough working knowledge of adaptive diabetes equipment, the VR counselor must obtain a written recommendation before purchasing adaptive equipment. The recommendation also must include who is to provide training on the equipment.

The diabetes educator, a physician, or the VR diabetes program specialist can provide the recommendation.

Training on Blood Glucose Meter and Insulin Drawing Devices

Policy

The customer can receive training on equipment from:

  • a qualified diabetes educator listed in RHW; or
  • the VR diabetes program specialist.

Services Provided by Diabetes Educators

Procedures

Diabetes educators have appropriate licensing as health professionals. Professional licensing includes certified diabetes educator, registered nurse, or dietician, preferably with specialization and certification in diabetes education. Diabetes educators are certified by the diabetes program specialist.

The diabetes program is designed for individuals with severe disabilities who need one-on-one training primarily. Occasionally, group training may be arranged when appropriate and when it will benefit the customers of a region.

VR counselors and caseworkers must follow the guidance below.

  1. The VR counselor assesses whether community diabetes education programs, including free or low-cost programs, are available. Alternatively, the VR counselor uses the comparable benefits to arrange diabetes self-management education training through recognized or accredited diabetes programs in local hospitals or health centers. Customers whose disability does not impact their ability to participate in traditional group training receive diabetes services at this level.
  2. If the customer's disability is severe and the customer could benefit from specialized diabetes education with an understanding of self-management adaptive techniques, equipment, tools or teaching skills, then referral to a contracted diabetes education provider through the diabetes program is recommended. (Severe disabilities include blindness, cognitive issues, or any disability that might make participation in group diabetes education difficult.)
  3. If the customer has participated in community diabetes education and is still struggling to manage the diabetes, referral to a contracted diabetes education provider is recommended. For example, when the customer has participated in community diabetes education, but he or she continues to have issues, then one-on-one education by a contracted provider may be needed to identify reasons for the mismanagement. The VR counselor might consider whether the customer's struggle is with diabetes knowledge and skills, or if it could be caused by depression, anger, or other issue for which a licensed professional counselor should be contracted.

Diabetes educators may provide services in evaluation and training:

  • on tools and techniques for managing diabetes;
  • on insulin-drawing devices and blood glucose monitors; and
  • for education needs (for example, meal planning and injection techniques).

Diabetes educators also provide the following services:

  • Education on diabetes health maintenance
  • Training on diabetes education services
  • Information about resources that are available in the customer's area and how to access those services

See the VR Standards for Providers Chapter 7: Diabetes Self-Management Education Services for contract requirements for diabetes educators.

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C-704: Durable Medical Equipment

This section provides policies and procedures for purchasing durable medical equipment (DME), including hearing aids, which are medical assistive devices and supplies. VR is the payer of last resort.

The VR counselor applies the policies in C-704-1 through C-704-11 to all medical assistive devices and supplies, regardless of category.

Comparable benefits (B-310-5) and required customer participation in cost of services (B-310-6) must be applied before VR funds are expended.

Because VR uses tax revenue for case service expenditures, the division must purchase the least expensive services that meet the customer's vocational needs. For more information, see the requirements in D-203-1: Best Value Purchasing.

With respect to VR's responsibility for payment, after the customer's primary and/or secondary benefit coverage has been applied and customer's ability to pay has been determined, VR may pay to the provider an amount equal to the customer's co-payment, coinsurance, or deductible due. VR payment does not exceed the insurance allowed amount or the allowable VR rate or VR contract rate, whichever is less.

Medical assistive devices and supplies fall into three categories, which have policies and procedures that are specific to each. The categories are as follows:

  • Medical assistive devices and supplies, noncontract
  • Medical assistive devices and supplies, contract
  • Medical assistive devices and supplies, nonspecific

C-704-1: Bids and Specifications

Bids are required when a single purchase is expected to exceed $5,000, unless the item is under contract or listed in MAPS. The VR counselor follows the purchasing guidelines in VRSM D-200: Purchasing Goods and Services in addition to the applicable guidelines in this section.

The service authorization must include a complete description of the items to be purchased. See the ReHabWorks Users Guide.

C-704-2: Purchases from Hospitals

Medical assistive devices and supplies that are purchased from contracted hospitals must be:

  • listed on the hospital invoice; and
  • paid for under the terms of the hospital contract.

To determine the proper procedure to purchase items not listed here, the VR counselor contacts the Central Office program specialist for physical restoration.

C-704-3: Ownership of Medical Assistive Devices

Medical assistive devices purchased for a customer by VR are the property of the State of Texas.

C-704-4: Required Review before Purchase

The DME that requires review by the Central Office program specialist for rehabilitation technology and VR Manager approval comprises:

  • power wheelchairs over $15,000 of the contracted rate;
  • manual wheelchairs over $10,000 of the contracted rate; and
  • all other DME over $5,000 of the contracted rate.

Note: The contract rate is the manufacturer's suggested retail price (MSRP) minus 18 percent.

C-704-5: Procedures for Purchasing Contracted Medical Assistive Devices, Excluding Hearing Aids

The VR counselor uses the following procedure to buy all contracted medical assistive devices, except for hearing aids.

  1. The VR counselor obtains a prescription, puts a copy in the case file, and documents the action in a case note.

    Note: Written recommendations are required for the initial purchase of all contracted medical assistive devices and replacement items.

  2. The VR counselor reviews and follows the item-specific requirements for the following assistive devices:
    • Rehabilitation or hospital beds
    • Patient lifts
    • Manual wheelchairs
    • Power wheelchairs
    • Scooters
    • Assistive devices for the bathroom
    • Seating and positioning systems

After an initial prescription is received, the VR counselor obtains specifications (type, size, and special features) by arranging for the customer to be evaluated by:

  • a physiatrist;
  • a physical or occupational therapist;
  • a rehabilitation engineer; or
  • an assistive technology professional.

C-704-6: Replacement Wheelchairs

The VR counselor obtains an estimate of the cost for refurbishing the original chair from the local provider of wheelchair repair services.

The VR counselor applies best value principles in considering whether repair or replacement is the more cost-effective course.

When purchasing a replacement chair, the VR counselor gets the customer's current (within six months) prescription and a reevaluation by a physiatrist, a physical therapist, or an occupational therapist.

Repairs do not have to be purchased from a contract provider. For information on wheelchairs, scooters, and other repairs, see C-704-9: Medical Assistive Devices and Supplies—Noncontract, Noncontract Items Requiring Special Consideration.

C-704-7: Documentation and Fees

Contractors agree to provide DME rates and instructions outlined in VR Standards for Providers Chapter 8: Durable Medical Equipment, 8.5 Methodology for Payment.

VR is the payer of last resort.

Comparable benefits (B-310-5) and required customer participation in cost of services (B-310-6) must be applied before VR funds are expended.

Because VR uses tax revenue for case service expenditures, the division must purchase the least expensive services that meet the customer's vocational needs. For more information, see the requirements in D-203-1: Best Value Purchasing.

With respect to VR's responsibility for payment, after the customer's primary and/or secondary benefit coverage has been applied and customer's ability to pay has been determined, VR may pay to the provider an amount equal to the customer's co-payment, coinsurance or deductible due. VR payment does not exceed the insurance allowed amount or the allowable VR rate or VR contract rate, whichever is less.

Payment for fabricated goods that are invoiced must be based on the vendor-provided specification approved by the VR counselor. This includes:

  • payment for development of schematics, drawings, or other required descriptive materials;
  • installation;
  • setup and training;
  • written instructions on use and maintenance; and
  • the availability of self-repair information, parts, warranty, and post-warranty repair.

The VR counselor is authorized to pay the provider for the entire functional unit upon receipt of an invoice. The invoice must include the current MSRP and discount rate for the item purchased. A copy of the MSRP list or order form must be attached to the invoice.

VR staff:

  • verifies with the customer that the goods or services were provided; and
  • documents in the case file that the goods and services were provided before payment.

C-704-8: Contracted Goods and Services

Procedure

Contract administration staff solicits and manages contracts for VR goods and services. Some goods or services must be purchased under contract. Before purchasing a good or service, the VR counselor uses RHW to find out whether a contract is required. When the service authorization is generated, RHW assigns the contract number based on the vendor and the type of purchase. Refer to the ReHabWorks Users Guide Chapter 16: Case Service Record for more information about creating a service record.

Customer goods and services that are purchased under a contract include, but are not limited to:

  • rehabilitation technology;
  • employment services such as:
    • job readiness;
    • job placement;
    • job coaching;
    • job skills training;
    • supported employment services;
    • self-employment services;
  • hospital services;
  • inpatient or outpatient services; and
    • supported self-employment services;
  • PABI services for VR;
  • residential services;
  • nonresidential services and equipment, including:
    • some medical equipment;
    • DME;
    • manual wheelchairs (fully functional chairs);
    • scooters;
    • seating and positioning systems;
    • patient lifts;
    • power wheelchairs (fully functional chairs);
    • hospital beds;
    • power units and controllers; and
    • hearing aids; and
  • vehicle modifications

C-704-9: Medical Assistive Devices and Supplies—Noncontract

The following procedures apply to noncontract medical assistive devices and supplies. See Examples of Medical Assistive Devices and Supplies, Noncontract for a list of examples in this category.

  1. The VR counselor determines whether a written recommendation or prescription is required. Written recommendations are required for:
    • the initial purchase of medical assistive devices and supplies; and
    • replacement items when the medical condition is progressive.
  2. If required, the VR counselor obtains and places in the case file a written recommendation and/or prescription from:
    • a physician;
    • a physician assistant;
    • an advanced practice nurse;
    • a dentist; or
    • an optometrist.

    Note: When the written recommendation and/or prescription do not describe the item, the VR counselor obtains a letter of specification from an appropriate certified paramedical specialist (physical or occupational therapist, orthotist, or prosthetist).

  3. The VR counselor follows procedures outlined below in Noncontract Items Requiring Special Consideration, if applicable.

Noncontract Items Requiring Special Consideration

Noncontract items requiring special consideration are listed in the following table.

Item

Required Consideration

Dentures or dental appliances

Manager's approval is required.

Prescription drugs

A prescription from a physician (MD or DO), physician assistant, or advanced practice nurse, or the prescription number from the named pharmacy, is required.

Repairs

Repairs to prosthetic or orthotic devices do not require a medical professional's recommendation or prescription. Payment for repair labor charges must not exceed $50 per hour.

Transcutaneous electrical nerve stimulator

The device must be rented for 7–14 days before the VR counselor may purchase it.

If the VR counselor purchases it, the vendor must agree to apply the rental fees to its total cost.

C-704-10: Hearing Aids

Hearing aids may be authorized when they are expected to improve the customer's ability to participate in employment and/or training that is required for a specific employment outcome. The VR counselor documents the expected outcomes in the case file as part of the assessing and planning process.

For customers ages 18 and younger, TWC must use comparable benefits when possible when planning services related to hearing aids, cochlear implants, and BAHA. To this extent, TWC may pay for any deductible, co-payments, and/or coinsurance for the provision of these goods and services if the total cost (insurance paid amount plus VR funds paid toward cost) does not exceed allowable VR contract rates.

 The VR counselor develops the IPE to purchase hearing aids after receiving:

When the VR counselor receives a recommendation for a complete-in-canal (CIC) hearing aid, he or she ensures that the audiologist sufficiently justifies the added benefits of a CIC aid when compared to an alternative style with the same capabilities.

It is recommended that the VR counselor consult with a Texas Health and Human Services Commission Deaf and Hard of Hearing Services deaf and hard of hearing technology specialist (HLRS) for consideration of additional technology before purchasing the hearing aids.

For information on purchasing hearing aids, see D-200: Purchasing Goods and Services, D-210: Medical and Psychological Services (MAPS).

When an audiologist or hearing-instrument specialist provides a vocational justification that warrants an aid without a manual telecoil, it is recommended that the VR counselor consult with a local deaf and hard of hearing technology specialist before purchasing the aid. The VR counselor may request a workplace or environmental assessment completed by the deaf and hard of hearing technology specialist to identify additional technology needs.

Hearing Aid Recommendations

The selected provider must complete the DARS3105D, Hearing Evaluation Report Hearing Aid Recommendations indicating the:

  • brand name and model number (not serial number);
  • type of hearing aid, such as:
    • behind-the-ear;
    • in-the-ear;
    • in-the-canal;
    • complete-in-canal; or
    • bilateral contralateral routing of signal;
  • color selection;
  • receiver information;
  • earmold information;
  • quantity of hearing aids;
  • cost of hearing aids; and
  • any required justifications.

Payments for Service Charge to the Hearing Aid Dispenser

The service charge is the dispenser's usual and customary charge, not to exceed MAPS, for:

  • initial fitting, including activation of a telecoil;
  • up to four follow-up visits for adjustments, including:
    • post fitting evaluation; and
    • report of hearing aid performance and customer level of satisfaction; and
  • instructions in the care and use of the instrument.

Upon receipt of a completed and signed DARS3105E, Hearing Aid Fitting and Post-Fitting Report, payment is authorized for the service charge. However, if the customer does not keep the post fitting appointment, VR staff contacts the customer before the 30-day trial period ends to verify that the customer has received and is satisfied with the hearing aids.

Payment for Hearing Aids to the Manufacturer

VR pays the hearing aid manufacturer for the hearing aids. The service authorization is forwarded to the dispenser so that it can be submitted to the manufacturer along with the hearing aid order.

Earmolds and Canal Impressions

Earmolds and canal impressions may be:

  • required for hearing aid purchases;
  • purchased from the audiologist or hearing aid dispenser;
  • paid for separately (not to exceed MAPS); and
  • purchased for diagnostic purposes.

Custom-made ear plugs, which look like earmolds and are intended for sound protection, may be purchased to preserve the customer's residual hearing while performing work duties.

Binaural

Binaural aids may be purchased:

  • when recommended by the audiologist or hearing aid service provider; and
  • when a documented vocational benefit exists.

Repair

Payment for repair of a hearing aid, including labor, plus shipping and handling charges, must not exceed the cost of a new hearing aid.

Hearing Accessories

An audiologist or hearing aid dispenser may recommend certain accessories and devices that work with the hearing aids to enhance the customer's ability to hear and understand conversational speech and environmental sounds. An example of such devices is one that streams sounds from the telephone, television, and music player, as well as a compatible microphone, directly to the hearing aids.

Another accessory that may be purchased is a hearing aid drying kit, which draws moisture from the hearing aids to prolong their life span.

Frequency Modulation System

The VR counselor may purchase a frequency modulation (FM) system directly from a manufacturer or an audiologist. However, the VR counselor may not pay a service fee, including any fitting and dispensing fees, when he or she purchases an FM system through an audiologist.

When additional training is needed for an FM system, the VR counselor contacts the deaf and hard of hearing technology specialist to request training for the customer on the use of the device and to perform troubleshooting of any issues with the device. Services provided by the deaf and hard of hearing technology specialist are free and may be used when available. If the necessary training is not available from the deaf and hard of hearing technology specialist, the VR counselor may negotiate payment with the provider for training the customer on the use of the device and for solving problems that arise with the device.

C-704-11: Cochlear Implant and Bone Anchored Hearing Aid Processor Replacement

The VR counselor may authorize replacement of cochlear implant and bone anchored hearing aid (BAHA) processors when they are expected to improve the customer's ability to participate in employment and/or training that is required for a specific employment outcome identified on the IPE. As part of the assessing and planning process, the VR counselor documents the expected outcomes, such as the expectation of an improved ability to understand spoken communication or respond to environmental cues.

TWC must use comparable benefits when possible when planning services related to hearing aids, cochlear implants, and BAHA for customers ages 18 and younger. To this extent, TWC may pay for any deductible, co-payments, and/or coinsurance for the provision of these goods and services if the total cost (insurance paid amount plus VR funds paid toward cost) does not exceed allowable VR contract rates.

Replacement of processors may not be authorized solely for the sake of upgrading to newer technology.

VR is the payer of last resort.

Comparable benefits (B-310-5) and required customer participation in cost of services (B-310-6) must be applied before VR funds are expended.

Because VR uses tax revenue for case service expenditures, the division must purchase the least expensive services that meet the customer's vocational needs. For more information, see the requirements in D-203-1: Best Value Purchasing.

With respect to VR's responsibility for payment, after the customer's primary and/or secondary benefit coverage has been applied and customer's ability to pay has been determined, VR may pay to the provider an amount equal to the customer's co-payment, coinsurance or deductible due. VR payment does not exceed the insurance allowed amount or the allowable VR rate or VR contract rate, whichever is less.

Careful consideration of the following must take place when assessing the need for such replacement:

  • The customer's vocational goal, including tasks, functions, and work conditions, particularly where it relates to the customer's ability to hear and understand conversational speech and/or environmental sounds
  • The potential impact on the customer's ability to obtain and maintain employment if replacement is not made
  • The availability of assistive technology to enable the customer to gain full benefits in training or on the job
  • The status of the customer's device, especially relating to:
    • warranty coverage;
    • physical condition; and
    • need for repair, if any.

The evaluation report completed by the audiologist and otologist must include:

  • the diagnosis;
  • recommendations for treatment, including a letter of medical necessity; and
  • anticipated prognosis.

The VR program specialist for the Deaf and hard of hearing (for customers accessing VR services) or the manager of field support for the Blind Services Division (for customers accessing deafblind services) must review a courtesy case packet before planning device replacement.

The courtesy case packet includes the:

  • medical, audiological, speech, and language evaluations and reports as specified above; and
  • justification of how device replacement will lessen the vocational impediment.

After the VR program specialist reviews the courtesy packet, he or she enters in RHW a case note granting approval of device replacement.

The cost of the recommended replacement processor may exceed the threshold set in MAPS. When this occurs, medical director approval is required to override the pre-set rate in MAPS. To obtain approval, the VR counselor sends an email to VR Medical Services along with the:

  • evaluation report from the audiologist;
  • manufacturer's quote for processor replacement; and
  • VR justification for the upgrade.

All medical services related to replacement of processors are performed by otologists and licensed audiologists.

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