(a) Medical
assistance payments shall not be made for certain health services or items for
reasons including, but not limited to the following:
(1) The procedure, service, or material is of
generally unproven benefit;
(2) It
is of an experimental nature;
(3)
It is excluded by federal regulations or state rules;
(4) It is not considered by the department to
be medically necessary;
(5) The
same or similar results may be obtained by another method at a reduced
cost;
(6) The procedure is
frequently followed by severe complications which may be in themselves
life-threatening or require prolonged medical care or secondary operations;
or
(7) Prior authorization is
required but has not been obtained.
(b) Based on subsection (a), the following
procedures or services are excluded and the medical assistance program shall
not pay any services in association with them:
(1) Drugs not approved by the U.S. Food and
Drug Administration;
(2) Long term
psychiatric institutional treatment;
(3) Treatment of a person confined to a
public institution regardless of where the treatment is performed;
(4) The follow-up examination or treatment of
Hansen's disease after the diagnosis has been established regardless of whether
the patient is contagious except for surgical or rehabilitative procedures to
restore useful function;
(5)
Treatment for tuberculosis when such treatment is available free to the general
public;
(6) Acupuncture;
(7) Naturopathic, chiropractic, or Christian
Science or faith healing services;
(8) Private duty nursing;
(9) Circumcision after twelve months of age
unless there is documentation of phimosis severe enough to prevent retraction,
recurrent balanitis, severe verrucae of or under the prepuce or severe
adhesions between glans and prepuce;
(10) Repair of umbilical or ventral herniae
unless they are painful or bowel is present in the sac;
(11) Excision or destruction of benign skin
or subcutaneous lesions except hemangiomas, plantar warts, molluscum
contagiosum, leukiplakia or milia without medical justification;
(12) Hysterectomies and sterilization
procedures not complying with the restrictions under sections 17-1737-47 and
17-1737-48;
(13) Reversal of
elective sterilization procedures;
(14) Rhinoplasties except following
accidental injury resulting in significant obstruction of breathing;
(15) Gastroplasty or other surgical
procedures on the stomach or bowel, or both, when performed for morbid obesity
unless the operation may logically be expected to improve an established
medical condition such as cardiac or respiratory decompensation or severe
hypertension. Guidelines issued by the department shall be met;
(16) Orthodontic services except for the
provisions of section 17-1737-75(c)(1) and fixed bridgework;
(17) Orthoptic training;
(18) Tinted and contact lenses except as
described under section 17-1737-76 (visual services);
(19) Personal comfort items such as radios,
televisions, telephones, fans, or air conditioners;
(20) Standard household items such as beds,
linens, cooking utensils, or blenders;
(21) Cosmetic, reconstructive, or plastic
surgery performed primarily to improve or change physical appearance, performed
primarily for psychological purposes, or to restore form but which does not
correct or materially improve bodily function. However, consideration may be
given when the purpose of the procedure is to:
(A) Correct a congenital anomaly;
(B) Restore body form following an accidental
injury; or
(C) Revise disfigurement
or extensive scars, or both, resulting from neoplastic surgery;
(22) Specific cosmetic surgery
procedures including:
(A) Sex transformation
treatments, procedures, hormones, or other medication for the establishment or
maintenance of gender reassignment except that medication may be allowed if the
sex of the individual has been changed by court order;
(B) Cosmetic, reconstructive, or plastic
surgery procedures performed primarily for psychological reasons or as a result
of the aging process;
(C)
Augmentation mammoplasties except following medically indicated mastectomies
for carcinoma, precancerous conditions, or extensive fibrosis or traumatic
amputation;
(D) Reduction
mammoplasties unless there is medical documentation of intractable pain not
amenable to other forms of treatment as a result of increasingly large
pendulous breasts;
(E)
Paniculectomies and other body sculpturing procedures;
(F) Removal of tattoos;
(G) Hair transplants;
(H) Electrolysis;
(I) Insertion of testicular prostheses,
unilateral or bilateral;
(J)
Jejuno-ileal by-pass procedures for morbid obesity;
(K) Ear piercing;
(23) In vitro fertilization
procedures;
(24) Medications,
devices, or agents for the treatment of erectile dysfuction in males;
(25) Swimming lessons, summer camp, gym
membership, weight control classes, or smoking cessation classes;
(26) Personal use of physical therapy
equipment that is customarily used by a physical therapist in a physical
therapy treatment or modality including, but not limited to, tilt tables,
whirlpools, mats, play equipment, or exercise equipment;
(27) Modifications to motor vehicles;
and
(28) Equipment to access motor
vehicles or modifications to access motor vehicles.
(c) The UCC shall apply these exclusions in
facilities and for recipients under its review. In other cases authorization of
the department shall be obtained before performing any of the above procedures
where exclusions are allowed.
(d) A
medical service, supply, or durable medical equipment excluded from coverage
may be approved on a case by case basis by the deparment if there is sufficient
justification to support the medical necessity, as determined by its medical
consultant.
(e) All other forms or
types of health care services and supplies not specifically mentioned in this
chapter shall not be included in the program. Questions regarding a form or
type of health care service or supply shall be directed to the medical
consultant.
(f) New tests,
procedures, equipment, supplies, and other services for which payment has not
been claimed previously shall not be considered for inclusion until information
satisfactory and acceptable to the program has been received and approval
given. This particularly applies to tests and procedures not included in the
HCPCS code, where several procedures are being clumped under one heading, or a
single procedure is divided into several components.
