RPM 5.3.4 Physical Restoration Services or Procedures with Special Requirements
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Adaptive or Assistive Technology
You may purchase an assistive or adaptive device when it is required to address your consumer's vocational need. Be aware, however, that many assistive and adaptive products on the market today do not meet DRS's best-value purchasing criteria.
For example, technologically advanced products not shown to be safe and effective by independent clinical evidence do not meet best-value criteria and should not be purchased. See Goods and Services Not to Be Purchased at This Time in the Counselors' Toolbox for a list of some commonly requested devices.
If you are uncertain about whether a product meets DRS best-value criteria, contact the CPBS physical restoration specialist or the program specialist for physical disabilities for guidance.
Medical Assistive Devices and Supplies
See Chapter 7: Purchasing, 7.4 Purchasing Medical Assistive Devices and Supplies.
Bariatric Surgery for Surgery for Morbid Severe (Morbid) Obesity
(Revised 10/08)
The LMC must review and the area manager must approve providing the service before you submit the courtesy file to the DRS medical director to review and approve the surgical treatment of morbid obesity (to request medical director approval, see Chapter 11: Technical Information and References, 11.1 Required Approvals and/or Consultations).
Before submitting a case for review and approvals, the following must occur:
· The consumer's primary physician must refer the consumer for surgical evaluation and intervention to a specific surgeon who is known to be experienced and active in gastroplasty procedures for morbid obesity.
· There must be evidence of attempts at medically supervised weight loss. The supervising physician must document that the consumer participated in the program for at least 12 months, with at least monthly visits with the medical supervisor. The physician must state
o that the consumer complied or is complying with the program;
o whether or not this was or is a viable program for the consumer; and
o that, in his or her opinion, the consumer cannot make further progress in the program. (If you believe that the consumer's morbid obesity is so severe that participation in a weight-loss program before consideration of weight-loss surgery might not yield medically significant results, request guidance from the DRS medical director.)
· A physician's evaluation of the consumer's weight must
o provide the consumer's height and weight; and
o state whether the consumer is double normal weight, as measured by the Metropolitan Life Tables of Height and Weight.
· A functional capacity assessment must be performed.
· A job analysis must be performed by an occupational therapist or a physical therapist if the consumer is employed.
· The consumer's general health status must be stable. An endocrinologist or internal medicine specialist must document general health status and medical stability. The evaluation must rule out
o uncontrolled diabetes or other uncontrolled endocrine disease,
o uncontrolled hypertension,
o congestive heart failure,
o renal failure, and
o chronic obstructive pulmonary disease.
· A psychiatrist's or psychologist's evaluation must state that the consumer is a good candidate for the surgical procedure and postsurgery compliance, with the following considerations:
o a full psychological battery may not be needed to complete the requirement;
o the psychiatrist or psychologist should identify and include specific tests used to determine if the consumer is a good candidate; and
o you should review the specific request with the evaluator before requesting and authorizing service.
When the actions above are complete, refer the consumer to the surgeon for evaluation. The surgeon must provide specific recommendations identifying procedure(s) to be provided, including their related American Medical Association Current Procedural Terminology (CPT) codes.
A consumer is severely obese when his or her body mass index (BMI) is 40 or more. Severe obesity is a disability if it results in an impediment to employment. Before considering bariatric surgery as a service for a severely obese consumer, identify the consumer’s impediment to employment.
Determining If Severe Obesity Results in an Impediment to Employment
To determine if a consumer has an impediment to employment related to severe obesity, you must use the following procedure:
1. obtain documentation from a physician that shows the consumer’s height and weight and that the consumer has a BMI of 40 or more;
2. have a physical or occupational therapist or chiropractor perform a functional capacity assessment (FCA) to observe and evaluate the consumer’s functional capabilities and accurately measure the consumer’s work capacity;
3. have an occupational or physical therapist perform a job analysis, if the consumer is employed, to determine the functional requirements of the consumer’s job; and
4. review the FCA and job analysis to determine whether the consumer can perform the critical tasks of his or her job. If the consumer can perform the critical tasks of his or her job, there is no impediment to employment related to severe obesity. An unemployed consumer must demonstrate an inability to meet the physical demands of the chosen realistic job goal as defined in Choices.
Considering Workplace Modifications or Assistive Devices Instead of Surgery
If a consumer has an impediment to employment related to severe obesity, determine whether services such as workplace modifications or assistive devices would be appropriate alternatives to bariatric surgery.
Procedure for Requesting Approval for Bariatric Surgery
If you have determined that a consumer has significant impediments to employment related to severe obesity, you may request approval to provide bariatric surgery services. Submit a courtesy file to the DRS medical director that includes documentation described in the following steps:
1. obtain documentation from the supervising physician that the consumer participated in a medically supervised weight loss program for at least 12 months with at least monthly visits with the medical supervisor. The physician’s documentation must state
o the effectiveness of the program and consumer compliance; and
o an opinion that the consumer cannot make further progress in the program;
or
if the consumer has not participated in a medically supervised weight loss program, you may submit a request to the DRS medical director to waive this requirement. Waivers are granted only if the consumer’s obesity is so severe that participation in a program will not yield weight loss sufficient to remove or adequately reduce the consumer’s impediment to employment.
2. obtain from a primary care physician, endocrinologist, or internal medicine specialist clearance for bariatric surgery and documentation of medical stability of other conditions the consumer may have, such as
o diabetes mellitus,
o other endocrine disease,
o hypertension,
o congestive heart failure,
o renal failure, or
o chronic obstructive pulmonary disease;
3. arrange for an evaluation by a psychologist or psychiatrist. Before you request and authorize this service, make sure the psychologist or psychiatrist understands that the purpose of the evaluation is to determine whether the consumer is a good candidate for bariatric surgery and will likely be compliant with postsurgery instructions and dietary restrictions.
4. refer the consumer to an experienced bariatric surgeon for evaluation. Before requesting and authorizing this service, ensure that the surgeon will provide specific recommendations for the consumer including the American Medical Association Current Procedural terminology (CPT) codes;
5. have the LMC review the consumer’s case;
6. submit the case to the area manager for review. If the area manager approves the service, proceed with the final step in this procedure; and
7. send the courtesy case to the DRS medical director for final approval of bariatric surgery. (To request medical director approval, see Chapter 11: Technical Information and References, 11.1 Required Approvals and/or Consultations.)
Nursing Home Care
See Home Health or Nursing Home Care.
Occupational Therapy
Purchase occupational therapy (OT) when the consumer must increase coordination, strength, or range of motion.
A physician recommends, and later reviews, the provision of OT. A licensed occupational therapist provides these services.
See Outpatient Services for limitations.
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5.3.4 Physical Restoration Services or Procedures with Special Requirements
(Revised 10/08, 12/09, 04/10)
*Listed below are physical restoration services or procedures that have special requirements. You must review these requirements before including any of them in the consumer's plan.*
*Based on 34 CFR Section 361.50(a)
· breast implant removal;
· chiropractic treatment;
· cochlear implant;
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Home Health or Nursing Home Care
Provide home health care or care in a nursing home if the attending physician recommends them in the following situations:
· you may provide home health care if the consumer resides a great distance from the attending physician, and it is impractical to transport the consumer back and forth for follow-up care; or
· you may provide nursing home care if the consumer does not require hospitalization, but does require more nursing and medical attention than is available in the consumer's home.
See Outpatient Services for limitations.
Providers of home health care must be licensed by the Texas Department of State Health Services.
Nursing homes must meet the provider qualifications stated in Chapter 7: Purchasing, 7.2 Health Care Professionals—Required Qualifications.
Gym Memberships or Home Exercise Equipment
DRS does not purchase gym memberships or home exercise equipment, including home equipment for water therapy or strengthening.
Intercurrent Illness
When a short-term illness hinders vocational rehabilitation services, provide acute medical care as necessary. This supplemental service is limited to acute illnesses such as
· infection,
· pneumonia,
· appendicitis,
· ectopic (tubal) pregnancy,
· dental treatment,
· simple fractures, or
· minor injuries.
These illnesses usually require less than 10 days of hospitalization or visits to the doctor's office or clinic for treatment, thus not altering the vocational plan.