1. Purpose and Scope. This chapter includes the procedures that DEEOIC claims staff use in evaluating and approving requests for ancillary medical services, DME and supplies, and related expenses.
2. Requests for Ancillary Medical Services and Related Expenses. This chapter provides further guidance relating to the review process for requests pertaining to a wide variety of ancillary services and related expenses. A claimant, AR, treating physician, or a provider may request the services and related expenses described in this chapter. Requestors are to make their claims by sending them to the DEEOIC BPA via fax, mail, or electronic submission. The assigned MBE, or FAB staff person, who receive requests through OIS, forwards them to the BPA.
a. The BPA creates an electronic record of the request and initiates a thread to the FO at the DO where the claimant’s case file resides. The thread from the BPA advises the FO of a pending request for authorization of services. For DME or supplies requests, the thread details will include a statement indicating if any requested DME or supplies are subject to the OWCP Medical Fee Schedule.
b. The requestor must submit a Letter of Medical Necessity (LMN) (or an updated LMN in the event that reauthorization for an additional period of time is being requested). A LMN is the written explanation from the treating physician describing the medical need to assist the claimant in the treatment, care, or relief of their accepted work-related illness(s). To ensure that the physician’s opinion derives from a recent physical assessment of the claimant’s medical status, the physician is to document that a face-to-face visit/evaluation occurred between the claimant and the prescribing physician, within six months prior to the date that the physician orders the service. The LMN must clearly identify the type of ancillary medical service sought, explain why it is medically necessary for the accepted condition, and specify the duration of use. The requestor is to submit any supporting documentation substantiating the medical need for the requested service (i.e.; medical reports, prescriptions, therapy reports, diagnostic reports).
c. Requests submitted for authorization are to include the following:
(1) Claimant information such as name, case file number, date of birth, and telephone number.
(2) Provider, supplier, or requestor information including name, provider address, provider number, Tax ID number, National Provider Number (NPI), telephone number, and fax number.
(3) Prescribing/treating physician contact information including name, address, telephone number, and fax number.
(4) The billing code(s) such as HCPCS and/or Current Procedural Terminology (CPT), code modifier(s), total cost, begin date, and end date.
(5) Diagnosis code(s) for the condition(s) for which the item(s) is being prescribed.
(6) In addition, requests submitted for authorization for DME or oxygen therapy DME and oxygen medical supplies are to include the following:
(a) Supporting documentation that provides the need for DME and/or Medical Supplies (i.e.; prescription, narrative LMN, supporting medical documentation).
(b) Equipment billing code(s) (HCPCS/CPT), modifier(s), quantity, purchase price and rental price, total cost, begin date, end date, duration of use and frequency.
(c) The provider will need to bill with the appropriate billing modifier to receive reimbursement. If the billing modifier is missing or invalid, the BPA will deny the bill.
(d) Prior to payment being made for purchased equipment, the provider is to submit, along with the bill, proof of a transferred title to the claimant, bill of sale, and/or signed invoice by the claimant indicating receipt of the purchased equipment.
d. Upon receipt of an authorization request, not accompanied by appropriate medical evidence, the MBE begins development.
(1) The MBE sends a development letter to the claimant advising that he or she has received a request, but without the required supporting documentation. The MBE’s development letter to the claimant must include a clear description of the medical documentation needed to support the request, and grant the claimant 15 calendar days to provide the evidence. If the requested evidence is not received within the 15 day period provided, the MBE sends a second development letter, providing an additional 15 days to receive the requested evidence. The MBE also notifies the claimant that a lack of response or submission of insufficient evidence will result in a denial of the request. (Exhibit 29-1 provides a sample development letter for ancillary medical services. Exhibit 29-2 is a sample development letter for DME / Oxygen therapy and related medical supplies.) The MBE updates the correspondence section of ECS to record the issuance of the development letter, once mailed.
(2) A MBE may utilize the services of DEEOIC Nurse Consultants in assessing the rationale of the prescribing physician in justifying the medical necessity of prescribed ancillary services or DME. In any instance where a DEEOIC Nurse Consultant identifies a concern with the LMN from a claimant’s physician, the MBE must permit the claimant’s physician the opportunity to provide clarification. In those situations where the claimant’s physician does not provide clarifying rationale to address a deficiency in the evidence within 15 days, the MBE may refer the matter to a CMC for review.
e. Communicating the decision to the requestor. Upon completion of all appropriate development steps for the requested services, and upon review of all evidence submitted, the MBE communicates a decision to approve or deny such services to the requestor. The MBE sends an e-mail to the FO, who prepares and sends a thread to the BPA, authorizing or denying the claimed medical services or related expenses. The MBE also creates a correspondence entry in the Correspondence screen of ECS, documenting the decision.
f. Communicating the decision to the claimant. When the MBE receives a request for authorization, accompanied by appropriate medical evidence, the MBE prepares an authorization letter to the claimant, approving the requested services (See Exhibit 29-3 for a Sample Letter for authorizing ancillary medical services or Exhibit 29-4 for a sample letter authorizing DME, Oxygen Therapy and related supplies). The MBE sends a copy of the letter to the supplier/vendor designated by the claimant. The approval letter is to include the following information:
(1) Covered medical condition(s) for which the DME is approved, massage therapy is prescribed, or the condition to be treated with acupuncture.
(2) Authorized billing code(s) relevant to the approval.
(3) Time period (To and From dates) during which the DME rental/purchase is authorized and/or number of frequency and visits approved for massage therapy and acupuncture therapy (i.e.; two visits per week for eight weeks).
(4) Statement advising that fees are subject to the OWCP Medical Fee Schedule.
(5) Statement advising that if the rental is converted to a purchase, rental expenses incurred and paid will be deducted from the purchase price and only the difference will be reimbursed.
3. DME. A physician must prescribe all DME, supplies, and custom devices. DME serve a medical purpose and can withstand repeated use (e.g.; hospital beds, walkers, and wheel chairs, etc.).
a. A MBE must review all requests for the rental and/or purchase of DME to determine their medical necessity. Requests for DME rental or purchase require pre-authorization.
b. In instances where DME, supplies, and custom devices have a total purchase price greater than $500 and the OWCP Medical Fee Schedule does not apply, the MBE is to undertake development with the claimant.
(1) The claimant must submit two estimates from two different DME suppliers to include the supplier name and supplier contact information. These estimates must be for exactly the same type of DME, and/or supplies.
(2) Each potential supplier must submit a signed statement describing the DME, supplies, or unadorned item meeting the treating physician’s specifications, and a breakdown of all costs including delivery and installation, and the current Healthcare Common Procedure Code System (HCPCS) code for each DME, supply and/or item needed.
c. Where the purchase of DME, supplies or custom devices are less than $500 or when the OWCP medical fee schedule applies, the MBE may approve the purchase request, after appropriate medical evidence is received, without obtaining cost estimates.
d. The MBE reviewing a DME request may consider authorization for rental rather than purchase. In most situations, DME rental is the preferred choice. The MBE may authorize the rental of DME for up to six months.
(1) The MBE should review the LMN and the provider-submitted rental proposal to ensure that the DME will satisfy the needs of the claimant as outlined by his or her physician. If the MBE determines that the rental meets the medical requirements of the physician, he or she is to grant authorization for DME rental for six months (or less depending on the need of the claimant). The MBE mails a letter of authorization to the claimant, along with a copy to the chosen DME provider. Additional details on the DME authorization are provided later in this section.
(2) For each DME rental authorization that may extend beyond the initial authorization period, the MBE is to enter a reminder in ECS that reauthorization occurs at a six-month interval. The MBE must set the reminder to occur 60 days prior to the expiration date of authorized DME rental.
e. In certain situations, the MBE may authorize the purchase of DME or supplies. When considering the purchase of DME, the MBE is to use discretion to ensure that any authorization granted for the purchase of any DME satisfies the medical needs of the claimant. The MBE should not authorize a request for DME based on convenience, comfort, or other non- medical reasons.
f. DME purchases can only be approved if the MBE is able to obtain such an option from an enrolled provider.
(1) Items that should not be rented but considered for purchase include medical/surgical supplies (i.e.; ostomy, incontinence, dialysis, wound care), canes, crutches, and commodes.
(2) The MBE may evaluate a DME purchase, when the purchase price of such equipment or item is more cost effective than the rental price. For example, if the price of renting a standard wheelchair is more than the cost to purchase it, the MBE should approve the purchase of the wheelchair rather than renting it.
(3) When reauthorizing rentals, the MBE must consider whether the cost to purchase the equipment, minus the rental amount paid, is less than the total cost to authorize another six months of rental. If agreeable with the claimant and the DME provider, the MBE may authorize the purchase of such equipment. Otherwise, the MBE is to continue to review the claim as a DME rental.
(a) Situations may arise when the MBE previously authorized the rental of a DME, then subsequently receives a request for authorization to purchase that same item. Under these circumstances, it may become necessary to convert the rental to a purchase. If the MBE receives a request for a purchase, the rental charges were paid for the same DME with no break in service between the rental period and the approved purchase period and the provider who billed for the rental is the same as the provider now requesting the purchase, the MBE must request that the provider deduct the rental charges previously paid from the cost of the item being purchased. DEEOIC reimburses all post-purchase requests (from a rental) in accordance with the applicable OWCP Medical Fee Schedule amount.
g. Repair/Maintenance Cost. The MBE must authorize the cost for modifications and maintenance to DME equipment when evidence is received validating the need for changes/repair/maintenance of previously approved DME.
h. Replacement. A new request must be submitted if a claimant requires a replacement of previously purchased equipment approved by DEEOIC for purchase. The MBE must approve DME for replacement if the equipment is three years or older, inoperable and beyond repair, or the request demonstrates repair costs that exceed the cost to replace the equipment, and that the equipment is no longer covered by warranty, or if the equipment is lost or stolen. In the event the equipment is stolen, the claimant must furnish a police report documenting the incident. The MBE can consult with the NO MBPU for situations involving unique or unusual circumstance.
i. DME add-ons or Upgrades. DEEOIC will consider approval for DME add-ons or upgrades where the evidence substantiates the medical need for the enhancement. Add-ons and/or upgrades are not approved for the claimant’s convenience or where such enhancements do not significantly improved DME functionality.
j. Emergency situations. The MBE may authorize the rental of DME for a preliminary 30-day period while additional development is undertaken.
(1) If medical documentation from the treating physician supports the need for immediate DME authorization, the MBE provides approval for 30 days pending additional development.
(2) The MBE sends a letter to the treating physician (with a copy to the claimant) requesting necessary evidence to substantiate that the DME is medically necessary. This should occur within the preliminary 30-day authorization period. The MBE may grant extensions in increments of 30 days, not to exceed a total of six months, while awaiting necessary medical evidence.
k. When the MBE receives a request for authorization of DME and appropriate medical evidence does not accompany the request, the MBE begins development. Refer to Section 2(d) for further guidelines to begin development.
l. When the MBE receives a request for authorization of DME, accompanied by appropriate medical evidence, the MBE prepares a decision letter to the claimant authorizing the DME. Refer to Section 2(e-f) for further guidelines in communicating a decision.
4. Oxygen Therapy DME and Oxygen Medical Supplies. This section provides procedural guidelines the MBE follows when reviewing and authorizing requests for the rental or purchase of Oxygen Therapy DME or Oxygen Medical Supplies.
a. Physicians prescribe Oxygen Therapy DME and Oxygen Medical Supplies to treat patients diagnosed with different forms of pulmonary disease. Some examples of Oxygen Therapy DME and Oxygen Medical Supplies include stationary and portable oxygen concentrators, gaseous and liquid oxygen delivery systems, cannulas, tubing, regulators, etc. (Exhibit 29-5 provides definitions and describes the functions of some of the more commonly prescribed oxygen DME.) The MBE reviews requests for the rental and/or purchase of Oxygen Therapy DME and Oxygen Medical Supplies to validate their medical necessity. Refer to Section 2(c) to see what is required for authorization.
b. Upon receipt of the request for rental or purchase of Oxygen Therapy DME and/or Oxygen Medical Supplies, the MBE evaluates the medical evidence to determine if there is sufficient justification to authorize the request as medically necessary for the treatment or care of an accepted condition.
(1) As noted earlier in this chapter, the MBE must obtain a LMN from a claimant’s physician that provides a written explanation regarding the justification for any prescribed ancillary services or equipment. For Oxygen Therapy DME or Oxygen Medical Supplies, the prescribing physician must describe the diagnostic or clinical evidence that supports the medical necessity for the prescribed care in treating the accepted pulmonary condition.
c. Additional Information. If the MBE determines the evidence is deficient, for example, the physician has not provided a clear description of the needed Oxygen Therapy DME and/or Oxygen Medical Supplies, or has not provided information on the duration or use of the prescribed equipment, the MBE initiates development. Refer to Section 2(b) for guidance on development.
d. Upon receipt of appropriate evidence establishing the medical necessity for Oxygen Therapy DME and/or Oxygen Medical Supplies, the MBE proceeds to assess whether it is appropriate to authorize a short-term rental, continuous rental, or a purchase of the requested DME.
(1) For authorization of equipment rentals, the DEEOIC will reimburse monthly charges for the approved equipment. A rental period for oxygen equipment is one month (30 or 31 days) and is equivalent to one unit of service. When oxygen equipment is purchased, the DEEOIC will reimburse for a one-time charge, not to exceed the total allowable amount as set forth in the OWCP Medical Fee Schedule.
(2) If the request for oxygen equipment is for a period of 90 days or less, oxygen equipment shall be reimbursed on a monthly rental basis according to the OWCP Medical Fee Schedule. The rental reimbursement amount includes delivery, set-up, education, and training for the claimant, and is not separately reimbursable.
(3) If the request for oxygen equipment is for a period of less than 30 days (partial month), reimbursement occurs on a daily basis. The MBE is to authorize units by the number of days that is being requested (e.g.; the request is for dates of service 4/1/2016 – 4/20/2016. The maximum number of units authorized is 20).
(4) If the request for oxygen equipment is for a period of more than 90 days, the MBE is to approve continuous rental, up to one year, or purchase of prescribed oxygen equipment if requested by the DME supplier.
(5) In emergency or urgent situations (such as the claimant being discharged from the hospital to home with urgent oxygen needs), the MBE can authorize up to a 30-day rental period for oxygen equipment, while additional development is undertaken. The MBE may grant additional extensions of 30-day increments during development, not to exceed a six month period.
e. Authorization Limitations. The MBE is to adhere to the following restrictions when evaluating claims for Oxygen Therapy DME and/or Oxygen Medical Supplies.
(1) Approval for a portable oxygen system (liquid or concentrator) will only be made in combination with a request for a stationary system, or after verification by the MBE that the claimant already has a stationary system in the home.
(2) Approval should not be given for more than one delivery system within a claimant’s home. A claimant is entitled to one stationary and one portable oxygen system during an authorization period unless there are extenuating circumstances justified by medical rationale (LMN).
(3) Approval for a mechanical ventilator will be coordinated by the DEEOIC Medical Director. The DO will obtain the properly completed LMN, a copy of the hospital admission history and physical, hospital discharge summary, and a detailed report from the claimant’s treating physician containing diagnosis, prognosis, proposed treatment regime, and the qualified professional(s) who will monitor the claimant and the ventilator. Once the completed information package is obtained, the MBE forwards it to the DEEOIC Medical Director for review and consideration. The MBE addresses any such requests to the DEEOIC Medical Director, through the DEEOIC Bill Pay Mailbox. Further information regarding this mailbox is discussed in Chapter 10 – Resource Centers
f. Upon the approval of either rental or purchase of the prescribed Oxygen Therapy DME and/or Oxygen Medical Supplies, the MBE prepares a decision letter to the claimant and the requestor as outlined above in Section 2, e-f, authorizing the equipment and/or supplies. Renewal of an existing authorization requires the claimant to obtain a LMN demonstrating a continuing need for the oxygen therapy DME or oxygen medical supplies.
g. DEEOIC will reimburse for repair, maintenance, non-routine service, modifications necessary to make the equipment operable, and replacement of medically necessary oxygen equipment that a claimant owns. DEEOIC will not provide separate reimbursement for maintenance and service for DME covered under a manufacturer or supplier warranty agreement unless the charges are excluded from the warranty. Reimbursement for repair, maintenance, non-routine service, or replacement of rented oxygen equipment is included in the monthly payment allowance and is not separately reimbursable.
h. All repair, maintenance, and non-routine service requests for authorization must include the following:
(1) Supporting documentation itemizing each repair/maintenance/non-routine service.
(2) The request for authorization is to indicate that the equipment is claimant-owned (non-rented) and out of warranty.
(3) DEEOIC will not authorize separate travel time or equipment pick-up and/or delivery time. Services are reimbursed according to the OWCP Medical Fee Schedule.
(4) DEEOIC allows up to two hours of service within a 120-day period. If a MBE receives a repair request for more than two hours of service within a 120-day period, the MBE forwards the request and supporting documentation to the NO for review through the DEEOIC bill pay mailbox. The MBE is to list details of the documented thread, including the document control number retrieved from the Xerox Transaction Content Management (XTCM) stored image retrieval system and/or attached supporting documentation.
(5) The request for authorization is to indicate whether a temporary replacement or “loaner” will be required. If a temporary replacement or loaner is required, DEEOIC will authorize the temporary equipment on a rental basis for up to a one-month period, not to exceed the estimated repair time.
(a) The temporary replacement request is to include a description of the equipment being dispensed, and is to be the same type of equipment that the claimant uses to treat their illness.
(b) A new LMN is not required for the repair or temporary equipment as long as the type of equipment and/or the medical necessity is unchanged. DEEOIC will cover the cost for repair up to the OWCP Medical Fee Schedule maximum allowable amount, not to exceed the cost of a replacement.
(6) A new request must be submitted if a claimant requires a replacement of previously purchased equipment approved by DEEOIC for purchase. The MBE must approve DME for replacement if the equipment is three years or older, or it is inoperable and beyond repair, or the request demonstrates repair costs that exceed the cost to replace the equipment, and that the equipment is no longer covered by warranty, or if the equipment is lost or stolen. In the event the equipment is stolen, the claimant must furnish a police report documenting the incident. The MBE can consult with the MBPU for situations involving unique or unusual circumstance.
i. DME suppliers may not automatically deliver additional oxygen accessories or medical supplies to claimants without a request from the claimant, an order from the treating physician, or a pre-determined schedule that is medically necessary. Accessories and supplies are comprised of, but not limited to, regulators, wheeled carts, stands, battery packs and chargers, cannulas, tubing, oxygen contents, etc. When authorizing contents and content refills:
(1) For the Rental of a Stationary Gaseous System/Liquid: The content refills are included in the rental price. Therefore, contents are not separately reimbursable.
(2) For the Rental of a Portable Gaseous System/Liquid. The MBE can approve contents for the duration of the rental of a portable gaseous system or portable liquid system. One unit of contents is equal to one month’s supply. Therefore, when authorizing contents for the rental period of a portable gaseous system, the MBE should only authorize one unit per month.
(3) For the Purchase of a Gaseous System/Liquid. Purchased systems do not include contents, thus, when authorizing the purchase of a gaseous system or liquid system the MBE authorizes contents for a period of one year. Contents are authorized based on one unit per month (i.e.; 12 units = one year). The claimant must provide an updated LMN that supports the need for continued authorization of additional contents.
5. Massage Therapy/Acupuncture Treatments. This section provides procedural guidance with regard to the review and development process leading up to an authorization or denial of a request for Massage Therapy and/or Acupuncture Treatments.
a. The treating physician must prescribe massage therapy and/or acupuncture treatment only for the treatment or care of the claimant’s covered medical condition(s). Along with the signed prescription from the treating physician, the requestor must submit a LMN to reflect that an initial face- to-face visit was held with the claimant. Face-to-face visits are only required for the initial pre-authorization request. The narrative of the LMN should describe the unique physical and therapeutic benefits that the claimant will derive from massage therapy or acupuncture treatment, and specify the frequency and duration of care to be provided in allotments of time (e.g.; twice a week for eight weeks).
b. When the CE receives a massage therapy and/or acupuncture treatment request unaccompanied by an LMN, the MBE begins development. Refer to Section 2(d) for further guidelines to begin development.
c. If the MBE receives the appropriate medical evidence within the 30-day development period, the MBE prepares a letter to the claimant authorizing massage therapy and/or acupuncture treatment. Refer to Section 2(e-f) for further guidelines in communicating the approval.
d. The initial authorization period may be fewer than, but should not exceed eight weeks, and the MBE may approve up to two visits per week, for 16 visits during the initial authorization period. Each visit is equal to a maximum of 1.5 hours. Reauthorization, including obtaining updated medical evidence is required for any request for additional massage therapy or acupuncture treatment after the initial eight-week period. The MBE may not authorize more than 60 massage therapy and/or acupuncture treatment visits per calendar year.
e. If, at the end of the initial eight-week authorization period, the MBE receives a new request for additional massage therapy and/or acupuncture treatment, the MBE must conduct a new evaluation of the medical necessity for continuation of care. If the request is appropriate (updated medical documentation adequately explains the medical necessity for continuing massage therapy and/or acupuncture treatment), the MBE grants authorization for the extension of care within the authorization parameters of no more than two visits per week and a maximum of 60 visits per year.
f. Massage therapists and/or acupuncture providers, must hold a valid massage therapist’s license or certification in the state where services are rendered.
g. Massage therapy and/or acupuncture treatment services must be conducted in an appropriate setting (i.e.; medical clinic, medical office) and should be billed daily (i.e.; one date of service per OWCP-1500 line).
(1) The service provider must submit medical notes to the DEEOIC’s BPA, along with their bill, describing the particular therapeutic care provided during each visit with the claimant. The notes should describe the effect of the massage therapy, including any specific improvements in functionality or in achieving relief from the symptoms of a compensable illness. The BPA then forwards the medical notes to the DO for review.
(2) The OWCP Medical Fee Schedule does not provide a separate allowance for massage therapy and/or acupuncture supplies (i.e.; tables, equipment). The cost of supplies is factored into the fee schedule amount.
h. If the MBE receives a request for in-home massage therapy and/or acupuncture treatment, the claimant must be homebound in order to receive authorization for such services. Medical evidence from the treating physician must demonstrate that the claimant is medically unable to travel to obtain massage therapy and/or acupuncture treatment. Once the MBE receives convincing evidence that the claimant is not able to travel for care, and sufficient documentation exists regarding the medical necessity for care, the MBE may authorize in-home massage therapy and/or acupuncture treatment.
i. Massage therapy and/or acupuncture treatment is not restricted by medical diagnosis or condition, but is not appropriate when prescribed solely for prevention of future injury, recreation (spa therapy), and/or stress reduction.
6. Chiropractic Services. The MBE may authorize chiropractic services limited to treatment for correction of spinal subluxation, along with the tests performed or required by a chiropractor to diagnose such subluxation. A physician or chiropractor must document a diagnosis of spinal subluxation in his or her LMN as demonstrated by an x-ray before a MBE can authorize services, and the spinal subluxation must be related to an accepted condition.
7. Pulmonary Rehabilitation. The MBE is required to authorize pulmonary rehabilitation services when prescribed by the treating physician. The treating physician must submit a LMN describing the need for pulmonary rehabilitation and its association to an accepted work-related illness. The LMN must specify the type, amount, frequency, and duration of pulmonary rehabilitation. The LMN must also include measurable and expected outcomes and estimated timetables to achieve these outcomes. Pulmonary rehabilitation must be conducted in an outpatient hospital setting or doctor’s office. A MBE may authorize pulmonary rehabilitation for a period of up to six months. Recertification is required for any period beyond six months. Recertification should be completed before the current authorization expires, to allow for care to continue uninterrupted.
8. Hearing Aids. A claimant requesting hearing aid(s) must submit a LMN from his or her treating physician. The LMN must contain an explanation for obtaining hearing assistance due to an accepted work-related hearing loss. Services associated with the assessment, provision or fitting of hearing aids must be rendered by a licensed otolaryngologist, otologist, audiologist, or hearing aid specialist. Hearing aids are limited to one per ear every three years. The MBE must authorize needed repairs within the three-year period, if the manufacturer’s warranty has expired.
When submitting a bill for a hearing device dispensing fee, providers are to indicate the current Healthcare Common Procedure Coding System (HCPCS) procedure code that most appropriately reflects the quantity of hearing devices dispensed. For example, if a provider dispenses one hearing device to a claimant, the provider is required to indicate the HCPCS dispensing fee for a monaural hearing device. Hearing aid dispensing fees will be reimbursed per the OWCP fee schedule. The MBE only approves hearing aid dispensing fees when hearing aids have been authorized by DEEOIC.
9. Organ Transplants (including Stem Cell). Organ transplants are a complicated and medically challenging treatment option. As a result, a special level of review is required. Once the FO alerts the MBE to a request for organ transplant, the MBE immediately obtains all relevant documentation from the treating physician relating to medical necessity of an organ transplant. In particular, the MBE seeks a LMN describing the justification for the transplant, laboratory and diagnostic test results, CT or MRI scan results, and a transplant protocol. Once the MBE has obtained this information, the MBE forwards the information to the MBPU, via the DEEOIC Bill Pay Mailbox, requesting review for organ transplant authorization. The MBPU will then forward all pertinent information to the DEEOIC Medical Director, who prepares a memorandum approving or denying the transplant. The MBPU will then forward the signed memorandum to the jurisdictional office responsible for the claim.
a. With notification of approval, the MBE updates ECS Notes with a confirmation of organ transplant authorization. The MBE then prepares a letter of authorization to the claimant with a copy to his or her physician. The letter is to provide notification on the organ transplant authorization including:
(1) Covered medical condition(s).
(2) Authorized billing code(s) relevant to the approval.
(3) Statement advising that organ transplants must be performed at a Center for Medicare and Medicaid Services (CMS) approved facility.
(4) Statement advising that fees are subject to the OWCP fee schedule.
(5) Statement advising that an organ donor is not considered an “employee” or “claimant” within the meaning of DEEOIC and is not entitled to compensation for wage-loss or permanent impairment, nor is a donor entitled to benefits for any post-operative complications resulting from the transplant. Only those medical and related expenses of the donor, which are necessary to secure treatment for the employee, are allowable.
b. In-Patient or Outpatient Setting. Depending upon the transplant center, the condition of the patient, and geographic limitations, transplant procedures may occur on an in-patient or outpatient basis.
(1) Autologous transplants may be performed in either an in-patient or outpatient setting, depending upon the transplant center. This type of transplant requires stem cells that have been gathered and stored, coming directly from the patient.
(2) Allogenic transplants may also be performed in either an in-patient or out-patient setting. Allogenic transplants require that donor-blood stem cells be drawn, stored, and then transplanted into the patient.
c. Choice of Donors.
(1) The first choice of a donor is generally a family member or relative. If the transplant facility approves a related donor, transportation expenses and the cost of required medical procedures for obtaining the organ(s) or blood stem cells are reimbursable. The transplant facility submits bills to the BPA, referencing the employee’s (recipient) SSN, and including the medical documentation/ information pertaining to the donor. Donor travel is reimbursed following the same guidelines established for companion medical travel, and is paid directly to the employee.
(2) If no suitable match is available through a relative, an unrelated donor search must be authorized. The transplant center coordinates with the National Donor Program for the testing of each potential donor. The transplant center submits bills to the BPA for all such tests and procedures. Unrelated donors are not paid for their donation; the only coverage is for the medical expenses related to the organ donor procedure. These procedures are billed by the transplant facility, the same as with related donors, referencing the covered employee’s SSN on all bills.
d. Long-Term Living Expenses. Transplants involve prolonged outpatient procedures requiring the patient to remain within a short distance of the transplant center. If the MBE authorizes a transplant procedure and if the claimant requires extended residency near the facility, the MBE must authorize lodging, per diem, companion, and other travel-related expenses on a long-term basis.
10. Mental or Psychiatric Illness Treatment. A MBE may accept a mental or psychiatric illness under a Part B or Part E claim as a consequential illness to another accepted illness. In these situations, the MBE must obtain a narrative medical report from a licensed clinical psychologist, psychiatrist, or licensed clinical social worker which includes:
a. Diagnosis (with correct ICD10 code) and the initial date of diagnosis.
b. Medical rationale in support of how the mental or psychiatric illness is related to a condition accepted by the DEEOIC under Part B or Part E of the EEOICPA.
11. Experimental Treatment. The MBE may consider authorizing experimental treatment if the accepted condition is life threatening, conventional therapy has been tried to no avail and a significant body of data supports the view that the experimental procedure is indeed beneficial.
To request experimental treatment, the treating physician must send the treatment protocol, medical rationale, and peer-reviewed documents supporting the treatment to the MBE. The MBE forwards the information to the MBPU via the DEEOIC Bill Pay Mailbox. The MBPU will forward all pertinent information to the DEEOIC Medical Director, who prepares a memorandum approving or denying the experimental treatment. The MBPU will then forward the signed memorandum to the requesting DO.
Upon receipt of the approval from the DEEOIC Medical Director, the MBE sends an email to the FO, who prepares and sends a thread to the BPA, authorizing the experimental treatment approved by the DEEOIC Medical Director. The MBE also documents the approval in the Notes section of ECS. The CE sends a copy of the approval letter to the provider designated by the claimant to provide the service. The approval letter must contain the following information:
a. Covered medical condition(s).
b. Authorized billing code(s) relevant to the approval.
c. Statement advising that fees are subject to the OWCP fee schedule.
12. Sun Protective Clothing. This section describes the procedures a MBE follows when authorizing a claimant’s request for reimbursement of sun protective clothing. DEEOIC has established a maximum $400 limit for sun protective clothing per calendar year. Sun protective clothing used for general health or personal reasons is not covered.
a. Sun protective clothing is clothing specifically designed for sun protection and is produced from a fabric rated for its level of ultraviolet protection. Sun protective clothing is clothing that offers at least 30 or more Ultraviolet-A (UVA) and Ultraviolet-B (UVB) sun protection for claimants with accepted conditions of melanoma, other skin cancer or other significant dermatologic condition.
(1) For authorization, the MBE obtains the following information:
(a) A LMN from the treating physician describing a medical need for sun protective clothing.
(b) The claimant must submit a receipt documenting that the clothing was purchased from a sun protective clothing company (i.e.; Solumbra or Coolibar).
(2) Once appropriate documentation is received, the MBE approves the reimbursement for the sun protective clothing using the OWCP procedure code Clothing Modifications - CLMOD.
13. Vehicle Modifications and Purchases. This section provides clarification with regard to the evidence needed to approve vehicle modifications and purchases, and provides procedural guidance with regard to the process for review, development, and authorization of such requests.
a. Criteria for Modifications. Upon receipt of a LMN describing a medical need for vehicle modification, and if the claimant’s medical needs can be met by modifying or adding accessories/equipment to the claimant’s present vehicle, the MBE explores that option first, before considering replacement of the existing vehicle. When considering modifications to an existing vehicle, the MBE takes into consideration the type of vehicle currently owned, its age, and condition. Modifications must be consistent with the claimant’s pre-injury standard of living and should approximate that standard insofar as practical.
b. Proposals. If the MBE determines that the claimant’s medical needs warrant vehicle modification, the MBE advises the claimant in writing to submit a detailed written proposal containing the following information:
(1) The year, make, model, and body style of the vehicle to be modified, as well as current mileage, description of general mechanical condition, and any modifications currently needed or anticipated. The same applies regardless of whether the vehicle to be modified is new or used.
(2) Detailed written estimates from two licensed automobile dealers, or custom alteration facilities, itemizing the proposed vehicle modifications necessary to comply with the treating physician’s LMN. Estimates must include a breakdown of all parts, labor, and the respective costs associated with each item. The estimates should also state the amount of time required to perform the modifications.
c. Acceptance by the MBE. The MBE has the latitude to approve an estimate that the claimant favors, if the estimates are reasonably similar in scope and cost.
(1) Approval or Denial. Upon review of the evidence, the MBE approves or denies the request by sending a letter decision to the claimant advising of the approval, or reason(s) for denial of the request.
(2) Additional Information. If the MBE determines that additional information is necessary, the MBE sends a letter to the claimant requesting the additional documentation that is necessary to continue with the review process.
(3) Inadequate response. If the claimant does not respond to the development letter, or does not provide sufficient documentation to support the request, after considering all relevant evidence, the MBE issues a letter decision informing the claimant of the authorization denial.
d. Vehicle Purchase. If the claimant provides a LMN establishing that modifications to his or her currently owned vehicle are not feasible or practical, and that a substitute vehicle is required for the claimant to operate, the MBE reviews the case with a supervisor and the NO FO, and may authorize the purchase of a suitable replacement vehicle. Under these circumstances, credit must be taken for the value of the claimant’s existing vehicle. Purchase options include the following:
(1) Purchase of a used vehicle, (similar in quality to the claimant’s existing vehicle), equipped to accommodate the claimant’s disability and transportation needs.
(2) Purchase of a used vehicle that is suitable for modification as described above.
(3) Purchase of a new vehicle, modified, or suitable for modification, to meet the needs of the claimant, arising from an accepted condition.
(4) Whether a new or used vehicle is purchased, it must be a vehicle of comparable value as the vehicle currently owned and operated by the claimant (i.e.; a vehicle in a price range that closely approximates the level of income and/or standard of living of the claimant). For example, if the claimant owns a mid-priced Chevrolet, Ford, Honda or Toyota; purchase of a Cadillac, Lincoln, or Lexus SUV, would not represent a vehicle of comparable value. Once the baseline cost of a comparable quality vehicle has been established, the claimant may (at his or her option) choose to upgrade the baseline model, by adding additional equipment, with the difference in cost being paid for by the claimant.
(5) After determining the baseline cost of a comparable vehicle, the MBE must take credit for (deduct) the wholesale value of the claimant’s existing car when determining the allowance to be paid for a replacement vehicle. The wholesale value of the existing vehicle can be determined through a number of internet websites that make this information available free-of-charge. The MBE should advise the claimant of the source of their information, once the wholesale value of the claimant’s current vehicle has been determined.
(6) Sales Tax. State sales tax should be included in the cost of obtaining a replacement vehicle.
(7) Equipment that is medically necessary for the accepted condition should be factory-installed whenever possible.
(8) Maintenance Costs. The MBE authorizes necessary maintenance on the specialized equipment in a modified vehicle, whether installed in a new or used vehicle.
(a) Replacement cost of the specialized equipment, due to normal wear and tear, may be considered as well. Other parts of the vehicle will be maintained at the owner’s expense, even if the vehicle purchase was reimbursed by DEEOIC.
(b) Replacement of the vehicle, and all authorized equipment, can be considered if the claimant can establish that the age, mileage, and condition of the vehicle warrant such replacement. Any residual value remaining in the vehicle to be replaced would be applied as a credit toward the cost of a replacement vehicle.
(9) Proof of Insurance. The claimant bears the cost of obtaining automobile insurance and maintaining current vehicular registration in conformance with the laws of the state within which the claimant resides. Claimants are required to carry comprehensive (fire, theft, vandalism) and collision insurance on any vehicle for which DEEOIC has authorized reimbursement, unless the fair market value of the vehicle and its equipment is less than $2,500. The claimant may select the deductible of the insurance policy but will be responsible for any such deductible should an accident occur.
(10) Vehicle No Longer Needed. If the MBE obtains information that a vehicle purchased by DEEOIC is no longer needed, the MBE will send an email to the DEEOIC Bill Pay Box Mailbox alerting MBPU of the situation. DEEOIC is entitled to recover the fair market value of the purchased vehicle, less any percentage contribution the claimant made to the overall purchase price of the vehicle and its modifications. The MBPU will undertake appropriate action to attempt recovery of any funds collectable through sale of a DEEOIC purchased vehicle no longer needed by a claimant.
14. Housing Modifications. This section provides clarification with regard to the evidence needed to approve housing modifications, and provides procedural guidance with regard to the process for review, development, and authorization of housing modifications. The MBE considers home modification only when deemed medically necessary due to an accepted condition. A MBE’s responsibility is to grant authorization to modify an existing structure to accommodate the claimant’s medical needs. The treating physician must describe in a LMN the particular home modifications needed to accommodate the claimant’s work-related illness.
a. Modifications to Owned Property. Modifications to a house must be consistent with the claimant’s pre-injury standard of living and should approximate that standard insofar as practical, with respect to the quality of construction materials and workmanship.
(1) Modifications may include certain additions where warranted. For example, if a ground-floor recreation room is converted to a bedroom, to accommodate a wheelchair-bound individual, and if no ground-floor bathroom facilities exist, then the addition of a bathroom on the ground floor could be approved. Similarly, if there is no suitable space for conversion of a bedroom on the ground floor, then the addition of a bedroom on the ground floor could be approved, if no other reasonable alternative exists.
(2) Modifications may include certain appliances, such as air conditioning or air filtration equipment, if deemed to be medically necessary by the treating physician, and necessary for the relief of accepted medical conditions. For example, if the claimant suffers from respiratory or cardiac conditions that have been accepted, his or her physician may order that the claimant be kept in an air conditioned environment, in which case the expense for these modifications would be allowed.
(3) When considering modification requests, the MBE should consider whether a portion of a home can be modified, as compared to a whole-house modification. An example of this would be one or two room air conditioning units, versus installing a whole-house air conditioning system.
(4) Maintenance expenses. The MBE approves maintenance expenses for equipment furnished to the claimant, as well as replacement costs, after the normal life expectancy of the appliance.
b. Modifications to Non-Owned Property. Any modifications to property not owned by the claimant, and his or her family, are subject to approval by the landlord or owner. This is in addition to the preceding guidelines established for owned property. When presented with a request for modifications to non-owned property, the MBE considers the following points:
(1) Rental property may be subject to federal Americans with Disabilities Act (ADA), state, or local statutes that mandate barrier-free accessibility for persons with disabilities. The claimant should discuss any change in housing needs with his or her landlord, who may be able to offer modifications or alternative accommodations better suited to the needs of the individual.
(2) If the landlord is unable or unwilling to pay for modifications, or offer other suitable accommodations, approval must still be obtained from the landlord prior to making any changes or alternations to the non-owned property. Any such changes must be made at the claimant’s expense, and are subject to review and approval by DEEOIC, prior to any reimbursement.
(3) If the landlord/owner will not permit modifications, or if the costs are excessive, and if suitable housing arrangements are available elsewhere, within the same geographic area, it may be more cost- effective to consider paying relocation expenses rather than paying for modifications at the current location. If changing locations is the most cost-effective alternative, the MBE may authorize a subsidy for any increase in rent, if warranted, in addition to the relocation expense. For example, if the claimant lives in an apartment with stairs, and is no longer able to climb stairs due to his or her accepted condition(s), DEEOIC would reimburse the claimant for the most nearly comparable apartment available that offers an elevator and any other accommodations required to fulfill the claimant’s medical needs arising from the claimant’s accepted condition(s).
(4) The Government is entitled to reimbursement only for the value of special equipment that can be removed and sold separately, once the claimant no longer needs that equipment. Improvements or modifications, and any increase in property value resulting from such changes, accrue to the benefit of the owner.
c. Proposals. If the MBE determines that the claimant is eligible for housing modifications, the MBE asks the claimant to submit a detailed written proposal for review and consideration. The MBE advises the claimant that the proposed housing modifications should be of a quality and grade consistent with the existing architecture and construction materials, not superior to them. Further, the claimant should be cautioned that structural modifications must not compromise the integrity of the existing structure.
Modifications will be no more expensive than necessary to accomplish the required purpose. For example, when remodeling a bathroom, it may be feasible to re-install an existing sink at wheelchair height, for less than the cost of discarding the sink and buying a new one.
Conversely, modifications must be in keeping with the standard of the décor of the current or pre-illness accommodations. For example, if the claimant’s dwelling requires that a sink or commode be changed for handicap accessibility, and if it is necessary to tear out and replace tile, then the tile in the entire bathroom or kitchen may have to be replaced with similar quality tile in order to maintain the architectural décor of the room.
Proposals must include the following information:
(1) A medical report detailing the physical limitations for which the requested modifications are necessary. This report should be prepared by a physician who is a recognized authority in the appropriate medical specialty.
(2) An itemization of all modifications proposed. Where substantial modifications are required, the detailed changes should be recommended by a medical or rehabilitation professional familiar with the needs of the disabled.
(3) If the claimant lives in a rented or non-owned premise, a written statement from the landlord/owner must be obtained, approving and authorizing the specific plans and proposed modifications.
(4) The MBE reviews the itemized proposal and determines if the specified modifications are warranted. If the MBE identifies technical issues regarding implementation, the MBE develops the issue further to identify alternate solutions.
d. Fees and Bids.
(1) Reasonable fees may be paid for the medical or rehabilitation professional’s visit to the site, and for the preparation of the detailed report. The same applies to any architectural drawings that are required for significant structural changes.
(2) No fee will be paid for attorneys or similar representatives engaged by the claimant to assist with the proposal. Any fee charged by an AR remains the claimant’s obligation.
(3) The claimant must provide two or more bids for the proposed changes from licensed and/or certified contractors. The bids submitted must be for exactly the same modifications so that comparison of the competitive bids can be made.
(a) If construction work is required, the bids obtained must be for binding estimates of the cost. No fees will be paid for the bids or estimates.
(b) If special accessories or devices are required, the MBE stipulates that the price quoted by the vendor includes any necessary installation.
(4) The MBE reviews the bids to determine that the same workmanship and materials are specified in the competitive bids, and normally selects the lowest cost bid, unless there is a sound reason for a higher-cost alternative, such as increased durability. If the MBE selects a bid other than the lowest-cost bid, a memorandum to the file is required, explaining any variance or the justification for a higher bid.
(5) Additional Information. If the MBE determines that additional information is necessary, the MBE sends a letter to the claimant requesting additional documentation that is necessary to continue with the review process.
e. Approval and Payment Options. Upon approval of the request, the MBE writes a detailed letter decision to the claimant advising of the approval (Exhibit 29-6 provides a sample of the home modification approval letter.) The approval letter is to include guidance to the claimant of the payment options available and requests that the claimant respond in writing, indicating his/her preferred payment option. For payment of home modification, the following is necessary:
(1) The claimant submits medical evidence and two proposals for home modifications. Upon review the MBE approves the lower cost bid proposal and sends a letter to claimant stating DEEOIC agrees to the approved scope and cost of repairs, and, at the claimant’s request, will make direct payment to the enrolled contractor, once the agreed upon work has been completed. The letter states that upon completion of the agreed-upon work, the claimant must submit a written attestation to DEEOIC stating that the agreed upon work has been completed by the contractor, to the claimant’s satisfaction, and requesting that payment be made to the contractor. The MBE sends a courtesy copy of this letter to the contractor.
(2) Upon receipt of the claimant’s attestation and request to pay the contractor, the MBE acknowledges the claimant letter and advises that the enrolled contractor should submit Form OWCP- 1500, along with a final invoice, in order to receive payment of the agreed upon price. The OWCP Code for HOME MODIFICATION - HSMDF is used, when preparing the Form OWCP-1500.
(3) In certain situations, the MBE may authorize payment of a pre-construction deposit if required by the contractor whose bid has been accepted by the MBE. In these situations, the contractor is to specify the total cost for specified home modification, along with the amount of any deposit (up to one-third of the total cost) required to initiate work. With MBE approval, the contractor may then submit Form OWCP-1500, to receive partial payment for the deposit amount of the estimated cost. The OWCP code for HOME MODIFICATION - HSMDF is used when preparing the Form OWCP-1500. Upon completion of the work, the claimant must submit a written attestation to DEEOIC stating that the agreed upon work has been completed by the contractor, to the claimant’s satisfaction, and requesting that final payment be made to the contractor. The contractor submits a separate Form OWCP-1500, requesting payment of the balance of the agreed upon amount.
(4) For guidance regarding problems encountered during the course of home modifications, or for other billing questions, (e.g.; billing difficulties, disputes or other irregularities), the MBE should contact the NO Policy Branch for assistance.
15. Health Facility Membership and Spa Membership. This section describes procedures when a claimant requests authorization for reimbursement of fees to join a commercial health club or spa.
a. Authorization. Membership in a health club or exercise facility, or treatment at a spa, may be authorized when recommended by the treating physician as likely to treat the effects, cure or give relief from a covered illness. All requests for reimbursement of health facility and spa fees require prior authorization from the MBE. In all cases where such membership is requested, the MBE determines whether the membership is likely to be effective and cost-efficient.
b. Payment. Whenever a request for payment of health club/spa membership is received, the MBE obtains the following information:
(1) Information from Physician. The MBE obtains the following information from the treating physician:
(a) A description of the specific therapy and or exercise routine needed to address the effects of the covered illness, including the frequency with which the exercises should be performed.
(b) The anticipated duration of the recommended regimen (i.e.; weeks, months).
(c) An opinion as to the actual/anticipated effectiveness of the regimen, treatment, goals attained/sought, and frequency of examinations to assess the continuing need for the regimen.
(d) A description/list of the specific equipment and or facilities needed to safely perform the regimen.
(e) The nature and extent of supervision, if any, required for the safety of the claimant while performing the exercises.
(f) An opinion stating whether exercise can be performed at home, as part of a home exercise program, or a recommendation as to what kind of public or commercial facility could provide the prescribed exercise routine.
(2) Information from Claimant. In addition, the MBE obtains the following information from the claimant:
(a) The full name, address, and distance from the claimant’s home or work location, of any public facilities (no membership required) and those commercial facilities (membership required) able to accommodate the prescribed regimen.
(b) If applicable, the specific reason(s) membership in a commercial health club/spa is required when public facilities are available, and or where the doctor indicates the regimen can be performed at home.
(c) A signed statement from the health club/spa manager stating that the club/spa can fully provide the exercise regimen prescribed by the treating physician, and a breakdown of the fees and charges for various membership options and terms. The statement should describe all facilities, services, and special charges not included in the membership fee.
c. Approval.
(1) The MBE must write a letter to the claimant advising of the approval. The letter must include the following:
(a) The date the DO received the request.
(b) The period of time which the approval will cover.
(c) The amount approved (i.e.; monthly or annual fee).
(d) The type of membership approved.
(e) Two copies of a blank OWCP-957.
d. Additional Information. If the MBE determines that additional information is necessary, the MBE sends a letter to the claimant (with a copy to the treating physician) requesting additional documentation that is necessary to continue with the review process. In the letter, the MBE provides 15 days for receipt of the requested information.
e. Period of Service. The MBE may approve health facility membership for up to twelve months. Recertification is required for any period beyond twelve months.
16. Medical Alert Systems. This section describes procedures the MBE follows when a claimant requests authorization for medical alert system.
a. Definition. A medical alert system is an electronic device connected to a telephone line. In an emergency, the system can be activated by either pushing a small button on a pendant or pressing the help button on the console unit. When the device is activated, a person from the 24-hour central monitoring station answers the call, speaks to the claimant via the console unit, assesses the need for help, and takes appropriate action. A medical communication system qualifies as a medical alert system if it includes the following requirements:
(1) An in-home medical communications transceiver;
(2) A remote, portable activator (Personal Pendant);
(3) A central monitoring station staffed by trained attendants 24 hours a day, seven days a week (optional).
b. Authorization. All requests for medical alert systems require prior authorization from the MBE. A request for a medical alert system must be documented with a letter of medical necessity from the treating physician, linked to the accepted condition, which includes a statement that the claimant has an acute or chronic condition which can require urgent or emergency care.
(1) Period of Service. The MBE may authorize the medical alert system for up to twelve months at a time. The need for such equipment should be recertified by the prescribing physician prior to the expiration of the authorization period.
(2) Billing. Systems that require a one-time connection fee and monthly monitoring fee may be approved, based on the claimant’s needs and the medical justification. The equipment provided is leased and must be returned when no longer needed to avoid further charges. DEEOIC is not responsible for any additional charges incurred for failure to return equipment or failure to timely return the equipment in a timely manner.
c. Approval.
(1) The MBE writes a letter to the claimant advising of the approval. The letter includes the following:
(a) The date the DO received the request;
(b) The period of time which the approval will cover;
(c) The amount approved.
d. Additional Information. If the MBE determines that additional information is necessary, the MBE sends a letter to the claimant (with a copy to the treating physician) requesting specific documentation that is necessary to continue with the approval process. In the letter, the MBE provides 15 days for receipt of the requested information.
17. Medical Expense Reimbursement for Extended Travel. This section describes procedures to be followed for authorizing medical travel requests over 200 miles round-trip, and the process for approving claims for reimbursement, regardless of whether the claimant obtained prior approval for the trip.
a. Authorization. DEEOIC requires pre-authorization for reimbursement of transportation, lodging, meals, and incidental expenses incurred when a claimant travels in excess of 200 miles round trip for medical care of an approved condition. DEEOIC’s BPA processes reimbursement claims for claimant travel without pre-authorization when travel is 200 miles or less round trip. (Exhibit 29-7 provides a sample Travel Authorization Letter.
b. Processing. DEEOIC’s BPA processes reimbursement claims in accordance with Government Services Administration (GSA) travel guidelines. Per diem rates for overnight stay and mileage reimbursement rates are published on the GSA website, and air fare reimbursement is based on actual ticket cost up to the amount of a refundable coach ticket (Y-Class airfare).
c. Prior Approval. Upon acceptance of a medical condition, the claimant receives a medical benefits package from the DEEOIC that includes instructions on how to submit a written request for prior approval of medical travel when such extended travel (over 200 miles round trip) is required. Despite these instructions, it is not uncommon for claimants to submit their request for reimbursement after a trip has been completed, and without having obtained prior approval.
(1) Travel Exceeding 200 Miles. Medical expense reimbursement for travel exceeding 200 miles round trip must be authorized by the MBE. Claims that are submitted to DEEOIC’s BPA, for reimbursement of travel expenses arising from medical travel in excess of 200 miles roundtrip, will not be processed for payment unless authorization has been provided by the DO.
d. Requests. Upon receipt of a travel authorization request from the claimant, the MBE takes immediate action to ensure that the request meets one basic requirement: that the medical treatment or service is for the claimant’s approved medical condition(s). The medical provider’s enrollment in the DEEOIC program is not a prerequisite to approving medical travel if the claimant chooses to receive medical services from a non-enrolled provider.
(1) Companion. If the travel request involves authorization for a companion to accompany the claimant, the claimant must provide medical justification from a physician. The justification must be in written form, relating the treatment to the accepted condition and rationalizing the need for the companion. If the doctor confirms that a companion is medically necessary, and provides satisfactory rationale, then the MBE may approve companion travel. In the alternative, the MBE can authorize the claimant to stay overnight in a hospital or medical facility, and can approve payment for a nurse or home health aide if a companion is not available. The MBE must use discretion when authorizing such requests and may approve one of the above alternatives when there is a definite medical need, accompanied by written justification from the physician.
(2) Mode of Travel. The MBE may allow the claimant to specify his or her desired mode of travel. It is the MBE’s role to authorize the desired mode of travel for the time period(s) requested. When a request is received from the claimant that does not identify the mode of transportation, the MBE contacts the claimant by telephone and assists in determining the desired mode of travel. (RC staff may assist in this process.)
e. Approval. Once the basic requirements for travel over 200 miles are met, as outlined above, the MBE prepares and sends the claimant a travel authorization letter following the guidelines below. The MBE may approve an individual trip, or any number of trips within a specified date range, all in one letter to the claimant. Once an initial authorization letter has been sent, future visits to the same doctor or facility may be approved by telephone, and confirmed by a follow-up letter.
f. Authorization Letter. The authorization letter delineates the specifics of the trip being authorized, based upon the mode of travel the claimant has selected. In the travel authorization letter, the MBE advises the claimant that travel costs are reimbursable only to the extent that the travel is related to obtaining medical treatment. In the letter, the MBE also invites the claimant to contact the nearest RC for assistance prior to or upon completing any trip to complete Form OWCP-957, Request for Reimbursement.
g. Adjudication. When adjudicating claims submitted after the trip has been completed, but for which prior approval was not obtained, the MBE follows the same steps as for pre-authorized trips, to the point of sending an authorization package. At that point the MBE sends only the authorization (or denial) letter to the claimant, not an entire authorization package.
h. Notifying the BPA. In conjunction with sending the claimant an approval or denial of a travel request, the MBE conveys his/her decision to DEEOIC’s BPA via the office’s FO, who is the POC with DEEOIC’s BPA for such issues. The CE prepares an e-mail to the FO, who in turn generates an electronic thread to the BPA. In the e-mail the MBE provides the information specified below. The MBE must also enter the following information into ECS:
(1) Approved dates for a single trip or in the alternative, a date range and number of trips authorized within that time frame.
(2) Approved mode of transportation.
(3) Starting point and destination, (e.g.; claimant address and provider address, city & state at a minimum).
(4) Authorization for rental car reimbursement, if appropriate.
(5) Companion travel if approved.
i. Approval Package. The approval package must include the following:
(1) Two copies of the detailed authorization letter.
(2) Two copies of a blank OWCP-957.
(3) A prepaid express mail envelope, addressed to DEEOIC’s BPA, for the claimant’s use.
18. Enteral Formula. Enteral formula is a nutritional replacement for patients who are unable to get enough nutrients in their diet. Patients prescribed enteral formula consume it by mouth or through a feeding tube. The DEEOIC requires prior authorization for enteral formula.
a. Requests for the authorization of enteral formula may originate from an employee, a designated AR or a medical provider. The DEEOIC medical bill processing contractor is tasked with registering all authorization requests for enteral formula in its electronic case tracking system. If the contractor receives the authorization request directly, they will record it and forward the request, as a thread, to the appropriate DO for processing. If the DO receives the authorization request via mail or fax, it is routed through the FO to the medical bill processing contractor for record creation and thread initiation.
b. Once the assigned MBE receives a thread for authorization of enteral formula, he or she must undertake a review of the evidence in the case file to make a determination as to whether or not the request is medically necessary in the care of the covered employee’s accepted work-related medical condition(s).
(1) Requests for enteral formula must be substantiated by a LMN from the employee’s treating physician. The LMN must provide a description of the employee’s medical need for enteral formula based on a face-to-face examination of the patient occurring within 60 days of the date of the LMN. In addition, the physician must identify the accepted work-related medical condition (preferably with a specific diagnosis code) that is necessitating the need for enteral formula. The physician must provide a description of the type of formula he or she is prescribing, along with a discussion of the specific quantity, frequency and duration of use. The physician may also provide guidance on how the patient receives the formula (orally or via feeding tube). The LMN signed by the treating physician must include his or her official practice address, telephone and fax number.
c. When the MBE receives a request for authorization of enteral formula accompanied by an appropriate LMN, the MBE prepares a decision letter to the claimant authorizing the enteral formula at the prescribed level. The MBE grants authorization of enteral formula in six-month increments.
d. Upon receipt of requests for enteral formula unaccompanied by a sufficient LMN, the MBE undertakes development by contacting the prescribing physician and the claimant to request evidence necessary to allow for authorization. A MBE can refer requests with unclear medical support to a DEEOIC nurse consultant for review and expert advice on the proper course of action. If, after development, the MBE determines that the medical evidence is insufficient, he or she issues a letter decision denying the authorization request. The letter decision is to include a narrative as to why the evidence is insufficient to warrant authorization. The MBE is to send a copy of the letter decision to the provider, if applicable. The letter decision is to include the following language:
If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.
e. Once the MBE determines to approve or deny the request, the MBE sends an email to the FO, who prepares and sends a thread to the medical bill processing contractor, authorizing or denying the enteral formula request. The MBE creates a correspondence entry in the Correspondence screen of ECS, documenting the decision, and bronzes the letter along with the supporting documentation into OIS.
f. An employee, a designated AR or a medical provider must request a renewal of an expiring authorization or modification of an existing authorization for enteral formula. In either of these situations, a LMN documenting the medical necessity of prescribed formula must accompany the request. A MBE may authorize enteral formula in ongoing six-month increments, so long as the requestor continues to submit sufficient evidence of medical necessity.
19. Rehabilitative Therapy Services. The DEEOIC requires prior authorization for the therapy services outlined below.
a. Types of Therapy Requiring Prior Authorization.
(1) Physical Therapy is the treatment of injuries or disorders using physical methods, such as exercise and massage. The goal of physical therapy is to relieve pain and to help the patient attain his or her maximum functional motor potential.
(2) Occupational Therapy involves treatment that helps develop adaptive or physical skills that will help the claimant to return to the ordinary tasks of daily living. Occupational therapy focuses on the use of hands and fingers, coordination of movement, fine motor skills and self-help skills such as preparing meals and dressing.
(3) Speech Therapy is the treatment of defects and disorders of speech and swallowing.
(4) Other rehabilitative therapy services is defined as a therapeutic service for which a provider charges a fee to render care outside of the scope of routine and customary medical care generally provided by a qualified physician.
b. The recommended other therapeutic service must be considered safe and effective by the medical community and intended to improve the health of the patient.
An appropriately licensed (in accordance with relevant state requirements) or credentialed specialist must perform the prescribed rehabilitative therapy.
c. Requests for the authorization of rehabilitative therapy, including physical therapy, occupational therapy, speech therapy or other rehabilitative therapy, may originate from an employee, a designated authorized representative or a medical provider. The DEEOIC Bill Processing Agent (BPA) must register all authorization requests for rehabilitative therapy services in its electronic case tracking system. The BPA will record authorization requests it receives and then forward the request, as a thread, to the Workers’ Compensation Assistant (WCA)/FO for processing. Authorization requests received at the DO via mail or facsimile must be routed through the WCA/FO to the BPA for record creation and thread initiation.
a. Once the assigned MBE receives a thread for authorization of a rehabilitative therapy, he or she must undertake a review of the evidence in the case to make a determination as to whether or not the request is medically necessary in the care of the covered employee’s accepted work-related medical condition(s).
b. The MBE must approve requests for a rehabilitative therapy initial assessment as long as the employee’s treating physician prescribes it. The MBE approves the request and sends an email to the WCA who then notifies the BPA to authorize an initial therapy assessment. The MBE sends a letter authorizing the initial assessment to the requestor with a copy to the employee. If the MBE receives a request for an initial rehabilitative therapy assessment without a physician’s prescription, he or she sends a letter to the employee (with a copy to the therapy provider) requesting a signed prescription for the initial assessment. In the letter, the MBE advises that the employee has 15 days within which to submit a signed physician’s prescription for an initial therapeutic evaluation.
If medical documentation or a signed physician’s prescription is not received within 15 days, the MBE must deny the request. The MBE sends an email to the WCA who then notifies the BPA to deny the request. The MBE sends a letter to the requestor with a copy to the employee denying the request and providing instruction to resubmit the request once the treating physician submits a signed prescription.
f. Requests for rehabilitative therapy must be substantiated by the results of the initial evaluation by the applicable therapy specialist and a LMN from the employee’s treating physician. The LMN must provide a description of the employee’s medical need for the requested rehabilitative therapy based on the results of the initial evaluation and the physician’s face-to-face examination of the employee occurring within sixty days of the date of the LMN.
The physician must provide a description of the type of rehabilitative therapy he or she is prescribing, along with a discussion of the specific quantity, frequency and duration of the therapeutic service. DEEOIC considers rehabilitative therapy services medically appropriate only if a qualified physician describes, with appropriate medical rationale, how the prescribed rehabilitative therapy will lead to an expected measurable improvement in one or more activities of daily living within a reasonable period. The LMN signed by the treating physician must include his or her official practice address, telephone and fax number.
g. When the MBE receives a request for authorization of rehabilitative therapy accompanied by an appropriate LMN, the MBE prepares a decision letter to the employee authorizing the requested therapy. The initial authorization period may be fewer than, but must not exceed 3 months (90 days). The assigned MBE may approve up to 3 visits per week by therapy discipline. Each visit is equal to a maximum of 1.5 hours (6 units). PT, OT, or ST services are limited to one hour (4 billable units) when the provider bills with combined codes. The MBE may not authorize therapy for any one discipline more than 60 visits per calendar year. The approval letter must contain the following information:
(1) Covered medical condition(s) for the rehabilitative therapy.
(2) Number and frequency of visits approved (e.g., 3 visits per week for 12 weeks).
(2) Authorized billing code(s) relevant to the approval.
(3) Dates for the authorized period.
(4) Statement to indicate that corresponding medical notes must be provided for each service date.
(4) Statement advising that fees are subject to the OWCP fee schedule.
h. Upon receipt of requests for rehabilitative therapy unaccompanied by a sufficient LMN, the MBE undertakes development by contacting the prescribing physician and the employee to request evidence necessary to allow for authorization.
(1) After 15 days has passed with no satisfactory response from the treating physician, or no response from the employee, the MBE prepares a second letter to the employee (accompanied by a copy of the initial letter), advising that following the previous letter, no additional information has been received from the treating physician. The MBE advises that an additional period of 15 days will be granted for the submission of necessary evidence, and if the information is not received in that time, the request for rehabilitative therapy may be denied by the DEEOIC.
(2) If the employee or the physician does not provide a response to the second request for information within the 30-day period allowed, the MBE issues a letter decision to the employee denying the claim for rehabilitative therapy. The MBE further sends an email to the FO, who sends a thread to the BPA for system update.
A MBE can refer requests with unclear medical documentation to a DEEOIC nurse consultant or CMC for review to obtain expert advice on the recommended course of action. Once the MBE has undertaken development, including allowance for the treating physician to provide further support for an unsubstantiated request for rehabilitative therapy, he or she can issue a letter decision denying the authorization if sufficient medical justification has not been forthcoming. The letter decision is to include a narrative as to why the evidence is insufficient to warrant authorization. The MBE is to send a letter to the employee along with a copy of the letter decision to the provider, if applicable. The letter decision is to include the following language:
If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.
i. Once the MBE decides to approve or deny the request, he/she sends an electronic mail message to the WCA/FO, who prepares and sends a thread to the BPA, authorizing or denying the rehabilitative therapy request. The MBE creates a correspondence entry on the correspondence screen of ECS, documenting the decision and bronzes the letter along with the supporting documentation into OIS.
j. An employee, an authorized representative, treating physician, or rehabilitative therapy provider must request a renewal of an expiring authorization or modification of an existing authorization for rehabilitative therapy and should do so prior to the expiration date of the existing authorization, to allow care to continue uninterrupted. In either of these situations, the requestor must submit a LMN documenting the continuing medical necessity of the request. Requests for rehabilitative therapy outside of this guidance must be evaluated on a case-by-case basis, including possible consultation with the DEEOIC Medical Director. The employee, or his or her AR, has final responsibility regarding the amount or type of rehabilitative therapy sought.
k. Rehabilitative therapy providers must conduct services in an appropriate setting; (i.e., in a clinic, professional office, or other similar location). If the MBE receives a request for in-home professional therapy, the employee must be homebound to receive such authorization. Medical evidence from the treating physician must demonstrate that the employee is medically unable to travel to obtain the therapy outside the home. Once the MBE receives convincing medical evidence that the employee is not able to travel for therapy, and sufficient documentation exists regarding the medical necessity for care, the MBE may authorize in-home rehabilitative therapy. Provider travel to and from an employee’s residence is not a billable service.
l. Rehabilitative therapy providers must submit appropriate clinical notes to the BPA, along with their bill, describing in detail the particular therapeutic care provided during each visit, and the time spent providing that care. The therapy notes must document compliance with the LMN. The notes should describe the effect of the rehabilitative therapy specific to unique features of the employee, including any specific improvements in functionality or in achieving relief from the symptoms of a compensable illness. The MBE may refer claims to the Program Integrity Unit for investigation of those situations where an applicable therapy provider does not provide an employee specific description of the services provided, lists vague or non-descriptive services or conducts therapy services that do not comply with the prescribing physicians LMN.
20. Ancillary Services or Expense Authorization RD. When a MBE decides to deny authorization for a claimed ancillary service or expense discussed in this chapter, the MBE sends a letter decision to the claimant. The letter decision is to include a narrative explanation as to why the evidence is insufficient to warrant authorization. The MBE is to send a copy of the letter decision to the provider, if applicable.
a. The letter decision is to include the following language:
If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.
Upon issuance of the denial letter, the MBE creates correspondence in ECS documenting the issuance of the decision letter denying the ancillary medical service.
b. RD. Should the claimant request a RD regarding denial of an ancillary medical service or related expense, the MBE completes the RD process in accordance with existing DEEOIC procedure. In particular, the MBE ensures that the narrative content of the Explanation of Finding includes a well-written discussion of the justification for the denial of authorization. The FAB is responsible for independently evaluating the recommendation of the MBE, along with the file evidence, and deciding whether to finalize the RD.