Prior authorization will not be required for outpatient speech therapy.*

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1 POLICY CHANGE: Authorization for All Outpatient Speech Therapy and Pediatric Outpatient Physical and Occupational Therapy NOT REQUIRED by Martin s Point Health Care Effective June 25, 2018 Thank you for your participation in the Martin s Point Generations Advantage and/or US Family Health Plan provider network(s). As promised in our conversations with many network providers, we have analyzed our therapy data and made authorization policy changes based on our findings. The following policy changes are effective for dates of service on or after June 25, SPEECH THERAPY Prior authorization will not be required for outpatient speech therapy.* PHYSICAL and OCCUPATIONAL THERAPY Prior authorization for outpatient physical and occupational therapy will not be required for children and adolescents (18 years and under).* Prior authorization for outpatient physical and occupational therapy will continue to be required for members 19 years and older. The number of initial authorized visits is updated to align with the expected total course of treatment. This will reduce the need to request authorization for extended visits unless the member has comorbidities or complications impacting treatment goals. Please see the updated initial visit grid on our website at TRICARE REMINDERS/EXCEPTIONS TO THE POLICY Applied Behavioral Therapy (ABA) ABA is not included in the Martin s Point Outpatient Therapy Policy. ABA services require prior authorization and have specific ABA codes.

2 Extended Care Health Option (ECHO Program) per TRICARE Policy Manual (Chap. 9, Sect. 18.1) Only ECHO authorized benefits may be processed as an ECHO claim. All ECHO claims must have an authorization. *For members 18 years and under who have Extended Care Health Option (ECHO) benefits, prior authorization is required when the ECHO benefit will be used to pay for outpatient speech/occupational/physical therapy claims. Special Education Services per TRICARE Policy Manual (Chap. 7, Sect. 18.3) For beneficiaries aged 3 to 21 who are receiving special education services from a public education agency, cost-sharing of outpatient occupational therapy services that are required by the IDEA and which are indicated in the beneficiary s Individualized Education Program (IEP) may not be cost-shared except when the intensity or timeliness of occupational therapy services as proposed by the educational agency are not sufficient to meet the medical needs of the beneficiary. For members 18 years and under not using ECHO benefits, authorization for outpatient speech/occupational/physical therapy is not required. Records may be requested for retroactive review to ensure services are not duplicative or unnecessary. If you have questions about this policy change, please contact Provider Inquiry at Thank you for your participation in our health plan network and for the excellent care you provide to our members. INITIAL THERAPY AUTHORIZATION GUIDELINES: PHYSICAL / OCCUPATIONAL: Initial Authorization Visit Guidelines Diagnosis Total # Auth Visits after Evaluation/ 2-3 Month Treatment Duration Spine Bulging/protruding/herniated discs 16 Compression fracture of vertebrae 10 Low back pain 8

3 Neck pain/cervicalgia 10 Pain without radiculopathy 8 Sciatica/pain radiation 12 Scoliosis 6 Strain/sprain cervical - upper back and neck 10 Strain/sprain lumbosacral 8 Surgical Spine Discectomy 10 Fusion 10 Laminectomy 10 Upper Extremity (Non-Surgical Shoulder) Adhesive capsulitis 14 Brachial plexus injury 10 Dislocation 10 Impingement 10 Pain/sprain/strain 10 Rotator cuff tendinitis 10 Thoracic outlet syndrome 12 Surgical Shoulder Acromioplasty/impingement release/subacromial decompression 16 Dislocations/instability repeated-open (Bankart procedure) 18 Fracture-closed 20 Fracture-ORIF 18 Other scope procedure 10 Repair tendon rupture 18 Rotator cuff tear repair 24 SLAP (superior labral tear) 18 Total shoulder arthroplasty/replacement 24 Elbow Dislocation 8 Epicondylitis (medial/lateral) 10

4 Nerve or fascial compression/release 10 Other surgery 10 Pain/sprain/strain 8 Status post fracture-orif 20 Total elbow arthroplasty/replacement 20 Wrist/Hand Carpal tunnel release/syndrome 12 DeQuervain's (tenosynovitis) 16 Fracture-ORIF 10 Joint replacement 24 Pain/sprain/strain 8 Lower Extremity Pelvis/Hip Hip fracture 16 Hip impingement/tenosynovitis 14 Pelvis fracture 10 Piriformis syndrome (sciatic nerve lesion) 12 Pain/sprain/strain 10 Tendinitis 10 Total hip arthroplasty/replacement 20 Non-Surgical Knee/Thigh/Leg Chondromalacia 12 Dislocation/subluxation 8 Fracture 10 Pain 8 Sprain 10 Strain 10 Surgical Knee Anterior cruciate ligament repair 16 Medial collateral ligament repair 16 Fracture-ORIF 24 Other open procedure 12 Other scope procedure 10 Patellar fracture 24

5 Posterior cruciate ligament repair 16 Total knee arthroplasty 20 Non-Surgical Ankle Fracture 10 Pain/sprain/strain 6 Tendinitis 10 Tenosynovitis 6 Surgical Ankle Achilles tendon rupture/repair 24 Fracture-ORIF 20 Ligament rupture/reconstruction 24 Other open procedure 10 Other scope procedure 10 Total ankle arthroplasty 20 Non-Surgical Foot Capsulitis/enthesopathy 10 Fracture 10 Metatarsalgia 10 Tarsal tunnel syndrome 10 Tendinitis 10 Tenosynovitis 10 Surgical Foot Bunionectomy 10 Fracture - ORIF (metatarsal/tarsal) 10 Other open procedure 8 Other scope procedure 8 Tarsal tunnel release 10 Other Amputation 24 Amyotrophic lateral sclerosis (ALS) 24 Bell's Palsy 12 Burns 20 Cerebrovascular accident (CVA) - Late 24

6 Cerebrovascular accident (CVA ) - New 24 CRPS/Complex regional pain syndrome 10 Dizziness and giddiness 8 Fibromyalgia 16 General muscle pain 12 Guillain-Barre Syndrome 24 Headache 6 History of falling 8 Lymphedema 12 Multiple Sclerosis 24 Osteoarthritis/degenerative joint disease 8 Paralysis related to surgery 8 Parkinson's disease 16 Rheumatoid arthritis 8 RSD/Reflex sympathetic dystrophy syndrome 10 Urinary incontinence/pelvic floor 6 Vertigo 12 Weakness 8