Provision of Medical Restoration Services Traditional & Non-Traditional

(Issued September 2007)(Reviewed May 2014)

Purpose

To provide DVR staff with information to assist them in determining if the provision of medical restoration services is appropriate in a specific case, how to proceed once a determination is made, and considerations when including in the IPE.

Rationale

Determining whether a restoration service should be provided is not always an easy decision to make. This guidance piece has been developed to assist staff in working through the decision process. It is not meant to be all-inclusive; individualized needs and situations should be considered. Counselors should ensure they are working closely with consumers and their medical providers throughout this process.

If you are unsure of the appropriateness of a service, take the time necessary to make the best determination for the case. Gather information that will assist in your decision making, consult with co-workers and supervisors, and use your team as a resource. When a decision has been reached, document your reasoning and incorporate expectations and benchmarks into the IPE.

Definition:

34 CFR 361.5(b)(40) Physical and mental restoration services means-

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;
Diagnosis of and treatment for mental or emotional disorders by qualified personnel in accordance with State licensure laws;
Dentistry;
Nursing services;
Necessary hospitalization (either inpatient or outpatient care) in connection with surgery or treatment and clinic services;
Drugs and supplies;
Prosthetic and orthotic devices;
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;
Podiatry;
Physical therapy;
Occupational therapy;
Speech or hearing therapy;
Mental health services;
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;
Special services for the treatment of individuals with end-stage renal disease, including transplantation, dialysis, artificial kidneys, and supplies; and
Other medical or medically related rehabilitation services (traditional or non-traditional*).

I. Should DVR Provide a Restoration Service?

The following decision matrix is designed to help you work through the process with the consumer.

Is the service necessary to assist the consumer in achieving their IPE goal? AND Has consideration been given to alternatives such as job restructuring, informal support networks, etc.?

YES

NO

If the medical restoration service is not needed to achieve the IPE goal, and if appropriate alternatives have not been considered, the service should not be provided at this time.

Will the service/treatment (traditional or nontraditional*) eliminate or substantially reduce an impediment to employment within a reasonable period of time? AND Are the time frames appropriate? The medical information should address the above two questions. (You may want a second opinion. DVR is able to purchase a medical review.) (If the treatment will need to be ongoing and continue beyond the case with DVR, there is an expectation that the consumer be able to sustain the treatment on their own before we close the case. This should be addressed in the IPE. )

YES

NO

Further information is needed to make the decision.

Have comparable benefits been fully explored and secured if available to assist with payment of the treatment (e.g., local programs, student health center, consumer contribution, or insurance, that would not interrupt or delay services)?

YES

NO

Further research is needed prior to approving the service.

Proceed to include the service in the IPE, using the DVR fee schedule. If the service is a Non-Traditional restoration service see the below information for consideration in your decision.

Non-Traditional Treatment?

Items to Consider:

*The following points should also receive consideration when non-traditional treatment is being considered:

The provision of non-traditional restoration services (e.g. acupuncture, massage therapy, spiritual healing) should be determined on an individual basis. The above flow chart and the following questions should be reviewed with consumers, and in consultation with your supervisor if needed, when determining what services are appropriate in their case.

Is the treatment appropriate in treating the limitation? You and the consumer may need to conduct some basic research. Contact the medical provider for additional information. You may need to purchase a medical review.
Are there multicultural and/or religious issues that should be considered?
Why does the consumer feel this treatment would be of benefit over traditional treatment options?
Is the treatment provider qualified in treating this limitation (e.g., is a state license required to provide this treatment)?
Have traditional treatments covered by insurance been considered or attempted in the past? What were the results of those?

II. After the decision is made the counselor should ensure the following is completed:

Clearly case note your reasoning for providing the service.
Include the service in the IPE.
Attach all supporting documents in IRIS.
Follow the DVR fee schedule.
If the requested service is denied, the reasons for denying the service should be case noted. Inform the consumer in writing of the decision and give them their CAP and appeal rights.

III. Writing Restoration Services in the IPE:

Progress benchmarks should be included. A treatment schedule should be determined using information obtained from medical professionals and through a discussion with the consumer.
Include when and how progress will be measured.
Include who is responsible for the payment of the service (e.g., insurance is covering the treatment and DVR is covering the co-pay).
If the service is on-going, there should be continual research for any available comparable benefits that can assist the consumer that were not available before.
If determined that the treatment will be ongoing and continue beyond the case with DVR, will the consumer be able to fund the service on their own? This needs to be addressed in the IPE.