OHCA Policies and Rules
317:30-5-728. Physical therapy (PT) for alternative treatments for pain management
[Revised 09-12-22]
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.
(3) Frequency/coverage. A PA for PT for adult treatment of pain management services may be approved for a total of forty-eight (48) units per calendar year. A PT unit for the treatment of pain management in adults is 15 minutes. A visit may consist of multiple units of service on the same date, the time for units of service is added together and rounded up only once per visit.
(4) Reimbursement. All alternative treatments for pain management services, that are outlined in Part 82 of this Chapter, are reimbursed per the methodology established in the Oklahoma Medicaid State Plan.
(5) Discontinuation of services.
(A) If the member's condition is not improving, or the member's condition is regressing, then services will not be considered medically necessary.
(B) The OHCA may withdraw authorization of payment at any time if it is determined that the member and/or provider is not in compliance with any of the requirements set forth in this section.
(6) Non-covered services.
(A) PT provided solely for maintenance.
(B) Therapeutic or physical modalities used to augment a PT program.
Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.
