CurrentAmerigroupPolicy N/A

Therapy for Children's Disabilities - Georgia Plan

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Defines medical necessity, documentation, authorization and coverage criteria for speech, occupational and physical therapy for children with developmental disabilities under Amerigroup's Georgia Medicaid plan (EPSDT). Affects providers requesting outpatient therapy for eligible pediatric members.

Policy Summary

PayerAmerigroup

PolicyTherapy for Children's Disabilities - Georgia Plan

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 18, 2010

Next Review DateN/A

Key ActionSubmit prior authorization with baseline standardized assessment, physician-signed active treatment plan, required attachments (IEP/IFSP or attestation), and interval progress notes to support approval for up to six months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthstypical initial approval period

SS ≤ 69severe/profound threshold

3meaningful change (SS/DQ)

1meaningful change (scaled score)

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CurrentAmerigroupPolicy N/A

Therapy for Children's Disabilities - Georgia Plan

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Policy Summary

PayerAmerigroup

PolicyTherapy for Children's Disabilities - Georgia Plan

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 18, 2010

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthstypical initial approval period

SS ≤ 69severe/profound threshold

3meaningful change (SS/DQ)

1meaningful change (scaled score)

Coverage and Medical Necessity Criteria

Medically necessary therapy (initial and maintenance)

Covered when ALL of the following are met (medical necessity and documentation requirements):

Medical necessity and documentation: Therapy must be prescribed to correct or ameliorate defects, illnesses, or health conditions and supported by documentation including baseline standardized assessment, measurable treatment goals, and required attachments (IEP/IFSP or attestation, testing, progress notes).see documentation module

Determination is based on EPSDT and state contract language.

Approval period and reassessment: Medically necessary services may be approved for up to six months; re-evaluation is required at least every six months and continuation is contingent on documentation of significant improvement or achievement of specific treatment goals.6 months

Shorter certification periods may apply when expected response to therapy is questionable due to complicating conditions.

Maintenance therapy criteria

Explanation of barriers that prevent caregiver performance of the maintenance plan in the child's natural environment.
A time-limited plan (2-4 weeks) to transfer therapy tasks to the caregiver and change the therapist role to supervisory with occasional clinical/educational/administrative services.
Documentation of attempts to teach maintenance services/techniques to the caregiver and the results of those attempts.
Documentation of decline in function when therapy was previously decreased or discontinued.

Denial / Not medically necessary

Not covered / denied when ANY of the following apply:

Denial conditions: Requests with incomplete information; no significant improvement demonstrated over at least six months of treatment; the member's condition no longer meets the definition of disability; duplication of services (same treatment areas/goals or addressing the same types and degrees of disability as other concurrently provided services, including IEP/IFSP).N/A

Requests not meeting review criteria may be forwarded to the medical director for determination.

Services that are experimental, investigational, or cosmetic are excluded per the referenced state contract and Amerigroup policy language (see Section 4.5.5 and related Georgia DCH provisions). Services provided pursuant to an IEP/IFSP for members age 3–21 remain fee-for-service Medicaid and are not the contractor's responsibility; the contractor is responsible for medically necessary IDEA Part C services for members up to and including age two and for other medically necessary services as defined in the contract.

Therapy is considered not medically necessary when it fails to demonstrate significant improvement after an appropriate course of active treatment (generally at least six months), when a condition no longer meets the policy definition of disability, when services are duplicative of concurrently provided services (for example, identical goals or treatment areas provided via an IEP/IFSP or other providers), or when maintenance therapy does not legitimately require the skilled services of a therapist. Requests with incomplete information may also be denied after medical director review if required documentation is not submitted.

Diagnosis Codes, Testing Thresholds, and Examples

Diagnosis codes / required diagnosis examplesICD-10 | ICD-9 | mixed

ICD-9 / ICD-10 (after 10/01/15)	Primary diagnosis code to be provided (document lists ICD-9 and notes ICD-10 after 10/01/15)
299.00, 299.80, 299.90	Autism spectrum disorders - additional documentation required

Developmental testing thresholds — inv-06

Standard score thresholdStandard score less than 85 indicates developmental disability

Scaled score thresholdScaled score less than 7 indicates developmental disability

Developmental Quotient (DQ) thresholdDevelopmental quotient (DQ) less than 80 indicates developmental disability

Significant change definitionSignificant change defined as ±3 points in standard score or DQ, or ±1 point in scaled score

Severe/profound deficit example — inv-07

Severe/profound score exampleStandard Score (SS) of 69 or below may still warrant additional therapy depending on frequency, setting, or additional needs of the child

Authorization, Documentation, and Denial Risks for Providers

Prior Authorization

Prior authorization: initial approval and reauthorization every 6 months

Medically necessary therapy services may be authorized for up to six months; continuation/reauthorization requires documentation of baseline standardized assessment, measurable objective changes in functional status, and re-evaluation every six months. Shorter certification periods may be used when expected response is questionable due to complicating conditions.

Initial approval period: up to six months.
Reauthorization requires baseline standardized assessment and demonstration of measurable objective functional change; re-evaluation required every six months.
Shorter certification periods may be applied when response is questionable.

Step Therapy

Maintenance therapy must include time-limited caregiver transfer plan and teaching attempts

Maintenance therapy is allowed only when requirements are met: provide an explanation of barriers preventing caregiver performance; include a time-limited transfer plan (2–4 weeks) to change the therapist role to supervisory; document attempts to teach the caregiver and results; and document decline in function when therapy was previously decreased or stopped.

Background and Policy Scope

Developmental disability is defined by functional impairment on standardized assessment — for example, a standard score <85, scaled score <7, or developmental quotient (DQ) <80 (with DQ calculated as developmental age divided by chronological age × 100 and corrected for prematurity when applicable). Medically necessary therapy must be prescribed to correct or ameliorate identified deficits and be supported by baseline standardized assessment, measurable treatment goals, and required documentation. Initial authorizations are typically for up to six months, and continuation depends on documented significant improvement (see definitions for numeric thresholds) or achievement of specified goals; maintenance therapy is permitted only when caregiver transfer plans and documentation meet the policy's requirements.

Definitions and Thresholds

Developmental disability / Developmental Quotient (DQ) — inv-16

Definition of developmental disabilityInability to perform age-appropriate functional skills as indicated by standard test scores <85, scaled score <7, or DQ <80

DQ formulaDQ = (developmental age / chronological age) × 100; adjust for preterm birth before 37 weeks in first 24 months

Alternative instrumentsDisability may be defined by other testing instruments subject to review (e.g., Buros Center for Testing)

Speech/language disability definitions — inv-17

Stuttering criteriaStuttering qualifies as disability only when ALL are present: SSI scores in moderate or severe range; symptom duration >6 months; associated struggle behaviors

Misarticulation intelligibility thresholds

Policy Summary

PayerAmerigroup

PolicyTherapy for Children's Disabilities - Georgia Plan

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 18, 2010

Next Review DateN/A

SourceLink

On This Page

Determination contextDecisions made on individual basis after review of treatment notes and/or peer-to-peer discussion

Relation to school servicesAdditional therapy outside the school setting may be appropriate despite severe scores

Describe barriers preventing caregiver from performing maintenance in the natural environment.
Include a 2–4 week time-limited plan to transfer skills to the caregiver and shift therapist to supervisory role.
Document attempts to teach maintenance techniques to the caregiver and outcomes of those attempts.
Document decline in function after prior decrease or discontinuation of skilled services, if applicable.

Documentation Required

Required documentation: submit Attachment 1 items and physician-signed treatment plan

Submit the information listed in Attachment 1 with authorization requests: primary diagnosis with ICD code, pertinent past medical/family history, corrected age if <3 years and born preterm, prior rehabilitation therapy history, IEP/IFSP or attestation, hearing and vision screens, results of standardized testing if ≥6 months since last testing, copies of interval progress notes from prior certification, and a physician-signed active treatment plan within the past six months showing sessions, units, duration, and measurable goals.

Primary diagnosis and ICD-9/ICD-10 code.
Pertinent past medical/family history and comorbid diagnoses.
Corrected age for children <3 years born preterm.
Previous rehabilitation therapy history (dates/providers).
IEP or IFSP: copy attached or attestation if none exists.
Hearing and vision screen dates/method/results.
Results of standardized testing if ≥6 months since last testing and copies of interval progress notes.
Physician-signed active treatment plan within past 6 months specifying sessions/week, units/session, duration (weeks), and specific measurable goals.

Documentation Required

Provider attestation required when no IEP/IFSP (Attachment 2)

When no IEP or IFSP exists, the provider must complete the attestation (Attachment 2) confirming they reviewed the facts, discussed services with the parent/legal guardian, and that no IEP/IFSP exists; if an IEP/IFSP does exist it must be submitted with the request.

Provider must sign Attachment 2 attesting review and parental discussion and confirming absence of IEP/IFSP.
If an IEP/IFSP exists, a copy should be submitted with the authorization request.

Denial Risk

Incomplete information can lead to denial after medical director review

Requests submitted with incomplete information may be denied for lack of medical necessity after review by a medical director; the requesting provider will be notified of the specific missing information.

Incomplete authorization requests are subject to denial following medical director review.
Provider will be informed of what specific information is missing.

Denial Risk

Denial risk if no significant improvement after ≥6 months or condition no longer meets disability definition

Therapy may be denied as medically unnecessary if no significant improvement (per policy definitions) can be demonstrated after at least six months of treatment, or when the member's condition no longer meets the policy definition of disability.

No significant improvement over a treatment period of at least six months can result in denial.
Services will be denied when the member no longer meets the definition of disability.

Denial Risk

Requests duplicative of IEP/IFSP or concurrent services will be denied

Services that provide the same treatment areas, goals, or processing codes and address the same types and degrees of disability as concurrently provided services (e.g., IEP/IFSP or other community providers) will be considered duplicative and denied as medically unnecessary.

Duplication defined by same general treatment areas/goals or same types/degrees of disability despite differences in setting, intensity, or modality.
Determination of duplication is made individually after review of treatment notes or peer-to-peer discussion.

Intelligibility to unfamiliar listener: <25% (18–23 months), <50% (24–35 months), <75% (36–47 months), <100% (>=48 months)

Dialect considerationMisarticulation in presence of dialectical differences is not considered disordered per ASHA guidance

Significant improvement / Decline in function — inv-18

Significant improvement (scores)Increase in standard score or DQ by ≥3 points, or scaled score by ≥1 point constitutes significant improvement

Significant improvement (functional)Achievement of a specified developmental milestone, self-care skill, or adaptive ability within a specified timeframe as in the treatment plan

Alternate metricDecrease in ICF Qualifier Code by one in one or more domains indicates significant improvement; decline defined analogously