471 NAC 23-004. SERVICE REQUIREMENTS

004. SERVICE REQUIREMENTS. 004.01 MEDICAL NECESSITY. Nebraska Medicaid incorporates the definition of medical necessity set forth in these regulations . Services and supplies that do not meet the definition of medical necessity are not covered. 004.02 SERVICE CRITERIA. Nebraska Medicaid covers speech-language pathology and audiology 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. 004.03 COVERED SERVICES. Nebraska Medicaid covers speech-language pathology and audiology services when the following criteria are met: (1) The services are ordered by a licensed physician, nurse practitioner (NP), physician assistant (PA), or a treating practitioner; (2) The services are medically necessary; (3) The services are such that only a licensed speech-language pathologist or audiologist can safely and effectively perform the service; (4) The speech-language pathology or audiology service meets at least one of the service criteria; and (5) The services are offered through a home health agency. 004.03(A) MAINTENANCE PROGRAM. The speech pathologist or audiologist must: (i) Evaluate the beneficiary’s needs; (ii) Design a maintenance program; and (iii) Instruct the beneficiaries, family members, or nursing facility staff in carrying out the program. 004.03(B) SERVICES FOR BENEFICIARIES AGE 21 AND OLDER. For beneficiaries age 21 and older, Nebraska Medicaid limits coverage to 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), speech-language pathology, and audiology sessions provided to the recipient. 004.04 NON-COVERED SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY SERVICES. Nebraska Medicaid does not cover the following speech-language pathology or audiology services: (A) Maintenance therapy ; (B) Therapy for vocational and prevocational assessment and training; (C) Therapy for functional capacity evaluations, educational testing, drivers training, or training in non-essential self-help or recreational activities, visual perception training, or treatment of psychological conditions; (D) Therapy for dysfunctions that are self-correcting ; (E) Therapy for delays in speech development that is not due to a specific medical condition or brain injury; or (F) Therapy for the following conditions or diagnosis categories: (ii) Behavior problems; (iii) Attention disorders; (iv) Conceptual handicap; or (v) Learning disability.