Non-Covered Services

1. Physical or occupational therapy that is provided without a prescription from a physician or other licensed practitioner of the healing arts within the practitioner’s scope of practice under state law
2. Speech-language or audiology services provided without a written referral from a physician or other licensed practitioner of the healing arts within the practitioner’s scope of practice under state law
3. Services for contracture that are not severe and do not interfere with the member’s functional status or the completion of nursing care as required for licensure of the Long-Term Care Facility (LTCF)^*
4. Ambulation of a member who has an established functional gait pattern^*
5. Services for conditions of chronic pain that do not interfere with the member’s functional status and that can be treated by routine nursing measures^*
6. Services for ADLs when performed by the therapist, therapy assistant, or therapy aide^*
7. Bowel and bladder retraining programs^*
8. Art and craft activities for the purpose of recreation
9. Services not medically necessary
10. Services not documented in the member’s health care record
11. Services not part of the member’s plan of care
12. Services specified in a plan of care that is not reviewed and revised as medically necessary by the member’s attending physician
13. Services that are not designed to improve or maintain the functional status of a member with a physical impairment or a cognitive or psychological deficit
14. Services by more than one provider of the same type for the same diagnosis unless the service is provided by the school district as specified in the member’s IEP
15. A rehabilitative and therapeutic service that is denied Medicare payment because of the provider’s failure to comply with Medicare requirements
16. Vocational or educational services, including functional evaluations and IEP-related services
17. Services provided by a therapy aide or therapy student
18. Psychosocial services
19. Record keeping documentation and travel time (the transport and waiting time of a member to and from therapy sessions)
20. Services provided by a rehabilitation agency that takes place in a sheltered workshop, Day Training and Habilitation (DT&H) center, Day Activity Center (DAC), or a residential or group home that is an affiliate of the rehabilitation agency
21. Yearly assessments of long-term care (LTC) residents to meet Omnibus Budget Reconciliation Act (OBRA) regulations^*
22. Training or consultation provided by an audiologist to an agency, facility, or other institution
23. Work Hardening Programs
24. Services provided by a long-term care facility that are included in the costs covered by the per diem payment

^*These items are considered rehabilitative nursing and are part of the LTCF per diem payment.

PW_11-19_587
Updated_10/29/2020