Current through September 17, 2024
The following services are not intended to be an
all-inclusive, or exhaustive, list of non-covered services.
005.01
SURGICAL
PROCEDURES. The Department does not cover:
(A) Acupuncture;
(B) Angiocardiography, single plane,
supervision and interpretation in conjunction with cineradiography or
multi-plane, supervision and interpretation in conjunction with
cineradiography;
(C)
Angiocardiography, utilizing CO2 method, supervision and
interpretation only;
(D)
Angiography, coronary, unilateral selective injection supervision and
interpretation only, single view unless emergency;
(E) Angiography, extremity, unilateral,
supervision and interpretation only, single view unless emergency;
(F) Artificial Heart Transplant;
(G) Ballistocardiogram;
(H) Basal metabolic rate (BMR);
(I) Bronchoscopy, with injection of contrast
medium for bronchography or with injection of radioactive substance;
(J) Circumcision, female;
(K) Excision of carotid body tumor, with or
without excision of carotid artery, when used as a treatment for
asthma;
(L) Extra-intra cranial
arterial bypass for stroke;
(M)
Fabric wrapping of abdominal aneurysm;
(N) Fascia lata by incision and area
exposure, with removal of sheet, when used as treatment for lower back
pain;
(O) Fascia lata by stripper
when used as a treatment for lower back pain;
(P) Hypogastric or presacral neurectomy
(independent procedure);
(Q)
Hysterotomy, non-obstetrical, vaginal;
(R) Icterus index;
(S) Ileal bypass or any other intestinal
surgery for the treatment of obesity;
(T) Kidney decapsulation, unilateral and
bilateral;
(U) Ligation of femoral
vein, unilateral and bilateral, when used as treatment for post-phlebotic
syndrome;
(V) Ligation of internal
mammary arteries, unilateral or bilateral;
(W) Ligation of thyroid arteries (independent
procedure);
(X) Nephropexy:
fixation or suspension of kidney (independent procedure), unilateral;
(Y) Omentopexy for establishing collateral
circulation in portal obstruction;
(Z) Perirenal insufflation;
(AA) Phonocardiogram with interpretation and
report, and with indirect carotid artery tracings or similar study;
(BB) Protein bound iodine (PBI);
(CC) Radical hemorrhoidectomy, whitehead
type, including removal of entire pile bearing area;
(DD) Refractive keratoplasty including
keratomileusis, keratophakia, and radial keratotomy;
(EE) Reversal of tubal ligation or
vasectomy;
(FF) Sex change
procedures;
(GG) Splanchicectomy,
unilateral or bilateral, when used as a treatment for hypertension;
(HH) Supracervical hysterectomy: subtotal
hysterectomy, with or without tubes or ovaries, one or both;
(II) Sympathectomy, thoracolumbar or lumbar,
unilateral or bilateral, when used as a treatment for hypertension;
and
(JJ) Uterine suspension, with
or without presacral sympathectomy.
005.02
OBSOLETE
TESTS. Obsolete tests may be covered only if the physician who
performs the test justifies the medical necessity for the test. The Department
will determine that satisfactory medical necessity exists from the physician's
justification. The Department does not routinely cover the following diagnostic
tests because they are obsolete and have been replaced by more advanced
procedures:
(A) Amylase, blood isoenzymes,
electrophoretic;
(B) Chromium,
blood;
(C) Guanase,
blood;
(D) Zinc sulphate turbidity,
blood;
(E) Skin test, cat scratch
fever;
(F) Skin test, lymphopathia
venereum;
(G) Circulation time, one
test;
(H) Cephalin
flocculation;
(I) Congo red,
blood;
(J) Hormones,
adrenocorticotropin quantitative animal tests;
(K) Hormones, adrenocorticotropin
quantitative bioassay;
(L) Thymol
turbidity, blood;
(M) Skin test,
actinomycosis;
(N) Skin test,
brucellosis;
(O) Skin test,
leptospirosis;
(P) Skin test,
psittacosis;
(Q) Skin test,
trichinosis;
(R) Calcium, feces,
24-hour quantitative;
(S) Starch;
feces, screening;
(T) Chymotrypsin,
duodenal contents;
(U) Gastric
analysis pepsin;
(V) Gastric
analysis, tubeless;
(W) Calcium
saturation clotting time;
(X)
Capillary fragility test (Rumpel-Leede);
(Y) Colloidal gold;
(Z) Bendien's test for cancer and
tuberculosis;
(AA) Bolen's test for
cancer; and
(BB) Rehfuss test for
gastric acidity.
005.03
SERVICES REQUIRED TO TREAT COMPLICATIONS OR CONDITIONS RESULTING
FROM NON-COVERED SERVICES. The Department may consider payment for
medically necessary services that are required to treat complications or
conditions resulting from non-covered services.
005.04
EXPERIMENTAL AND
INVESTIGATIONAL SERVICES. The Department does not cover medical
services which are considered investigational or experimental or which are not
generally employed by the medical profession. While the circumstances leading
to participation in an experimental or investigational program may meet the
definition of medical necessity, the Department prohibits payment for these
services.
005.04(A)
RELATED
SERVICES. The Department does not pay for associated or adjunctive
services that are directly related to non-covered experimental/investigational
services.
005.04(B)
COVERAGE REQUESTS FOR NEW SERVICES. Requests for
Nebraska Medicaid coverage for new services or those which may be considered
experimental or investigational must be submitted to the Department before
providing the services, or in the case of true medical emergencies, before
submitting a claim. The request for coverage must include sufficient
information to document that the new service is not considered investigational
or experimental for Nebraska Medicaid payment purposes. Reliable evidence must
be submitted identifying the status with regard to the criteria below,
cost-benefit data, short and long term outcome data, patient selection criteria
that is both disease/condition specific and age specific, information outlining
under what circumstances the service is considered the accepted standard of
care, and any other information that would be helpful to the Department in
deciding coverage issues. Additional information may be requested by the
Department.
005.04(C)
INVESTIGATIONAL OR EXPERIMENTAL CRITERIA. Services are
deemed investigational or experimental by the Medical Director, who may convene
ad hoc advisory groups of experts to review requests for coverage. A service is
deemed investigational or experimental if it meets any one of the following
criteria:
(i) There is no Food and Drug
Administration (FDA) or other governmental or regulatory approval given, when
appropriate, for general marketing to the public for the proposed
use;
(ii) Reliable evidence does
not permit a conclusion based on consensus that the service is a generally
accepted standard of care employed by the medical profession as a safe and
effective service for treating or diagnosing the condition or illness for which
its use is proposed. Reliable evidence includes peer reviewed literature with
statistically significant data regarding the service for the specific disease,
proposed use, and age group. Also, facility specific data, including short and
long term outcomes, must be submitted to the Department;
(iii) The service is available only through
an Institutional Review Board (IRB) research protocol for the proposed use or
subject to such an Institutional Review Board (IRB) process; or
(iv) The service is the subject of an ongoing
clinical trial(s) that meets the definition of a Phase I, Phase II, or Phase
III Clinical Trial, regardless of whether the trial is actually subject to Food
and Drug Administration oversight and regardless of whether an Institutional
Review Board (IRB) process or protocol is required at any one particular
institution.
005.05
CUSTODIAL OR RESPITE
CARE. The Department does not cover hospital services that are
custodial or respite care.
005.06
PRIVATE DUTY NURSING. The services of a private-duty
nurse or other private-duty attendant are not covered as a hospital
service.
005.07
PROSTHETICS. The Department does not cover external
powered prosthetic devices.
005.08
FACILITY BASED PHYSICIAN CLINICS. Physician clinic
services provided in a hospital, or a facility under the hospital's licensure,
are considered to be a physician's service and are reimbursed
accordingly.
005.09
TOBACCO CESSATION SERVICES. Tobacco cessation services
are not covered as a hospital service.
005.10
HOSPITAL ACQUIRED
CONDITIONS. The Department will not make payment for conditions
which are a result of avoidable inpatient hospital complications and medical
errors that are identifiable, preventable, and serious in their consequences to
patients. This means that the Department will, at a minimum, identify as a
hospital acquired conditions (HAC), those diagnoses codes that have been
identified as Medicare hospital acquired conditions (HAC) when not present on
hospital admission.
005.11
HEALTH CARE-ACQUIRED CONDITIONS. A health
care-acquired condition (HCAC) means a condition occurring in any inpatient
hospital setting, identified as a hospital- acquired condition (HAC) by
Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) as
related to total knee replacement or hip replacement surgery in pediatric and
obstetric patients. The Department will not make payment for conditions which
are a result of avoidable inpatient hospital complications and medical errors
that are identifiable, preventable, and serious in their consequences to
patients.
005.12
NON-COVERED PORTABLE X-RAY SERVICES. The Department
does not cover the following portable x-ray services:
(A) Procedures involving
fluoroscopy;
(B) Procedures
involving the use of contrast media;
(C) Procedures requiring the administration
of a substance to the patient or injection of a substance into the patient or
special manipulation of the patient;
(D) Procedures which require special medical
skill or knowledge possessed by a doctor of medicine or doctor of osteopathy or
which require that medical judgment be exercised;
(E) Procedures requiring special technical
competency or special equipment or materials;
(F) Routine screening procedures;
and
(G) Procedures which are not of
a diagnostic nature.
