California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51309 - Psychology, Physical Therapy, Occupational Therapy, Speech Pathology and Audiological Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Psychology, physical therapy, occupational therapy, speech pathology and
					 audiological services are covered when provided by persons who meet the
					 appropriate requirements specified in Article 2 and Article 3 of this Chapter.
The written prescription of a physician, dentist or
						podiatrist is required for physical therapy and occupational therapy services.
						Speech pathology and audiological services shall be provided only upon the
						written referral of a physician or dentist.
(b) Physical therapy services shall include
					 physical therapy evaluation, treatment planning, treatment, instruction,
					 consultative services, and application of topical medications. Services do not
					 include the use of Roentgen rays or radioactive materials or the use of
					 electricity for surgical purposes including cauterization. Services are limited
					 to treatment immediately necessary to prevent or to reduce anticipated
					 hospitalization or to continue a necessary plan of treatment after discharge
					 from the hospital.
(c) Occupational
					 therapy services shall include occupational therapy evaluation, treatment
					 planning, treatment, instruction and consultative services.
(d) Such services, except physical therapy,
					 are subject to the limitations set forth in Section
					 51304(a).
					 Physical therapy services may be provided after prior authorization and
					 approval of a treatment plan is obtained from the Medi-Cal consultant.
(1) The authorization request shall include
					 diagnosis, modalities, frequency, therapeutic goals, duration of treatment and
					 date of progress review where applicable. The physician's, dentist's or
					 podiatrist's prescription shall be attached to the authorization
					 request.
(2) Authorization for
					 physical therapy services shall be contingent upon compliance with the
					 following requirements:
(A) There is direct
					 and specific relationship of the services to written treatment plan prescribed
					 by the physician, dentist or podiatrist after consultation with a qualified
					 physical therapist.
(B) The
					 complexity and sophistication of the level of service or condition of the
					 beneficiary requires the judgment, knowledge and skills of a physical
					 therapist.
(C) Provision of the
					 services is with the expectation that the beneficiary will improve
					 significantly in a reasonable and generally predictable period of time or to
					 establish an effective maintenance program in connection with a specific
					 disease state.
(D) Service is to be
					 performed by a qualified physical therapist who meets the standards set forth
					 in Section
					 51201.1 of this chapter.
(E) The service is considered, under accepted
					 standards of medical practice, to be a specific and effective treatment for the
					 beneficiary's condition.
(F) The
					 service is reasonable and medically necessary for the treatment of the
					 beneficiary's condition.
(3) Professional physical therapy necessary
					 to establish or periodically reevaluate a palliative or maintenance therapy
					 program may be authorized. Services which do not require the skills of a
					 physical therapist shall not be covered or authorized.
(4) Prior authorization shall not be granted
					 for more than 30 treatments at any one time. Authorizations shall be valid for
					 up to 120 days. A request for reauthorization shall include a statement
					 describing the beneficiary's progress toward achieving the therapeutic goals
					 included in the treatment plan.