For Dates of Service Before January 1, 2020

Aural Rehabilitation Therapy Following a Cochlear Implant

Providers are required to complete and submit the following forms to ForwardHealth to request PA for aural rehabilitation services for members who have reached 35 treatment days in their lifetime and require aural rehabilitation therapy from a speech-language pathologist immediately following a cochlear implant:

• PA/RF
• PA/TA

Prior Authorization/Therapy Attachment

Providers are required to submit the entire PA/TA (all three pages of the PA/TA) but are only required to complete the following elements of the form:

• Section I, Elements 1-12. In Element 12 (Requested Start Date), providers are required to enter the date of stimulation.
• Section II, Element 13. Providers are required to clearly identify the following:
• Date of cochlear implant surgery, in MM/DD/CCYY format.
• Date of stimulation, in MM/DD/CCYY format.
• Pre-linguist or post-linguist (applies only to members over 18 years of age).
• Section VIII, Element 22 (SIGNATURE — Providing Therapist) and Element 23 (Date Signed).

Established Grant Date

The grant date of approved PA requests for therapy services will be the initial stimulation date. Wisconsin Medicaid must receive the PA request no more than 30 calendar days before the stimulation date, or no more than 14 days after the stimulation date.

Aural Rehabilitation Services for Members Under 18 Years of Age Following a Cochlear Implant

Wisconsin Medicaid will grant a maximum of 60 visits of aural rehabilitation therapy over a 20-week period following the stimulation date of the cochlear implant for members under 18 years of age. The grant date of the PA request will be the stimulation date. The expiration date will be 20 weeks from the stimulation date.

Aural Rehabilitation Services for Members 18 Years of Age and Older Following a Cochlear Implant

Wisconsin Medicaid will grant a maximum of 13 weekly visits of aural rehabilitation therapy over 13 weeks following the stimulation date of the cochlear implant for members 18 years of age and older with post-linguistic skills. The grant date of the PA request will be the stimulation date. The expiration date will be 13 weeks from the stimulation date.

For members 18 years of age and older with pre-linguistic skills, Wisconsin Medicaid will grant a maximum of 26 visits over 26 weeks of aural rehabilitation therapy following the stimulation date of the cochlear implant. The grant date of the PA request will be the stimulation date. The expiration date will be 26 weeks from the stimulation date.

Requesting Extension of Aural Rehabilitation Therapy

Subsequent PA requests to extend therapy services will require completion of the entire PA/TA, as well as attachment of the required documentation indicated in the PA/TA Instructions. Wisconsin Medicaid may approve subsequent PA requests for a period of up to six months if the documentation submitted supports the medical necessity of the request.

Procedure Codes

Providers are required to use CPT procedure code 92626 (Evaluation of auditory rehabilitation status; first hour) and, if warranted, procedure code 92627 (Evaluation of auditory rehabilitation status; each additional 15 minutes) for evaluation and re-evaluation. Providers are required to use procedure code 92507 (Treatment of speech, language, voice, communication, and/or auditory processing disorder) with modifier UC (therapy following a cochlear implant) for aural rehabilitation following a cochlear implant. The use of modifier UC represents services for the improvement of speech and language related to the cochlear implant and results in increased reimbursement.

Members commonly receive SLP services prior to receiving a cochlear implant. Providers should submit claims for procedure code 92507 without modifier UC for these services.

Maximum Allowable Number of Visits and Weeks

The following table provides the Wisconsin Medicaid maximum allowable number of visits and weeks for aural rehabilitation services following the date of stimulation of a cochlear implant that will be approved on a PA request: