Provider Update
Volume 16, Issue 4
October 1999
Y2K Readiness Disclosure
As the Department of Health and Hospitals (DHH) and Unisys continue down the road to Y2K readiness, it is important to keep you informed of additional steps being taken to achieve a smooth transition to the Year 2000.
Informational screens used by DHH and Unisys staff to assist with your inquiries have undergone the necessary changes to accommodate required Y2K data. This will allow us to continue to provide you with accurate, up-to-date information as we receive your inquiries in the coming year.
The General Accounting Office (GAO) has defined a multi-phased approach that describes the program and project management activities necessary to achieve Y2K readiness. DHH and Unisys have adopted this approach for the remediation and testing phases of the Y2K readiness project.
Required system changes in the remediation phase impacting program logic, processes, reporting, and so forth, are complete, tested, and implemented at this time. The "end-to-end" testing phase is now underway. This means that we are taking each process - claims, hospital precertification, prior authorization, etc. - and submitting Year 2000 test data from the initial point of entry into that system. The test data will travel through the entire process to the final disposition; thus, "end-to-end." The resulting output data is being reviewed for errors and problems are corrected with additional validation tests.
As part of our Y2K outreach program, during the Y2K "end-to-end" testing phase, we are conducting cross-sectional testing with targeted providers in order to validate major interfaces. This testing will also verify that claims are properly processed by the remediated system, thus assuring the provider community that proper payment will be rendered in a timely manner.
The Unisys Electronic Media Claims (EMC) Department is undergoing end-to-end testing to ensure that EMC submissions are Y2K ready. Please remember, EMC vendors and submitters will NOT have to change the process currently being used to submit EMC claims to Unisys. All required changes are being made by Unisys within the MMIS to convert the necessary data to Y2K status. Once the national standardized submission formats are finalized in the Fall of 2001, as currently scheduled, EMC processes will be modified to handle the new standards. Until then, DHH has decided to maintain current submission standards and employ standard windowing techniques for date conversions to handle Y2K dates.
The DHH transition to the new Medicaid Eligibility Determination System is nearing completion. As mentioned in the June/July issue of the Provider Update, the eligibility files were frozen for a period of time. This freeze is now lifted and eligibility files are being updated on a daily basis. However, in some isolated cases problems exist, and DHH will continue to issue letters of eligibility verification to recipients until these problems are resolved. Recipients may present these letters to you when requesting services.
The annual Medicaid provider training workshops being held September 28, 1999 through November 2, 1999, will include information concerning the Y2K readiness project and the transition to the MEDS eligibility system.
Our efforts to keep you informed of Y2K readiness will continue through articles in upcoming issues of the Provider Update. DHH and Unisys continue ongoing communication with the provider community through both written correspondence and the Y2K Hotline. Should you have Y2K questions or concerns, please contact the Unisys Hotline at 225-237-3210 or write to:
Unisys
Y2K Project Coordinator
P.O. Box 3396
Baton Rouge, LA 70821
Federal regulations found at 42 CFR 483.100 address the State's responsibility for pre-admission screening of individuals with mental illness and mental retardation. The requirement for screening is applicable to all individuals with mental illness and/or mental retardation who apply to Medicaid certified nursing facilities regardless of the source of payment for the nursing facility services. When a pre-admission screening has not been performed prior to admission, Medicaid reimbursement is available only for services furnished after the screening has been performed.
Since 1989 the State has utilized a contractor, Bock and Associates, to assess individuals and make a recommendation regarding the appropriateness of nursing facility placement. A decision was made by the Department that as of June 30, 1999, the responsibility for pre-admission screening would be placed with the Bureau's Health Standards Section. There is nothing about the current process that will change except that now facilities will make requests for pre-admission screening to their regional Health Standards office rather than Nursing Home Reform. Health Standards staff will also conduct the on-site assessment of the individual instead of an assessor with Bock and Associates.
The effective dates for facilities to begin making requests to regional Health Standards offices for pre-admission screening are as
follows:
Lafayette - 7/1/99
Baton Rouge - 8/1/99
Monroe - 8/15/99
Shreveport - 8/15/99
Alexandria - 8/15/99
Mandeville - 8/15/99
Thibodaux - 9/1/99
Lake Charles - 9/1/99
New Orleans - 9/1/99
Questions regarding these changes can be directed to Mr. George Varino at (225) 342-0118 or Ms. Terry Cooper at (225) 342-2795.
This is a reminder to all providers that Act 1142 of the 1997 regular session of the Louisiana Legislature requires that all Medicaid - related records be maintained in a systematic and orderly manner and be retained for a period of five years.
The Department of Health and Hospitals is currently in the process of updating the Medicaid provider files. The records of providers who have not participated, billed and been paid by Louisiana Medicaid since prior to July 1998 will be closed.
Claims for recipients who have Medicare and Medicaid coverage must be filed with the Medicare fiscal intermediary within 12 months of the date of service in order to meet Medicaid's timely filing regulations.
Claims which fail to cross over via tape and have to be filed hard copy to Medicaid must be filed to Medicaid within six months of the date on the Medicare Explanation of Medicare Benefits (EOMB), provided they were filed with Medicare within one year from the date of service.
� All outpatient services performed within 24 hours of the inpatient admission should be included in the inpatient stay.
Specifically, all outpatient services performed within 24 hours before the inpatient admission and 24 hours after the discharge should be included in the inpatient
stay.
� When a patient has outpatient services performed at one hospital while they are inpatient at another hospital, all charges should be included on the inpatient hospital's claim.
The hospital in which the patient is an inpatient is responsible for reimbursing the hospital performing any outpatient services during the patient's stay.
Management of Cancer Pain
Michael B. Cockerham M.S., Pharm.D.Associate Professor of Clinical Pharmacy
Practice
College of PharmacyUniversity of Louisiana at Monroe
Assistant Professor of Clinical Pharmacy (Gratis) School of Medicine Louisiana State University
Issues...
- Despite recent advancements in the understanding of pain, many cancer patients receive inadequate treatment. - The American Society of Clinical Oncology has identified many barriers to proper pain control in cancer patients.
- One of the most significant barriers to proper pain control among health professionals is the lack of education about pain assessment and treatment.
It is estimated that 1.2 million new cases of cancer will be diagnosed in the United States in 1999. One-third of these new cases will have pain at diagnosis and more than 70% of patients will develop significant pain during their illness. Despite recent advances in the understanding of pain, many of these patients receive inadequate treatment. Most pain management guidelines state that the majority of cancer pain can be effectively treated. Upwards of 90% of cancer pain can be controlled by relatively simple means. We have all the drugs we need to properly treat cancer pain if we use the current agents appropriately. Pain control is a high priority because it causes unnecessary suffering, diminishes activity, and may further weaken an already debilitated patient. It also prevents an otherwise stable disease patient from leading a productive life. No cancer patient should have to live or die with unrelieved pain.
The American Society of Clinical Oncology has identified many barriers to proper pain control in the cancer patient. These barriers are divided into three areas: Health Professional Barriers, Patient and Family Barriers and Health System Barriers. One of the most significant barriers to proper pain control among health professionals is the lack of education about pain assessment and treatment. There is also a belief that only "terminal" patients should receive maximal analgesia. Some health professionals do not believe that patients are good judges of the severity of their pain. Other barriers to proper pain control are lack of knowledge about the distinction between tolerance, physical dependence and psychological dependence (addiction), fear of opioid toxicity and fear of controlled substance regulations.
Patients and family members frequently underreport the severity of their pain to avoid confirmation of disease progression. They have a fear of toxicity and addiction associated with opioids. They may not understand that their pain can be treated, or possibly, they may not have the resources to acquire the necessary medications or procedures. The health care system may also contribute to the barriers through a lack of accountability, fragmentation of care of the patient among different providers, and lack of availability of some opioids at retail
pharmacies.
Assessment of Cancer Pain
The provider can not tell how much pain patients are suffering until the patient is asked. The patient self-report should be the primary source of assessment of cancer pain. Patients should describe the type of pain, the location of the pain, the intensity or severity of the pain, aggravating and relieving factors and goals for pain control. The initial assessment should occur with each new report of pain. The assessment should include a detailed history of the pain, physical examination, psychosocial assessment and appropriate diagnostic workup.
The level of pain should be assessed at each visit using a visual analog scale of 1 to 10. The Management of Cancer Pain: Clinical Practice Guidelines demonstrate several scales for demonstrating pain severity. The goal is to keep the level of pain below a four, as pain rated higher than a five interferes substantially with quality of life. Continued assessment of cancer pain is essential. Changes in pain pattern or development of new pain should trigger diagnostic evaluation and modification of the treatment plan. Accurate documentation of pain assessment and treatment is important at each patient visit. In a retrospective study, documentation of rescue doses for breakthrough pain, laxative prescriptions and bowel habits were never mentioned in approximately 70% of charts
reviewed.
Non-Pharmacologic Management of Cancer Pain
Individualization of therapy to the specific patient is the primary principle in management of cancer pain. Although management of cancer pain with medications is the cornerstone of treatment, there are many non-pharmacologic approaches to treating pain. Cutaneous stimulation with heat or cold along with massage, pressure and/or vibration are used to relax or "distract" the patient from the pain. Patients should be encouraged to remain active and participate in self-care through exercise. Twenty-five percent of patients in one study reported pain relief after exercise. During acute pain, however, exercise should be limited to range of motion. Prolonged immobilization should be avoided whenever possible. Counter stimulation techniques such as Transcutaneous Electrical Nerve Stimulation (TENS) and acupuncture have been reported, although the literature is inconclusive.
Other non-pharmacological interventions include hypnosis and relaxation. There are several studies supporting their use. The health care provider should educate the patient about pain management and correct myths about cancer pain treatment. Myths about addiction and tolerance with opioids are especially important. The goal of patient education is to involve the patient in his or her own care. Peer support groups and pastoral counseling can play an important role in pain management. Peer groups provide emotional support and access to information. There are many cancer support groups that may be found listed on the Internet or by contacting the local chapter of the American Cancer Society.
Although non-invasive therapies are preferred and should be used as first line treatments, there are instances where invasive techniques are required. Radiation therapy can relieve metastatic pain as well as relieve local disease extension. It is complementary to analgesic therapy and directly effects the cause of the pain. Neurolytic blockade, neuroablation and surgical intervention are used when other therapies are ineffective, poorly tolerated or clinically inappropriate.
Pharmacologic Management of Cancer Pain
Analgesic intervention should be part of the overall treatment plan for the cancer patient. The key to effective pain management is to individualize therapy and employ simple dosage schedules whenever possible. The least invasive methods are preferred and placebos should not be used. Schedule doses on a regular basis (i.e., "around the clock") to maintain the level of drug that will prevent the recurrence of pain.
Breakthrough pain is a serious problem in cancer patients. Therefore, it is important to plan for this by providing "rescue doses" of pain medications to be administered as needed. The goal of proper �around the clock� management is to administer two or fewer rescue doses per twenty-four hours. Patients and/or their caregivers should be encouraged to keep a written pain diary in which is recorded the time and severity of the pain, and the outcome of the intervention. This should all be part of a written management plan that is created and modified by the patient and the physician.
There are three main classes of drugs used to treat cancer pain: the non-steroidal anti-inflammatory drugs (NSAIDs), the opioids, and a diverse group called the adjuvant or co-analgesics. The oral route is preferred in most instances. It is the most convenient and cost effective method and most cancer pain can be managed by oral medications. Other routes may be necessary in the case of difficulty in swallowing, GI disturbances or unreliable drug absorption. Rectal, transdermal (fentanyl), intravenous and intraspinal routes may be appropriate in these situations. Intramuscular routes should be avoided. The intravenous Patient Controlled Analgesia (PCA) method offers continuous infusion pain relief as well as patient controlled breakthrough doses. This affords patients a degree of control over their own treatment. As mentioned earlier, the least invasive route is preferred when possible.
The World Health Organization analgesic ladder was devised to assist health care providers in treating mild to severe pain.
Step 1.
Step 1 on the ladder is for mild pain. Non-opioid drugs plus or minus an adjuvant agent should be used. The drugs in the non-opioid group include acetaminophen, aspirin and the other NSAIDs such as ibuprofen. Because the NSAIDs have both analgesic and anti-inflammatory effects, they are useful in relieving pain associated with tissue inflammation and bone disease. There is a ceiling effect with regard to dose and the predominate side effects are gastrointestinal. The major advantage to using acetaminophen over the other NSAIDs is the lack of platelet effect.
Step 2.
If pain persists or the patient presents with moderate pain, then Step 2 should be employed. An opioid such as codeine or hydrocodone should be added to the non-opioid; it should not be substituted. The dose of some mixed preparations such as the oxycodone/acetaminophen combination may be limited by the amount of acetaminophen in the preparation. When NSAIDs are used with opioids, the opioid can usually be maintained at a lower dose.
Step 3.
In step 3, patients are given opioids with higher potency than step 2, or they can be given the same drugs at higher doses. There is also the optional addition of non-opioids and adjuvant agents. The gold standard for this step is morphine. Other commonly used opioids are hydromorphone, codeine, oxycodone, methadone, levorphanol and fentanyl. Patients receiving opioids should not be given mixed agonist-antagonist agents, as they may precipitate withdrawal and increase pain. Examples of mixed agonist-antagonist agents are pentazocine, butorphanol, dezocine and nalbuphine. Contrary to some myths, there is no maximum dose of full agonist opioids, as they do not have a ceiling effect. The proper dose is the dose that is required to relieve pain. TABLE 1 lists the most common opioid agents and their equivalent doses.
Meperidine should not be used except for brief periods because its half-life is short and it has a toxic metabolite, normeperidine. Normeperidine may accumulate, particularly in a patient with reduced renal function, and cause CNS stimulation, which may lead to seizures.
TABLE 1. Common Opioid Dose Equivalents
| Drug |
IM/IV (mg) |
PO (mg) |
| Codeine |
130 |
200 |
| Oxycodone |
10 |
30 |
| Hydrocodone |
|
30 |
| Morphine |
10 |
30 |
| Hydromorphone |
1.5 |
7.5 |
| Methadone |
10 |
20 |
| Meperidine |
100 |
300 |
Opioid tolerance should not be confused with addiction. Tolerance is expected with long - term opioid treatment. Tolerance is defined as the need to increase dose requirements over time to maintain pain relief. This is usually correlated with progressive disease. Patients with stable disease usually do not require dose increase. Repeated requirements for breakthrough doses necessitate an increase in the maintenance dose. Upward titration is accomplished by increasing the maintenance dose thirty to fifty percent until an acceptable level of pain control is reached. Elderly patients may experience a similar level of pain intensity, but require a lower amount of opioid analgesia than younger adults. Doses should be started low and titrated cautiously in these patients. When patients require discontinuation of their opioids, it is important to taper the dose in order to prevent withdrawal symptoms. Discontinuing pain management may be required after successful completion of cancer therapy or following neuroablative procedures.
Adjuvant analgesics enhance analgesia, counteract the side effects of traditional analgesics or treat concurrent symptoms. They are commonly used in all steps of the analgesic ladder. Corticosteroids are helpful in patients with pain due to acute nerve compression, increased intracranial pressure and soft tissue infiltration. They also elevate mood, stimulate appetite and act as an anti-emetic. Anticonvulsants such as phenytoin, carbamazepine and valproic acid are useful in neuropathic pain. The tricyclic antidepressants are also used in neuropathic pain and for underlying depression and insomnia. These agents are dosed at levels lower than for an antidepressant effect. Topical agents such as capsaicin are also used for neuropathic pain. Capsaicin is thought to deplete substance P, thereby reducing afferent nerve transmission.
Pain prevention must be accompanied by side effect control or prevention. Most of the side effects with the exception of constipation will lessen as tolerance develops. Tolerance usually will develop in a few weeks. Almost all patients on around-the-clock opioid therapy will experience constipation. Bowel preps in the form of a stimulant laxative should be administered prophylactically to prevent constipation. Nausea can be treated with anti-emetics such as prochlorperazine. Respiratory depression is seldom seen in patients on long - term opioid therapy. It can, however, be reversed with naloxone, titrated in small increments to improve respiratory function without reversing analgesia. When sedation does not decrease, stimulants such as caffeine can be given. No opioid is universally better or worse than others with respect to the risk of adverse
effects.
Conclusion
Adequate pain relief can be provided to a vast majority of cancer patients. This can be accomplished through quality assessment and a rational approach using the World Health Organization guidelines. By correctly managing cancer pain, the health care provider can improve the quality of life of his or her patients while limiting side effects. No patient should have to live or die in pain.
References
Abrahm JL. The oncologist's expanding role. Cancer 1999; 85(8): 1645-8.
Ad Hoc Committee on Cancer Pain of the American Society of Clinical Oncology. Special Article: Cancer Pain Assessment and Treatment Curriculum Guidelines. J Clin Oncol 1992;
10:1976-82.
Agency for Health Care Policy and Research. Management of cancer pain: adults. AJHP 1994;
51:1643-56.
Cherney NI and Portenoy RK. Cancer Pain Management. Cancer 1993;
72:3393-415.
Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR Publication No. 94-0592. Rockville, MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, March
1994.
Landis SH, Murray T, Bolden S, et al. Cancer Statistics, 1999. CA: A cancer journal for clinicians. American Cancer Society 1999;
49:8-31.
Levy MH. Pharmacologic treatment of cancer pain. N Engl J Med 1996;335:1124-32.
Lyss AP and Portenoy RK. Strategies for limiting the side effects of cancer pain therapy. Semin in Oncology 1997 Vol 24, No 5, Suppl 16 (Oct.):
S16-34.
Mercadante S. Pain treatment and outcomes for patients with advanced cancer who receive follow-up care at home. Cancer 1999;
85:1849-58.
Vigano A, Bruera E and Suarez-Almazor ME. Age, pain intensity, and opioid dose in patients with advanced cancer. Cancer 1998;
83:1244-50.
Weber M and Huber C. Documentation of severe pain, opioid doses, and opioid-related side effects in outpatients with cancer: a retrospective study. Jnl Pain Sympt Manag. 1999; 17(1):
49-54.
Weinstein SM. Pharmacology of cancer pain. Highlights in Oncology Practice 1997;14:94-102.
New Criteria for Coverage of Augmentative and Alternative Communication (AAC) Devices in the DME Program
Effective June 5, 1999 the criteria used in the prior authorization of Augmentative and Alternative Communication (AAC) Devices in the DME Program was revised. The age restriction for Medicaid coverage of these devices was removed and new medical criteria for prior authorization was implemented. The medical criteria was developed based on the recommendations of a nationwide committee of communication specialists.
I. DEFINITIONS.
Augmentative and Alternative Communications (AAC) devices - electronic or non-electronic aids, devices, or systems that assist a Medicaid recipient to overcome or ameliorate (reduce to the maximum degree possible) the communication limitations that preclude or interfere with meaningful participation in current and projected daily activities.
Examples of AAC devices include:
1. Communication boards or books, speech amplifiers, and electronic devices that produce speech and/or written
output;
2. Devices that are constructed for use as communication devices as well as systems that may include a computer, when the primary use of the computer serves as the recipient's communication device;
and
3. Related components and accessories, including software programs, symbol sets, overlays, mounting devices, switches, cables and connectors, auditory, visual, and tactile output devices, printers, and necessary supplies, such as rechargeable batteries.
Meaningful participation - effective and efficient communication of messages in any form the recipient chooses.
Speech-language pathologist - an individual who has:
1. A certificate of clinical competence from the American Speech-Language-Hearing Association;
2. Completed the equivalent educational requirements and work experience necessary for the certificate; or
3. Completed the academic program and is acquiring supervised work experience to qualify for the
certificate.
II. GENERAL PROVISIONS.
Consideration shall be given for Medicaid reimbursement for AAC devices for Medicaid recipients of all ages if the device is considered medically necessary, the recipient has the ability to physically and mentally use a device and its accessories, and if any one or more of the following criteria is met:
A. Medical Necessity Determinations.
1. The following medically necessary conditions shall be established for recipients who/whose:
a. have a diagnosis of a significant expressive or receptive (language comprehension) communication impairment or disability;
b. impairment or disability either temporarily or permanently causes communication limitations that preclude or interfere with the recipient's meaningful participation in current and projected daily activities; and
c. had a speech-language pathologist(and other health professional,as appropriate):
i. perform an assessment and submit a report pursuant to the criteria set forth in sub-section B.Assessment/ Evaluation; and
ii. recommend speech-language pathology treatment in the form of AAC devices and services; and
iii. document the mental and physical ability of a recipient to use, or learn to use,a recommended AAC device and accessories for effective and efficient communication; and
iv. prepare a speech-language pathology treatment plan that describes the specific components of the AAC devices and the required amount, duration, and scope of the AAC services that will overcome or ameliorate communication limitations that preclude or interfere with the recipient's meaningful participation in current and projected daily activities; and
d. requested AAC devices constitute the least costly, equally effective form of treatment that will overcome or ameliorate communication limitations that preclude or interfere with the recipient's meaningful participation in current and projected daily activities.
2. The following are additional general principles relating to medical necessity determinations for AAC devices:
a. The cause of the recipient's impairment or disability (e.g., congenital, developmental, or acquired), or the recipient's age at the onset of the impairment or disability, are irrelevant considerations in the determination of medical need.
b. Recipient participation in other services or programs (e.g., school, early intervention services, adult services programs,employment) is irrelevant to medical necessity determination for AAC devices.
c. No cognitive, language, literacy, prior treatment, or other similar prerequisites must be satisfied by a recipient in advance of a request for AAC devices.
d. The unavailability of an AAC device,component, or accessory for rental will not serve as the basis for denying a prior approval request for that device, component,or accessory.
3. When the medical necessity cannot be determined for an AAC device pursuant to the criteria stated above and to the information submitted in support of a prior authorization request, the following steps shall be taken:
a. If Medicaid determines that any essential information in establishing medical necessity for the AAC device is incomplete, or has been omitted in the prior authorization request as required in susection
B.Assessment/ Evaluation, Medicaid will make direct contact with the speech-language pathologist who conducted the assessment for the recipient. Medicaid will then identify the specific, additional information that is needed and request that the additional information be submitted; and/or
b. If Medicaid determines that an additional interpretation of information in the prior authorization request is needed by the medical reviewer in establishing medical necessity for an AAC device, Medicaid will seek the advice of speech language pathologist(s) with extensive AAC experience recommended to Medicaid by the American Speech Language & Hearing Association (ASHA), the United States Society for Augmentative & Alternative Communication (USSAAC), and/or RESNA,who shall provide the required interpretation.
i. Only one request for additional information by direct contact with the speech/language pathologist and/or only one interpretation will be made per prior authorization request;
ii. If additional information requested by Medicaid from the speech/language pathologist who conducted the assessment, or if an additional interpretation requested from a consulting speech-language
pathologist, is not received by Medicaid within the 25 day time frame required of Medicaid for a prior authorization
determination, a decision will be made by the medical reviewer for Medicaid based on the information that has been submitted with the prior authorization request and on the reviewer's interpretation of that information. If the additional information or additional interpretation is provided at a later time, another request will need to be submitted by the provider to the Prior Authorization Unit for additional review.
B. Assessment/Evaluation.
1. An assessment, or evaluation, of individual functioning and communication limitations that preclude or interfere with meaningful participation in current and projected daily activities must be completed by a speech-language pathologist with input from other health professionals, (e.g., occupational therapists and rehabilitation engineers) based on the recommendation of the speech language pathologist and a physician's prescription, as
appropriate.
2. Requests for AAC devices must include a description of the speech-language pathologist's qualifications, including a description of the speech-language pathologist's AAC services training and experience.
3. An assessment (augmentative & alternative communication evaluation) must include the following information about the recipient:
a. Identifying Information;
i. Name;
ii. Medicaid Identification Number;
iii. Date of the Assessment;
iv. Medical and Neurological;
Diagnoses (primary, secondary, tertiary);
v. Significant medical history;
vi. Mental or cognitive status; and
vii. Educational level and goals.
b. Sensory Status
i. Vision and hearing screening (no more than one year prior to AAC evaluation)
ii. If vision screening is failed, a complete vision evaluation
iii. If hearing screening is failed, a complete hearing
evaluation
iv. Description of how vision, hearing, tactile, and/or receptive communication impairments or disabilities affect expressive communication
c. Postural, Mobility, & Motor Status
i. Gross motor assessment
ii. Fine motor assessment
iii. Optimal positioning
iv. Integration of mobility with AAC devices
v. Recipient's access methods (and options) for AAC devices
d. Current Speech, Language, & Expressive Communication Status
i. Identification and description of the recipient's expressive or receptive (language comprehension) communication impairment diagnosis
ii. Speech skills and prognosis
iii. Language skills and prognosis
iv. Communication behaviors and interaction skills (i.e., styles and patterns)
v. Functional communication
assessment, including ecological inventory
vi. Indication of past treatment, if any,
vii. Description of current communication strategies, including use of an AAC device, if any
Note: If an AAC device is currently used, describe the device, when and by whom it was previously purchased, and why it is no longer adequate for communication needs).
e. Communication Needs Inventory
i. Description of recipient's current and projected communication needs.
ii. Communication partners and tasks, including partners' communication abilities limitations, if any
iii. Communication environments and constraints which affect AAC device selection and/or features (e.g., verbal and/or visual output and/or feedback; distance communication needs).
f. Summary of Communication Limitations. Description of the communication limitations that preclude or interfere with meaningful participation in current and projected daily activities (i.e., why the recipient's current communication skills and behaviors prevent meaningful participation in the recipient's current and projected daily activities).
g. AAC Devices Assessment Components
i. Vocabulary requirements
ii. Representational system(s)
iii. Display organization and features
iv. Rate enhancement techniques
v. Message characteristics, speech
synthesis, printed output, display characteristics, feedback, auditory and visual output
vi. Access techniques and strategies; and
vii. Portability and durability concerns, if any.
h. Identification of AAC Devices Considered for Recipients
i. Identification of the significant characteristics and features of the AAC devices considered for the recipient
ii. Identification of the cost of the AAC devices considered for the recipient (including all required components, accessories, peripherals, and supplies, as appropriate).
i. AAC Device Recommendation
i.Identification of the requested AAC devices including all required components, accessories, software, peripheral devices, supplies, and the device vendor
ii.Identification of the recipient's and communication partner's AAC devices preference, if any
iii. Assessment of the recipient's ability (physically and mentally) to use, or to learn to use, the recommended AAC device and accessories for effective and efficient communication
iv. Justification stating why the recommended AAC device (including description of the significant characteristics, features, and accessories) is better able to overcome or ameliorate the communication limitations that preclude or interfere with the recipient's meaningful participation in current and projected daily activities, as compared to the other AAC devices considered
v. Justification stating why the recommended AAC device (including description of the significant characteristics, features, and accessories) is the least costly, equally effective, alternative form of treatment to overcome or ameliorate the communication limitations that preclude or interfere with the recipient's meaningful participation in current and projected daily activities.
j. Treatment Plan and Follow-Up
i. Description of short term communication goals (e.g., 6 months)
ii. Description of long term communication goals (e.g., 1 year)
iii. Assessment criteria to measure recipient's progress toward achieving short and long term communication goals
iv. Description of amount, duration, and scope of AAC services required for the recipient to achieve short and long term communication goals
v. Identification and experience of AAC service provider responsible for training (these service providers may include, e.g.: speech-language pathologists, occupational therapists, rehabilitation
engineers, the recipient's parents, teachers and other service providers)
k. Summary of Alternative Funding Source for AAC Device l. Description of availability or lack of availability, of purchase of AAC device through other funding
sources.
C. Trial Use Periods.
1. In instances where the appropriateness of a specific AAC device is not clear, a trial use period for an AAC device may be recommended (although it is not required) by the speech-language pathologist who conducts the AAC evaluation.
2. Prior authorization for rental of AAC devices shall be approved for trial use periods when the speech-language pathologist prepares a request consistent with the established requirements. The reasons for a trial use period request include,but are not limited to:
a. The characteristics of the recipient's communication limitations;
b. Lack of familiarity with a specific AAC device; and
c. Whether there are sufficient AAC services to support the recipient's use of the AAC device, or other factors.
3. If the speech-language pathologist seeks a trial use period, s/he must prepare a trial use period request that includes the following information:
a. The duration of the trial period;
b. The speech-language pathologist information and the recipient information as required in
c. The AAC device to be examined during the trial period, including all the necessary components (e.g., mounting device,
software, switches, or access control mechanism);
d. The identification of the AAC services provider(s) who will assist the recipient during the trial period;
e. The identification of the AAC services provider(s) who will assess the trial period; and
f. The evaluation criteria, specific to the recipient, that will be used to determine the success or failure of the trial period.
4. Trial use period requests must request Medicaid funding for the rental of all necessary components and accessories of the AAC device. If an accessory necessary for the trial use of a device by a recipient is not available for rental, but the communication device is available for rental for trial use, Medicaid may consider the purchase of the accessory for the trial use of the communication device by that
recipient.
5. Trial periods may be extended and/or different AAC devices provided, when requested by the speech-language pathologist responsible for evaluating the trial use period.
6. Results of trial use periods must be included with any subsequent request for prior authorization of purchase of the AAC device. Recommendations for the purchase of an AAC device, as a result of a trial use period of the device, must clearly indicate the patient's ability to use the device during the trial
period.
D. Repairs.
1. Medicaid will cover repairs to keep AAC devices, accessories, and other system components in working condition. Medicaid coverage for repairs will include the cost of parts, labor, and shipping, when not otherwise available without charge pursuant to a manufacturer's warranty.
a. Providers of AAC devices are expected to comply with the Louisiana New Assistive Devices Warranty Act.
i. One of the provisions of this law is that all persons who make, sell, or lease assistive devices, including AAC devices, must provide those who buy or lease the equipment with a warranty which lasts at least one year from the time the equipment is delivered to the customer.
ii. If, during the warranty period, the equipment does not work, the manufacturer or dealer must make an attempt to repair the equipment.
b. Medicaid additionally requires providers to provide the recipient with a
comparable, alternate AAC device while repairing the recipient's device during a warranty period.
c. Medicaid coverage may be provided for rental of an alternate AAC device during a repair period after expiration of the warranty.
d. Medicaid will not cover repairs, or rental of a loaner device, when repairs are made during a warranty
period.
2. When a device is received by the provider for the purpose of repair, the provider will conduct an assessment of the device to determine whether it can be repaired, and if so, prepare a written estimate of the parts, labor, and total cost of the repair, as well as the effectiveness (i.e.,estimated durability) of the repair. If the manufacturer or provider concludes that the device is not repairable and the replacement device is needed, written notice will be provided to the
recipient.
3. Medicaid coverage for repairs greater than $300.00 must be accompanied by a statement from the speech-language pathologist. The statement must indicate:
a. Whether there have been any significant changes in the sensory status (e.g.,
vision, hearing, tactile); postural, mobility or motor status; speech, language, and expressive communication status; or any other communication need or limitation of the recipient as described in B.2.(b through
g, and j); and
b. Whether the device remains the speech language pathologist's recommendation for recipient's use.
E. Replacement or Modification.
1. Modification or replacement of AAC devices will be covered by Medicaid subject to the following limitations:
a. Requests for modification or replacement of AAC devices and/or accessories may be considered for coverage after the expiration of three (3) or more years from the date of purchase of the current device and accessories in use.
b. Requests for modification or replacement require prior authorization and must include the recommendation of the speech-language pathologist.
c. Requests for replacements of AAC devices may be submitted for identical or different devices.
d. Requests for replacements of identical AAC devices must be accompanied by a statement from the provider that the current device can not be repaired or that replacement will be more cost effective than repair of the current device. Data must be provided about the following:
i. age;
ii. repair history (a)frequency, (b)duration, and (c)cost; and
iii. repair projections (estimated durability of repairs).
e. Requests for modification or replacement of AAC devices with different devices must include the following additional information:
i. A significant change has occurred in the recipient's expressive communication, impairments, and/or communication limitations. Modification or replacement requests due to changed individual circumstances must be supported by a new assessment of communication limitations by a speech-language pathologist, and may be submitted at any time; or
ii. Even though there has been no significant change in the recipient's communication limitations, there has been a significant change in the features or abilities of available AAC devices (i.e., a technological
change) that will overcome or permit an even greater amelioration of the recipient's communication limitations as compared to the current AAC device. A detailed description of all AAC device changes and the purpose of the changes must be provided with the results of a re-evaluation by a speech-language pathologist.
f. Requests for replacements of AAC devices due to loss or damage (either for identical or different devices) must include a complete explanation of the cause of the loss or damage and a plan to prevent the recurrence of the loss or damage.
III. PRIOR AUTHORIZATION.
A. All requests for AAC devices and accessories must be prior authorized by Medicaid in accordance with the criteria described in this rule.
B. Medicaid will not consider purchase of an AAC device when an alternative means of funding through another agency or other source (e.g., Louisiana Rehabilitation Services, school systems, private insurance, etc.) is available for the recipient. All requests should indicate the availability, or lack of availability, of purchase through other funding sources.