Medical Services for VR Customers
Discussion Paper
Background
Physical restoration is a vocational rehabilitation service that is available to eligible Vocational Rehabilitation (VR) customers through both the Texas Workforce Commission’s (TWC) Blind Services Division (BSD) and TWC’s Rehabilitation Services Division (RSD) Physical restoration services decrease, help manage, or stabilize physical barriers so that eligible customers can secure, keep, advance in, or return to competitive integrated employment. As defined in federal regulations at 34 CFR 361.5(39), physical and mental restoration services can range from corrective surgery or therapeutic treatment, to dentistry, to various types of therapy, and other medical or medically related rehabilitation services. The definition also includes nursing services, drugs, prosthetic and orthotic devices and eyeglasses or lenses, along with associated visual examination, services and training. Regarding corrective surgery or therapeutic treatment, the definition states: “corrective surgery or therapeutic treatment that is likely, within a reasonable period of time, to correct or modify substantially a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to employment.
Medical services that are sponsored or supported by VRS 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. Physical restoration services are available to individuals with a physical or mental impairment, defined at 34 CFR 361.5(40) as: (i) any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological, musculo-skeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine; or (ii) Any mental or psychological disorder such as intellectual disability, organic brain syndrome, emotional or mental illness, and specific learning disabilities.
Under federal regulations at 34 CFR 361.42, a designated State unit’s (DSU’s) determination of a customer’s eligibility for VR services must be based only on the following requirements:
(i) a determination by qualified personnel that the applicant has a physical or mental impairment;
(ii) a determination by qualified personnel that the applicant’s physical or mental impairment constitutes or results in a substantial impediment to employment for the applicant; and
(iii)a determination by a qualified VR counselor employed by the DSU that the applicant requires VR services to prepare for, secure, retain, advance in, or regain employment that is consistent with the individual’s unique strengths, resources, priorities, concerns, abilities, capabilities, interest, and informed choice.
During the development of the individualized plan for employment (IPE), the DSU must conduct an assessment for determining VR needs for each individual. Per 34 CFR 361.45(b), the purpose of this assessment includes determining the nature and scope of VR services to be included in the IPE, including medical services where necessary for the customer to achieve the employment goal. Making such an assessment requires a determination of vocational necessity, meaning that the medical condition presented by the customer constitutes an impediment to employment. The TWC VR counselor determines if the condition is an impediment to employment. Where required due to the specific condition or proposed service, the TWC VR counselor relies upon the professional judgment of the Local Medical Consultant to make a determination of medical necessity. Where making such an assessment requires further determination or review of medical or vocational necessity, TWC relies upon the professional judgment of the State Medical Director. Increasingly, as new procedures are developed or new uses for existing services or devices are proposed, TWC must ensure that the assessments are appropriate for the vocational rehabilitation purposes.
Issue
Currently staffs in RSD and BSD are working under separate program manuals. TWC staff is creating a single Vocational Rehabilitation Services Manual (VRSM) in anticipation of the combination of the two VR divisions by October 1, 2017. As staff creates the combined manual they are identifying sections that require alignment between the two divisions, revision of language to conform to WIOA, and sections that require additional guidance and review. For medical services, staff has identified the following three issues, which will be addressed in VRSM C-700, Medical Services:
1. Physical restoration services are not uniform between RSD and BSD. Although physical restoration services are currently available to customers in both RSD and BSD, services are not uniform between the two divisions. For example, low vision needs are not addressed in the RSD policy and physical restoration is not in BSD policy.
2. Physical restoration services are not aligned with federal regulations. Amendments to federal regulations changed the definition of “physical and mental restoration services.” Specifically, 34 CFR 361.5(39) (xv) now incorporates care for end-stage renal disease, which includes dialysis and transplants. Currently RSD does not provide these services.
3. Assessments of the vocational need for certain physical restoration services require medical knowledge or additional management review.
· The vocational need for certain increasingly commonly-used physical restoration services for back and neck is not always evident. Currently, approval of spinal injections is made at the manager level; however, managers lack medical qualification or knowledge to understand the medical prognoses and physical vocational impact that the procedure may have upon the customer.
· Under current practice, even before a customer’s individualized plan for employment (IPE) is completed, diagnostic cardiac testing, cardiac catheterization or angiography are services that can be provided without manager or medical review. These are costly tests that may require medical intervention at the time of the procedure. These tests are now being completed without an IPE in place or prior approvals.
· Requests are being made for services involving ‘dynamic splinting devices” although the use of these devices is not in current policy. There is no direction or clarification on the appropriate vocational purpose and an assessment requires medical training.
· Requests are made during the IPE process for procedures or devices that are experimental or whose efficacy, particularly vocationally, have not been evidenced. For example, Irlen Lenses are investigational and there is no direction or guidance regarding the appropriate vocational use. Current policy provides no clear direction for evaluating the vocational purpose and any assessment requires medical training.
· Another expensive and popular request has been for breast reduction. However, current policy provides no clear direction for evaluating the vocational purpose and any assessment requires medical training. Requests are being made for a new type of surgery “panniculectomy”, which is a separate surgery from bariatric surgery, but may be identified by customers. Current policy provides no clear direction for evaluating the vocational purpose and any assessment requires medical training.
· Currently it is clinical criteria to have a psychological evaluation prior to a trial spinal cord stimulator. This is not included in the current RSD policy.
· Currently procedures that require local anesthesia to customers can be purchased without medical review. This can be a potential issue if medical complications or vocational need are not monitored.
· Currently procedures do not require prior management or state office review and approval for residential Post-Acute Brain Injury (PABI) services. This is an extensive and costly service that requires additional review to ensure it is vocationally necessary.
4. The purchase of costly equipment should be made based upon the review by a medical professional, as evidenced by a prescription, and all purchases of costly equipment should be reviewed by management, consistent with agency contracting signoff procedures.
· Current policy does not specify the requirement that contracted medical device purchases will require a current prescription to purchase the equipment.
· Current policy does not require a review by the state office program specialist for approval and or consultation before costly Durable Medical Equipment is purchased. The review would ensure that appropriate policy and procedure are followed and the appropriate equipment under a best value methodology is purchased for the customer.
Decision Points
1. Staff recommends that when BSD and RSD are combined as one designated state unit, to ensure that services are made equally available to customers, physical restoration services and low vision will be available to all customers that are eligible and qualify for the specific physical restoration or low vision service. The customer qualifies by having a disability that creates a substantial impediment to employment, and an assessment that indicates that the customer would benefit from the service in order to secure, keep, advance in, or return to competitive integrated employment. As recently approved by the Commission, Diabetes Self-Management Services, contained within this chapter, have been updated to reflect that decision.
2. Align with WIOA federal regulations. Federal Regulations at 34 CFR 361.5(39) (xv) define “physical and mental restoration services” to incorporate special services for the treatment of individuals with end-stage renal disease, including transplantation, dialysis, artificial kidneys, and supplies. Current policies need to be updated to reflect this expanded definition. Given the medical nature of this determination, staff recommends adding this to policy with the direction that the case will need to be reviewed by the local medical consultant, manager, and state medical director.
3. Ensure that policies are clarified and approval of certain procedures is reserved to qualified personnel
a. Establish a procedure for breast reduction and require review and approval by the State Medical Director
b. Clarify in policy that panniculectomy is a separate surgery from bariatric surgery and will require approval from the LMC
c. Require review by the VRS optometric consultant before authorizing purchase of Irlen Lenses
d. Require that contracted medical devices must have a current prescription (6 months) to purchase the equipment
e. Require review and approval of the LMC and State Medical Director for the following procedures for back or neck pain to ensure that services are purchased appropriately and based on vocational need
i. Epidural injections of the spine
ii. Facet injections of the spine
iii. Medial Branch Block
iv. Radiofrequency Neurotomy
f. Require review and approval of the LMC and VR Manager prior to including services on the IPE of the following procedures for heart conditions to ensure that services are purchased appropriately and based on vocational need
i. Cardiac catheterization
ii. Angiography
g. Establish policy and procedure for Dynamic Splinting Devices and require consultation with the state office program specialist for physical disabilities to review current clinical criteria and best value considerations
h. Align VR policy with current clinical criteria by requiring a psychological evaluation prior to a trial spinal cord stimulator
i. Require LMC review for local anesthesia before purchasing and require consultation with the state office program specialist for physical restoration for local anesthesia services:
i. Not listed in the Maximum Affordable Payment Schedule (MAPS);
ii. With codes listed as $0; or
iii. With codes ending in “99” or the letter “T”.
j. Require review by the state office program specialist for rehabilitation technology of the following durable medical equipment purchases to ensure that appropriate policy and procedure are followed and that the appropriate and best value equipment is purchased for the customer:
i. Power wheelchairs over the $15,000 contracted rate,
ii. Manual wheelchairs over the $10,000 contracted rate, and
iii. All other durable medical equipment over the $5,000 contracted rate.
k. Require approval by the state office program specialist for physical disabilities for Residential Post-Acute Brain Injury services.
RCT Input
RCT asked why policy does not authorize treatment of active tuberculosis, sexually transmitted diseases, cancer, organ transplantation, or human immunodeficiency virus infection (HIV) or acquired immunodeficiency syndrome (AIDS). Staff explained that per 34 CFR 361.53, individuals with these medical conditions are referred to comparable benefits. Individuals with HIV and STDs and TB are referred to the health department for appropriate and available services. Individuals that are diagnosed with AIDS are referred to community and the health department resources.Cancer is an illness with an unknown medical prognosis. Organ transplant candidates usually have Medicare because of the severity of the medical condition.
RCT also relayed a concern regarding VRSM C-703-16 Functional Electrical Stimulation (FES) Devices; specifically, that the procedure for providing this device to customers does not allow for regional office reviews or exceptions to be made. Staff responded that the counselor must consider best value purchasing. VRS is following Medicare criteria and guidelines, and the customer must demonstrate that they have the resources to pay for long-term ongoing monthly maintenance and supplies. This part of the policy was moved to orthotic and prosthesis section so that it can have the same approval process to provide clarity for VR staff.
RCT recommended adding exceptions to policy in VRSM C-703-17 Gym Memberships and Home Exercise Equipment. Staff responded that exceptions cannot be made due to the risk of injury of unsupervised exercise. Physical therapy is available when appropriate and necessary for the customer to address the vocational impediment.
RCT recommended removing a statement limiting the customer to one follow-up review in Chapter C-703-21 Medical and Assistive Devices- which includes the procedures for submitting prosthetic reviews to University of Texas Southwestern. Staff responded that the purpose of the statement is to prevent multiple, unnecessary reviews. Policy currently allows for exceptions to be made by the counselor with appropriate justification.
RCT recommended removing “for the life of the case” in C-703-27 Rehabilitative Therapies, which states that a manager approval is needed for therapy exceeding 30 sessions or charges exceeding 4 units per session. The 30-session limit for the life of the case applies to each individual therapy and not a combined number of therapies. Staff responded that language was implemented to prevent ongoing multiple physical restoration services within the life of the case without an employment outcome. Exception may be made following manager review, as stated within the section. Life of the case is defined as application to closure and includes post-closure.
DP-VRSM C-700 Medical Services for VR Customers, May 26, 2017 1