471 NAC 14-004. SERVICE REQUIREMENTS

004. SERVICE REQUIREMENTS. 004.01 MEDICAL NECESSITY. Medical necessity requirements are outlined in these regulations. . Services and supplies that do not meet the requirements are not covered. 004.02 SERVICE CRITERIA. Nebraska Medicaid covers occupational therapy (OT) and physical therapy (PT) services when the following criteria are met: (i) The service is an evaluation; or (ii) The service is restorative therapy with a medically appropriate expectation that the beneficiary’s condition will improve significantly within a reasonable period of time; or (iii) The service is recommended in an approved individual program plan (IPP), and the beneficiary is receiving services through one of the following waiver programs: (1) Developmental Disabilities (DD) Adult Comprehensive Services Waiver; (2) Developmental Disabilities (DD) Adult Residential Services Waiver; (3) Developmental Disabilities (DD) Adult Day Services Waiver; (4) Community Supports Waiver; or (5) Home and Community Based Services Waiver for Children with Developmental Disabilities and their Families. 004.03 SERVICES FOR BENEFICIARIES AGE 21 AND OLDER. For beneficiaries age 21 and older, Nebraska Medicaid covers a combined total of 60 therapy sessions per fiscal year . The combined total of 60 therapy sessions per fiscal year includes all occupational therapy (OT), physical therapy (PT), and speech therapy sessions provided to the beneficiary. 004.04 COVERED SERVICES. Nebraska Medicaid covers occupational therapy (OT) or physical therapy (PT) services when the following criteria are met: (1) The services are ordered by a licensed physician, nurse practitioner (NP), or a treating practitioner; (2) The services are medically necessary; (3) The services are such that only a licensed occupational therapist (OT) or physical therapist (PT) can safely and effectively perform the service; and (4) The services are offered through a home health agency. 004.04(A) MAINTENANCE PROGRAM. The occupational therapist (OT) or physical therapist (PT) must: (i) Evaluate the beneficiary’s needs; (ii) Design a maintenance program; and (iii) Instruct the beneficiary, family members, or nursing facility staff in carrying out the program. 004.04(B) ORTHOTIC APPLIANCES AND DEVICES. Nebraska Medicaid covers orthotic appliances and devices when medically necessary for the beneficiary’s condition, and when the orthotic appliance or device is used during the therapy session. 004.04(C) SUPPLIES. Nebraska Medicaid covers supplies used during the course of treatment that require application by the occupational therapist (OT) or physical therapist (PT) when they are not incidental to the procedure. 004.05 NON-COVERED OCCUPATIONAL THERAPY (OT) OR PHYSICAL THERAPY (PT) SERVICES. Nebraska Medicaid does not cover occupational therapy (OT) or physical therapy (PT) services in the following situations: (A) Maintenance therapy ; (B) Therapy for hardening, vocational, prevocational assessment, and training; (C) Therapy for functional capacity evaluations, educational testing, drivers training, training in non-essential self-help or recreational activities, training related to a learning disability or attention disorder, visual perception training, or treatment of psychological conditions; (D) In-service training for nursing facility staff which is not beneficiary specific; (E) Rental of equipment; or (F) Take home supplies.