Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 82 - ALTERNATIVE TREATMENTS FOR PAIN MANAGEMENT › Section 317:30-5-728 - Physical therapy (PT) for alternative treatments for pain management

Current through Vol. 41, No. 20, July 1, 2024
PT is used to improve a person's ability to move, reduce or
					 manage pain, restore function, and prevent disability. For pain management, PT
					 is provided in a non-hospital based setting with the aim of decreasing pain and
					 suffering while improving physical and mental functioning.
(1)
Medical necessity.
All
				  services/diagnosis found in the full guidelines at
www.okhca.org/mau
for alternative
				  treatments for pain management should be determined to be medically necessary
				  for the affected member. Documentation in the member's plan of care should
				  support the medical necessity of the need for alternative treatments for pain
				  management services. The Oklahoma Health Care Authority (OHCA) will serve as
				  the final authority pertaining to all determinations of medical necessity.
				  Refer to Oklahoma Administrative Code (OAC)
				  317:30-3-1(f)
				  for policy on medical necessity.
(2)
Documentation/requirements.
All documentation submitted to request services should demonstrate, through
				  adequate objective medical records, evidence sufficient to justify the member's
				  need for the service, in accordance with OAC
				  317:30-3-1(f)(2).
(A)
Evaluations.
One (1) initial
				  PT evaluation and one (1) PT re-evaluation, when necessary, will be covered per
				  calendar year at a non-hospital-based setting and do not require a PA, when the
				  service is performed for the evaluation of therapy services related to
				  alternative treatments of pain management.
(B)
Prior authorization (PA).
Documentation, for a PA request, will include the following:
(i) The member is over twenty-one (21) years
				  of age;
(ii) A prescription or a
				  referral from the member's physician or other licensed practitioner of the
				  healing arts, dated within the previous ninety (90) days requesting the PT
				  services for pain management;
(iii)
				  Attestation stating that PT services are being used in place of opioid
				  treatment for pain or used to decrease the use of opioids;
(iv) Medical records, from the member's
				  physician or other licensed practitioner of the healing arts, documenting the
				  need for the pain management referral;
(v) Documentation from the physical therapist
				  that supports the need for the requested services;
(vi) A detailed report, from the physical
				  therapist, that is gathered from any tool, test, or measure;
(vii) Measurable goals that includes the
				  following:
(I) Timeframe;
(II) Baseline;
(III) Conditions for how goals are expected
				  to be met;
(IV) A statement of
				  rationale; and
(V) Prognosis for
				  achievement.
(viii) A
				  detailed intervention plan that includes:
(I)
				  Frequency and duration of the services and the anticipated length of the
				  intervention;
(II) Location of
				  where the services are provided;
(III) Member and/or family/caregiver
				  involvement in the management and carry-over of the intervention;
(IV) Reasons if the intervention was
				  unsuccessful.
(ix) A
				  completed therapy PA request form;
(x) For full guidelines, please refer to
www.okhca.org/mau
.
(C)
Subsequent PA requests.
Requests for a subsequent PA will include the following:
(i) All documentation found at (2)(B) (i)
				  through (viii) of this Section;
(ii) Detailed listing of previous goals,
				  including instances of which goals were unmet and why they were not
				  achieved;
(iii) Treatment goals for
				  acute pain/injury, chronic pain management, or chronic back pain;
(iv) Records showing persistent or recurrent
				  conditions;
(v) Treatment
				  evaluations that show avoidance/prevention or reduction of opioid
				  use;
(vi) A completed therapy PA
				  request form;
(vii) For full
				  guidelines, please refer to
www.okhca.org/mau
.