Printing - FECA-PT2 - National Association of Letter Carriers

(3) The therapy extends beyond the initial and additional approval periods.
As appropriate, the CE should authorize therapy based on the results of the second opinion
evaluation or refer the claimant for a referee examination for further resolution of the treatment
issues. Charges for physical therapy rendered after the initial 120-day period or other authorized
periods are not to be reimbursed until the process is completed and the CE has authorized the
extension.
h. If the need for additional therapy is not established, the CE should issue pre-termination
notice and prepare a formal denial as described in PM Chapter 2-1400.10.
2-0810-17 Authorization for Diagnostic Testing
17. Authorization for Diagnostic Testing. Diagnostic procedures are used to determine the exact
nature and extent of the claimant's condition. Such assessments often clarify the medical status and may
well save the claimant additional pain and time loss from work. This paragraph discusses when such tests
may be authorized, and by whom.
a. Development. If a diagnostic procedure such as an MRI, CAT scan, or arthroscopy pertains
to the accepted condition, or in unadjudicated cases to the part of the body which has been
injured, the request should not routinely be developed. Even in the case of arthroscopy, the
diagnostic nature of the test should take priority over its surgical nature when authorization is at
issue, and the procedure should be authorized and paid for without further investigation in a case
involving injury to the knee.
b. Sequence of Tests. For many conditions, a standard sequence for such tests exists--for
instance, in cases of back injury, an initial x-ray is generally followed by a CAT scan or MRI if
needed, with a myelogram performed if earlier procedures are inconclusive and the physical
findings warrant it. If the CE is unaware of the usual sequence for a particular condition, or if the
nature of the test is unfamiliar, a verbal consultation with the RN or DMA may be in order, but
unless a specific reason exists to obtain further information, the test should be authorized.
c. Authorization. The CE may grant authorization for tests in accordance with the guidelines
stated above. RNs may authorize non-invasive diagnostic procedure (CAT scans, MRIs, x-rays,
laboratory work, EMGs, pulmonary function tests, nerve conduction studies) without prior
authorization from the CE. They may not, however, authorize invasive tests such as arthroscopy
or myelogram.
FECA-PT2 Printed: 06/08/2010 350