DRS Rehabilitation Policy Manual Chapter 6: Physical Restoration Services

Revised September 2015

  • 6.4 Physical Restoration Services or Procedures with Special Requirements
  • 6.4.1 Adaptive or Assistive Technology
  • 6.4.2 Back Surgery and Steroid Injections
  • 6.4.3 Breast Implant Removal
  • 6.4.4 Cardiac Catheterization or Angiography
  • 6.4.5 Chiropractic Treatment
  • 6.4.6 Cochlear Implant
  • 6.4.7 Comprehensive Medical Treatment for Spinal Cord Injury
  • 6.4.8 Dental Treatment
  • 6.4.9 Diabetes Insulin Pumps
  • 6.4.10 Discograms
  • 6.4.11 Electrical Bone Stimulators (EBS)
  • 6.4.12 Eyeglasses and Contact Lenses
  • 6.4.13 Functional Capacity Assessment
  • 6.4.14 Functional Electrical Stimulation (FES) Devices
  • 6.4.15 Gym Memberships and Home Exercise Equipment
  • 6.4.16 Hearing Aids
  • 6.4.17 Home Health and Nursing Home Care
  • 6.4.18 Intercurrent Illness
  • 6.4.19 Medical Assistive Devices and Supplies
  • 6.4.20 Nursing Home Care
  • 6.4.21 Occupational Therapy
  • 6.4.22 Orthoses and Prostheses
  • 6.4.23 Osteomyelitisof the Extremities
  • 6.4.2324 Outpatient Services
  • 6.4.2425 Pain TreatmentManagement
  • 6.4.2526 Physical Therapy
  • 6.4.2627 Prescription Drugs and Medical Supplies
  • 6.4.2728 Procedures for Pregnant Consumers
  • 6.4.2829 Severe (Morbid) Obesity Surgery
  • 6.4.2930 Postbariatric Surgery Case Management
  • 6.4.3031 Speech Therapy and Speech Training
  • 6.4.3132 Spinal Cord Stimulator or Dorsal Column Stimulator
  • 6.4.3233 Weight-Loss Programs
  • 6.4.3334 Wheelchairs
  • 6.4.35 Wound Care
  • 6.5 Specialized Physical Restoration Programs
  • 6.5.1 Fees for Specialized Programs
  • 6.5.2 Back Schools
  • 6.5.3 Cardiac Rehabilitation Facilities
  • 6.5.4 Comprehensive Rehabilitation Hospital Programs
  • 6.5.5 Work Hardening
  • 6.5.6 Pain Management Programs or Pain Clinics
  • 6.5.7 Post-Acute Brain Injury (PABI) Rehabilitation Services for Vocational Rehabilitation (VR)
  • 6.5.8 Weight-Loss Programs

6.1 Physical Restoration Services

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6.4 Physical Restoration Services or Procedures with Special Requirements

*Listed below are physical restoration services or procedures that have special requirements. You must review these requirements before including any of them in the consumer's plan.*

*Based on 34 CFR Section 361.50(a)

  • 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;
  • diabetes insulin pumps;
  • discograms;
  • electrical bone stimulators (EBS);
  • eyeglasses and contact lenses;
  • functional capacity assessments (FCA);
  • functional electrical stimulation (FES) devices;
  • gym memberships and home exercise equipment;
  • hearing aids;
  • home health and nursing home care;
  • intercurrent illness;
  • medical assistive devices and supplies;
  • nursing home care;
  • occupational therapy;
  • orthoses and prostheses (also see FES devices, above);
  • osteomyelitis
  • outpatient services;
  • pain treatmentmanagement;
  • physical therapy;
  • prescription drugs and medical supplies;
  • procedures for pregnant consumers;
  • severe (morbid) obesity surgery;
  • postbariatric surgery case management;
  • speech therapy and speech training;
  • spinal cord stimulator or dorsal column stimulator;
  • weight-loss programs; and
  • wheelchairs; and
  • wound care

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6.4.23 Outpatient ServicesOsteomyelitisof the Extremities

Outpatient services may include

physician visits;

physical or occupational therapy;

speech, language, or hearing therapy; or

home health or nursing care.

Provide outpatient services only when prescribed by a physician, and *only if they are 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.*

*Based on 34 CFR Section 361.5(b)(40)

If the service provider requests an extension of treatment beyond his or her initial recommendation, assess the consumer's potential for continued progress. Your assessment may involve reviewing treatment progress notes and/or contacting the physician, LMC, and/or provider. If you determine that continuing treatment is appropriate,

you must clearly document in the case file how continued services are expected to contribute to achieving the employment goal;

you may approve up to a total of 30 visits or therapy sessions; and

you must obtain the area manager's approval for extending treatment beyond 30 visits or therapy sessions.

Osteomyelitis is a bone infection that can cause an unstable medical condition with an uncertain prognosis that usually requires complicated and extensive medical treatment. DRS sponsors medical treatment of an osteomyelitis infection only if the infection is a complication of DRS-sponsored surgery.

Proposed treatment of the osteomyelitis infection must be reviewed and approved by the DRS medical director. For all other consumers with a bone infection in the extremities, DRS will support the treatment option of amputation only as recommended by the treating physician and approved by the DRS medical director.

6.4.2423 Outpatient Services

Outpatient services may include

  • physician visits;
  • physical or occupational therapy;
  • speech, language, or hearing therapy; or
  • home health or nursing care.

Provide outpatient services only when prescribed by a physician, and *only if they are 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.*

*Based on 34 CFR Section 361.5(b)(40)

If the service provider requests an extension of treatment beyond his or her initial recommendation, assess the consumer's potential for continued progress. Your assessment may involve reviewing treatment progress notes and/or contacting the physician, LMC, and/or provider. If you determine that continuing treatment is appropriate,

  • you must clearly document in the case file how continued services are expected to contribute to achieving the employment goal;
  • you may approve up to a total of 30 visits or therapy sessions; and
  • you must obtain the area manager's approval for extending treatment beyond 30 visits or therapy sessions.

6.4.2425 Pain ManagementTreatment

Short term pain treatment may be authorized for a consumer to improve their functional ability to achieve an employment goal as defined on their individualized plan for employment (IPE). DRS does not sponsor long-term medical treatment for chronic medical conditions, including chronic pain.

When a consumer reports functional limitations related to chronic pain:

  • consider an orthopedic, neurological, or physical medicine and rehabilitation evaluation to determine if the pain source can be treated with conventional physical restoration services;
  • consider a functional capacity assessment followed by job placement services if there are no physical restoration treatment options and the consumer wants to work despite his/her pain;
  • screen for and coordinate treatment for co-morbid psychological diagnoses; and
  • evaluate pain medication use and potential safety risks.

Refer the consumer to available comparable benefits to meet long-term treatment needs.

(Revised 09/10)

Before sponsoring a consumer in a pain management program, verify that the pain management program complies with DRS criteria outlined in 6.5.6 Pain Management Programs or Pain Clinics, and that the consumer meets the following criteria:

assessments confirm that the consumer

ohas been thoroughly evaluated medically by a neurologist and/or orthopedic surgeon and/or neurosurgeon with no finding of a pain source that can be treated conventionally;

orecognizes that nothing further can be done to "cure" the pain and is motivated to learn to improve his or her functioning and live productively despite the pain; and

ois ready to assume the major responsibility of changing pain behavior patterns and improving his or her functioning; and

the referring physician will continue to be the consumer's physician while the consumer is attending the pain clinic, and will again evaluate the consumer after receiving a report of the consumer's progress at the pain clinic.

6.4.25 26 Physical Therapy

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6.4.26 27 Prescription Drugs and Medical Supplies

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6.4.27 28 Procedures for Pregnant Consumers

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6.4.28 29 Severe (Morbid) Obesity Surgery

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6.4.29 30 Postbariatric Surgery Case Management

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6.4.30 31 Speech Therapy and Speech Training

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6.4.31 32 Spinal Cord Stimulator or Dorsal Column Stimulator

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6.4.32 33 Weight-Loss Programs

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6.4.33 34 Wheelchairs

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6.4.35 Wound Care

Wound care may be authorized for a consumer when:

  • wound care is needed due to a complication of DRS-sponsored surgery; or
  • there is a reasonable probability that a short course of wound care treatment will result in wound healing of decubitus ulcers or diabetic foot ulcers sufficient to allow the consumer to complete planned services.

Since wound care often involves complicated treatment with an uncertain prognosis, consultation with the local medical consultant (LMC) and program specialist for physical disabilities is required before sponsoring treatment.

6.5 Specialized Physical Restoration Programs

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6.5.4 Comprehensive Rehabilitation Hospital Programs

These programs provide a coordinated and integrated service package, which can includeing:

  • 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 evaluation and training,

vocational evaluation and/or vocational counseling, and

rehabilitation engineering.

These are appropriate prevocational services for many consumers with the most significant disabilities (spinal cord injuries, etc.). See Chapter 3: Eligibility, 3.8 Required Assessments and Policies for Selected ConditionsDisabilities/Spinal Cord Injury, for information on providing these services before the consumer is accepted for regular vocational rehabilitation (VR) services.

For questions on selecting the most appropriate facility, contact the Central Office program specialist for neuromuscular disabilities.

See Chapter 17: Purchasing, 17.2 Health Care Professionals—Required Qualifications, for criteria that apply to comprehensive inpatient rehabilitation facilities.

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6.5.7 Post-Acute Brain Injury (PABI) Rehabilitation Services for Vocational Rehabilitation (VR)

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 non-residential setting.

Services are based on an assessment of the individual's assessed deficits. The goal of post-acute brain injury services for vocational rehabilitation consumers is to establish new patterns of cognitive activity and compensatory mechanisms in order to achieve a specific employment outcome.

Duration of Post-Acute Brain Injury Services

Post-acute brain injury (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 by CRS. Post-acute rehabilitation services are indicated on the Individualized Plan for Employment (IPE) as "up to 30 days of service” and may be extended to a maximum of 180 days, without an IWRP amendment, when recommended by the interdisciplinary team.

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

For more information about PABI services, see the DRS Standards for Providers Chapter 5. Providers of PABI services must adhere to all details outlined in that chapter.

Post-acute Brain Injury Service Array

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

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
Ancillary Services / Service Delivery Modality / Provider Qualifications
Audiology / Individual / LP
DME 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

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

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
Ancillary Services / Service Delivery Modality / Provider Qualifications
Audiology / Individual / LP
DME 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 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 (i.e.that is, not medical emergencies) and are not included as a core or ancillary service, a formal request process must be followed before services may be provided to DARS consumers.

Step / Issue / Notes
1 / The Interdisciplinary Team (IDT) or medical expert identifies a need for a service and/or therapy, which is not offered in the Service Array / Identification of service and/or therapy needed for rehabilitation purposes is based on medical assessment
2 / The IDT or medical expert sends the counselor a request for the service / The request for service must include supporting medical documentation and assessments to illustrate the necessity of the service and/or therapy and proposed billing codes (for example CPT, HCPCS, DARS rates) which will be used for billing purposes.
If additional information is needed for decision making purposes, the counselor contacts the facility.
3 / The counselor sends an email to his or her chain of command and central office with the following information:
  • Consumer name
  • Consumer ID
  • Consumer injury
  • Recommended therapy
  • Medical needs
  • Associated CPT/MAPS/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 area manager or staff acting on behalf of an area manager.
4 / The counselor and the area manager discuss and determine whether the service is appropriate and medically necessary. / The counselor and the area manager consider all information related to the consumer to determine whether the service is necessary.
If the service is not appropriate or medically necessary, the service is denied by the counselor and area manager. This decision is communicated to the facility and central office by the counselor. A case note must be entered to document the reason for denial.
If the service is appropriate and medically necessary, the case is shared with the chain of command, seeking approval.
5 / The 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 or is not appropriate. / If the service is determined appropriate and medically necessary, an email indicating approval by the area manager and regional management is sent to central office requesting final review and approval.
If the service is not appropriate or medically necessary, the service is denied by the counselor and area manager. This decision is communicated to the facility and central office by the counselor.
5 / Central office reviews the service and determines whether it is or is not appropriate to provide the service to the consumer. / Note: If more information is needed for decision-making purposes, the counselor must get the information at the request of central office.
6 / Upon determining whether the service is approved or not approved, the counselor communicates the decision to the facility. / The counselor provides answers to questions about the decision. If the facility disagrees with the decision, the appeals process must be implemented.
7 / An approved service requires a DARS3724 be completed. / This must be signed by the respective regional director or assistant commissioner of DARS.
8 / Issue a service authorization (SA) for services / All of the steps above must be completed before issuing an SA

Post-acute brain injury rehabilitation services use an interdisciplinary team approach to providing cognitive rehabilitation, independent living, and vocational services. These services are appropriate primarily for persons with acquired cognitive deficits from

traumatic brain injury,

cerebrovascular accidents, or

other neurological processes.

The goal of these services is to increase the consumer's ability to live as independently as possible and, for vocational rehabilitation consumers, to obtain and maintain employment.

You may provide these services on either a residential or nonresidential basis. A number of factors determine which is more appropriate for the consumer.

DRS individually approves providers of post-acute brain injury rehabilitation services. Services are delivered under contract.

6.5.8 Weight-Loss Programs

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