- Physical and mental restoration services means:
(i) Corrective surgery or therapeutic treatment that is likely, within a reasonable period of time, to correct or modify substantially a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to employment;
(ii) Diagnosis of and treatment for mental or emotional disorders by qualified personnel in accordance with State licensure laws;
(iv) Nursing services;
(v) Necessary hospitalization (either inpatient or outpatient care) in connection with surgery or treatment and clinic services;
(vi) Drugs and supplies;
(vii) Prosthetic and orthotic devices;
(viii) Eyeglasses and visual services, including visual training, and the examination and services necessary for the prescription and provision of eyeglasses, contact lenses, microscopic lenses, telescopic lenses, and other special visual aids prescribed by personnel that are qualified in accordance with State licensure laws;
(x) Physical therapy;
(xi) Occupational therapy;
(xii) Speech or hearing therapy;
(xiii) Mental health services;
(xiv) Treatment of either acute or chronic medical complications and emergencies that are associated with or arise out of the provision of physical and mental restoration services, or that are inherent in the condition under treatment;
(xv) Special services for the treatment of individuals with end- stage renal disease, including transplantation, dialysis, artificial kidneys, and supplies; and
(xvi) Other medical or medically related rehabilitation services (per 2001 Federal Regulation 34 CFR § 361.5 (b)(40)).
- Doctor or physician means Doctor of Medicine and Surgery, Doctor of Osteopathy, Doctor of Podiatry, Doctor of Chiropractic, and Optometrist.
- Physical and mental restoration services means:
The counselor may approve services for assessment purposes. For assessment by a specialist See Policy 1: Section A20. For HIV testing, See Policy 1: Section A9. For additional requirements for other services see the specific service within section A of this policy.
- Cross-reference: For policy and procedure, see Chapter 6, DIAGNOSTICS, Policy 1.
- Cross-reference: For services under Trial Work Experiences Plan or Extended Evaluation Plan, see Chapter 4.02, EXTENDED, Policy 1.
- Guidance: Items subject to consumer financial participation policy (wheelchairs, telecommunications and assistive listening systems, etc.) should be provided on a loan basis (rather than purchased) during eligibility determination.
- Additional criteria.
For additional eligibility criteria for a specific service, see subsections A1, A2, etc. of this policy.
- Under Employment Plan.
The counselor may approve services under an Employment Plan after the individual and counselor jointly establish the employment goal. Before committing to providing the service or authorizing it, the counselor shall (a) ensure it is consistent with policy and procedure for planned services, including requirements for physical or mental restoration Employment Plan, under Chapter 5, PLAN, Policy 2 and shall (b) document that all of the following eligibility criteria are met:
- The service is needed to achieve the Employment Plan employment goal (per 2001 Federal Regulation 34 CFR § 361.46).
- The physical or mental condition is medically documented as stable or slowly progressive (per State Regulation 22 VAC 30-20-120).
- The condition is not acute or transitory, or of such recent origin that the resulting functional limitations and the extent to which the limitations affect occupational performance cannot be identified (per State Regulation 22 VAC 30-20-120(b)). For acute or chronic conditions or medical emergencies, approval shall be allowed only according to the definition in subsection A1a above.
- The physical or mental impairment is a substantial impediment to employment. For definition of substantial impediment to employment, see Chapter 4.01, ELIGIBILITY, Policy 1.
Documentation may include, but is not limited to, the counselor’s relevant case notes, intake interview notes, etc.
- The individual requires additional vocational rehabilitation services. This means the Employment Plan must have at a minimum, vocational counseling and guidance, and may have other services as appropriate (per State Regulation 22 VAC 30-20-120). This requirement is based on General Accounting Office September 22, 1982 report (GAO/HRD-82-95) to the U.S. Secretary of Education.
- C&G in Service status.
During Service status, the counselor will provide counseling and guidance in areas such as length of treatment, projected date of return to work, work restrictions, information available on service provider, comparable benefits and billing procedures, necessary child care and housekeeping arrangements, following medical advice, DRS procedures for physical and mental restoration services, or other related topics. The decision of the dental consultant or medical consultant may be appealed through any of the avenues of appeal (see Chapter 15, APPEALS, Policy 1).
- Guidance: Include in the approval request: the medical (or dental) information and documentation that the condition is a substantial impediment to employment (e.g., intake interview, relevant case notes, etc.).
- Recommended by qualified vendor in writing.
Personnel qualified as defined in state licensing and certification laws recommends the service in writing (e.g., doctor’s orders, prescription, report, etc.) and will provide the service (Title 54.1 of the Code of Virginia). Treatment services may be provided either by the same person who provided the assessment/diagnostic services or by someone else. For qualified personnel for each service, refer to subsections A1, A2, etc. of this policy; vendor policy in Chapter 14.1, PURCHASING, Policy 2; and the DRS Services Reference Manual.
- The counselor documents pre-approval from the supervisor/medical consultant/dental consultant, as required for specific services (see subsections A2, A3, etc. of this policy).
- The pre-approval dollar level policy shall also apply (see Chapter 14.1, PURCHASING, Policy 3).
- Any medical service (this requirement does not apply to dental or mental services) not listed in the Services Reference Manual shall require written pre-approval from the DRS chief medical consultant.
- Written pre-approval from the DRS regional dental consultant may be required for any dental restoration services not listed in the Service Reference Manual.
- Over $5,000.
With the local medical consultant’s (when the local consultant has a conflict of interest or is not available, use medical consultant for another office, or chief medical consultant, or Wilson Workforce and Rehabilitation Center physician), written pre-approval, the counselor may approve an Employment Plan and amendments that include physical restoration services in which the total cost of the physical restoration package exceeds $5,000 (per agency mandate). The medical consultant will record the results of the review and approval on the Medical Consultant’s Work Sheet (RS-3g). The counselor shall maintain the completed RS-3g form in the case file. This requirement is in addition to the pre-approval dollar limit policy (see Chapter 14.1, PURCHASING, Policy 3).
- Exception: This requirement shall not apply to:
- i. Dental services, including temporamandibular joint dysfunction treatment (TMJ)
- ii. Eyeglasses
- iii. Hearing aid
- iv. Prosthetic or orthotic devices
- v. Psychological or psychiatric services
- Exception: This requirement shall not apply to:
- Refusal of service.
An individual may refuse physical and mental restoration services even when it is the opinion of a licensed medical professional that the limitations that cause an impediment to employment can be removed without injury to the individual. The individual shall be eligible only for vocational counseling and guidance and job placement services (per State Regulation 22 VAC 30-20-120).
- Guidance: In order to make an informed choice, the individual must receive information on the prognosis with and without the recommended physical or mental restoration services.
- Second opinion.
The counselor may authorize a second opinion at the individual’s request. In the event of conflicting medical opinions, the counselor shall authorize a third opinion and the decision shall be made on the two concurring opinions (per State Regulation 22 VAC 30-20-120).
- Bills for Unforeseen Medical Services.
See Policy 1: Section D3 of this chapter.
- Disallowed services.
- DRS staff shall not approve experimental procedures (per State Regulation 22 VAC 30-20-120). Per the American Medical Association, “experimental” means not recognized under generally accepted medical standards as safe and effective for treating a particular condition.
- DRS staff shall not approve procedures that are high risk to the patient (per State Regulation 22 VAC 30-20-120). This shall be determined on a case-by-case basis by the treating physician. For invasive procedures (e.g., surgery, catheterizations) and stress tests, the counselor shall obtain a written statement from the treating physician regarding the risk level for the patient. See Services Reference Manual for services that require this statement.
- DRS staff shall not approve services expected to have an uncertain or limited outcome for the patient (per State Regulation 22 VAC 30-20-120(e)). If the medical report indicates a procedure has an uncertain or limited outcome, DRS approval of the procedure shall be determined on a case-by-case basis by the DARS chief medical consultant in consultation with the treating physician.
- DRS staff shall not approve services contraindicated for the patient.
- DRS staff shall not approve incidental procedures performed in conjunction with a surgical procedure authorized by the counselor.
- DRS shall not cover “spend-down” for clients with Medicaid (See Policy 1: Section D4 of this chapter).
- DRS staff shall request payment only for those services that are part of the individual’s Employment Plan. (This requirement does not apply to VR services provided for diagnostic and evaluation purposes before the Employment Plan is developed). DARS shall not request payment for service unless the service is authorized in writing by the counselor before the service is provided or before the individual incurs the expense (per 2001 Federal Regulation 34 CFR § 361.50).
- Monetary loans to individuals are strictly prohibited by agency mandate.
- DRS shall not pay bad debts, liens, or judgments (e.g., outstanding medical bills); entertainment expenses, including costs of amusements and social activities; fines, court costs, and similar expenses; or the consumer’s interest payments (per federal OMB Circular A-87 revised May 10, 2004).
- Consumer responsibilities.
The client must satisfy all of the items in this policy (See Policy 1: Section B1 of this chapter).
Physical and mental restoration services, except when diagnostic in nature, are subject to consumer financial participation policy (2001 Federal Regulation 34 CFR § 361.54). See Chapter 14.3, FINANCIAL, Policy 1.
- Comparable benefits.
Physical and mental restoration services that are not medically necessary (per insurer or physician) but are required solely to determine eligibility or VR needs (and priority category for services if DRS is on Order Of Selection) are exempt from comparable benefits policy (per 2001 Federal Regulation 34 CFR § 361.53). Physical and mental restoration services, including diagnostic and evaluation services related to subsequent treatment of a medical or mental condition, are subject to comparable benefits policy (see Chapter 14.2, COMPARABLE, Policy 1). The counselor shall ensure that the insurer has pre-approved the service. Without pre-approval, the insurer may reduce or deny the insurance payment (thus increasing the DRS payment amount). Due to insurance contract restrictions, the service provider may not be able to bill DRS or the client for the unpaid balance (and would have to write off the loss).
- Guidance: When the insurer denies a pre-approval request, the counselor should only authorize the service when the counselor deems it essential to achieve the established employment goal (per agency mandate).
- Guidance: Comparable benefits resources include Medicare, Medicaid, Workers’ Compensation, private health insurance, Veterans Disability Benefits, employee benefit health insurance, Workers’ Compensation benefits, local Community Services Board (CSB), Medical College of Virginia, University of Virginia Hospital, etc.
Physical and mental restoration services are subject to DRS established purchasing policies and procedures. See Chapter 14.1, PURCHASING, Policy 1.