Current through September 17, 2024
005.01
FACILITY-BASED PHYSICIAN CLINICS. Physician clinic
services provided in a hospital location or a facility under the hospital's
licensure are considered to be a physician service, not an outpatient hospital
service.
(A) The Department does not recognize
facility or hospital-based non-emergency physician clinics for billing,
reimbursement, or cost reporting purposes except for itinerant physicians as
defined in 471 NAC 18.
(B) Services
and supplies incident to a physician's professional service provided during a
specific encounter are covered and reimbursed as physician clinic services if
the service or supply is:
(i) Of the type
commonly furnished in a physician's office;
(ii) Furnished as an incidental, although
integral, part of the physician professional service; and
(iii) Furnished under the direct personal
supervision of the physician.
005.02
HOSPITAL ADMISSION
DIAGNOSTIC PROCEDURES. In addition to the previously defined
medical necessity requirements, the Department will consider the following to
determine whether a diagnostic procedure performed as part of the admitting
procedure to a hospital is reasonable and medically necessary:
(A) The test is specifically ordered by the
admitting physician, or a hospital staff physician responsible for the
individual when there is no admitting physician;
(B) The test is medically necessary for the
diagnosis or treatment of the individual's condition; and
(C) The test does not unnecessarily
duplicate:
(i) The same test performed on an
outpatient basis before admission; or
(ii) The same test performed in connection
with a separate, but recent, hospital admission.
005.03
MINOR SURGICAL
PROCEDURES. Reimbursement for excision of lesions of the skin or
subcutaneous tissues include all services and supplies necessary to provide the
service. The Department does not make additional reimbursement for suture
removal to the physician who performed the initial services, or to a hospital.
If the sutures are removed by a non-hospital-based physician who is not the
physician who provided the initial service, the Department may approve separate
payment for the suture removal.
005.04
TREATMENT FOR
OBESITY. The Department will not make payment for services
provided when the sole diagnosis is obesity. While obesity is not itself
considered an illness, there are conditions which can be caused by or
aggravated by obesity. Treatment for obesity may be covered when the services
are an integral and necessary part of a course of treatment or treatment for
covered co-morbidities.
005.04(A)
INTESTINAL BYPASS SURGERY. Nebraska Medicaid does not
cover intestinal bypass surgery.
005.04(B)
BARIATRIC SURGERY FOR
OBESITY.This procedure must be performed at a Bariatric Surgery
Center of Excellence. Bariatric surgery for individuals with severe obesity may
be covered when the surgery is medically appropriate for the individual and is
performed to correct an illness which either causes the obesity or was
aggravated by obesity.
005.05
COSMETIC AND
RECONSTRUCTIVE SURGERY. Nebraska Medicaid covers cosmetic and
reconstructive surgical procedures and medical services, when medically
necessary, for the purpose of correcting the following conditions:
(1) Limitations in movement of a body part
caused by trauma or congenital conditions;
(2) Disfiguring or painful scars in areas
which are visible;
(3) Congenital
birth anomalies;
(4)
Post-mastectomy breast reconstruction; and
(5) Other procedures determined to be
restorative or necessary to correct a medical condition.
005.05(A)
EXCEPTIONS. To determine the medical necessity of the
condition, the Department requires prior authorization for cosmetic and
reconstructive surgical procedures except for the following conditions:
(i) Cleft lip and cleft palate;
(ii) Post-mastectomy breast
reconstruction;
(iii) Congenital
hemangiomas of the face; and
(iv)
Nevus removals.
005.06
STERILIZATIONS.
005.06(A)
COVERAGE
RESTRICTIONS. Nebraska Medicaid does not cover sterilization of
individuals:
(i) Under the age of 21 on the
date the individual signs Form MMS-100: Sterilization Consent Form;
or
(ii) Who are mentally
incompetent or institutionalized.
005.06(B)
COVERAGE
CONDITIONS. Nebraska Medicaid covers sterilizations only when:
(i) The sterilization is performed because
the individual receiving the service made a voluntary request for
services;
(ii) The individual is
advised at the outset and before the request or receipt of their consent to the
sterilization that benefits provided by programs or projects will not be
withdrawn or withheld because of a decision not to be sterilized;
(iii) Individuals whose primary language is
other than English is provided with the required elements for informed consent
in their primary language; and
(iv)
Suitable arrangements are made to communicate the required elements of informed
consent to an individual who has a communication
disability.
005.06(C)
PROCEDURE FOR OBTAINING SERVICES. Non-therapeutic
sterilizations are covered by Nebraska Medicaid only when:
(i) Legally effective informed consent is
obtained on Form MMS-100: Sterilization Consent Form from the individual on
whom the sterilization is to be performed. The surgeon must submit a completed
form to the Department before payment of claims can be considered;
and
(ii) The sterilization is
performed at least 30 days following the date informed consent was given. To
calculate this time period, day 1 is the first day following the date on which
the form is signed by the individual. Day 31 in this period is the first day on
which the procedure may be covered. The consent is effective for 180 days from
the individual's signature.
005.06(D)
EXCEPTION.
An individual may consent to be sterilized at the time of a premature delivery
or emergency abdominal surgery if at least 72 hours have passed since the
individual signed the informed consent for the sterilization. For a premature
delivery, the individual must have signed the informed consent at least 72
hours before the surgery is performed and at least 30 days before the expected
date of delivery. The expected delivery date must be entered on Form MMS-100:
Sterilization Consent Form.
005.06(E)
INFORMED
CONSENT. Informed consent means the voluntary, knowing assent of
the individual who is to be sterilized after they have been given the following
information and completed Form MMS-100: Sterilization Consent Form:
(i) A clear explanation of the procedures to
be followed;
(ii) A full
description of the discomforts and risks which may follow the procedure,
including an explanation of the type and possible effects of any anesthetic to
be used;
(iii) A description of the
benefits to be expected;
(iv)
Counseling concerning appropriate alternative methods, and the effect and
impact of the proposed sterilization including the fact that it must be
considered an irreversible procedure;
(v) An offer to answer any questions
concerning the procedures;
(vi) An
instruction that the individual is free to withhold or withdraw consent to the
sterilization at any time before the sterilization without prejudicing future
care and without loss of other project or program benefits to which the
individual might otherwise be entitled;
(vii) Advice that the sterilization will not
be performed for at least 30 days, except under the circumstances previously
specified; and
(viii) The
individual to be sterilized must be permitted to have a witness of his or her
choice present when informed consent was obtained.
005.06(F)
STERILIZATION CONSENT
FORMS. The surgeon will submit a completed Form MMS-100:
Sterilization Consent Form to the Department before payment of claims can be
considered. The Sterilization Consent Form must be signed and dated by the
individual to be sterilized, the person obtaining consent, the physician who
will perform the procedure, and the interpreter if one was
provided.
005.07
HYSTERECTOMIES. Nebraska Medicaid covers a medically
necessary hysterectomy if the following conditions have been met and a
completed form is submitted to the Department by the surgeon before claims for
the hysterectomy can be considered for payment:
(1) The individual who secured authorization
to perform the hysterectomy has informed the individual and her representative,
if any, orally and in writing, that the hysterectomy will make the individual
permanently incapable of reproducing; and
(2) The individual or her representative, if
any, has signed Form MMS-101: Informed Consent for Hysterectomy, acknowledging
receipt of the above information.
005.07(A)
EXCEPTION.
Informed consent is not required in the following situations. A copy of the
surgeon's certification of the following exceptions must be submitted to the
Department prior to consideration of payment for claims associated with the
hysterectomy:
(i) The individual was sterile
before the hysterectomy, and the physician performing the hysterectomy
certifies in writing that the individual was sterile before the hysterectomy
and states the cause of the sterility;
(ii) Nebraska Medicaid considers
post-menopausal women to be sterile. All claims related to the procedure must
indicate the individual is post-menopausal; or
(iii) The individual requires a hysterectomy
due to a life-threatening emergency situation and the physician determines
informed consent is not possible. The physician performing the hysterectomy
must certify, in writing, that the hysterectomy was performed under a
life-threatening emergency situation in which informed consent was not
possible. The physician must also include a certification of the
emergency.
005.07(B)
NON-COVERED HYSTERCTOMIES. Nebraska Medicaid does not
cover a hysterectomy if it was performed solely to make the woman sterile or,
if there was more than one purpose for the procedure, it would not have been
performed except to make the woman sterile.
005.08
INFERTILITY.
Nebraska Medicaid limits coverage for infertility to diagnosis and treatment of
medical conditions when infertility is a symptom of a suspected medical
condition. Reimbursement or coverage is not available when the sole purpose of
the service is achieving a pregnancy.
005.09
ALCOHOL AND CHEMICAL
DETOXIFICATION. Nebraska Medicaid limits alcohol and chemical
detoxification to medically necessary treatment, subject to the Department's
utilization review.
005.10
OSTEOGENIC STIMULATION. Electrical stimulation to
augment bone repair, also known as osteogenic stimulation, can be performed
either invasively or noninvasively.
005.10(A)
INVASIVE OSTEOGENIC STIMULATION. Nebraska Medicaid
covers use of the invasive device only for non-union of long bone fractures.
Nebraska Medicaid considers non-union to exist only after six months or more
have elapsed without the fracture healing.
005.10(B)
NON-INVASIVE OSTEOGENIC
STIMULATION. Nebraska Medicaid covers the use of the non-invasive
device only for non-union of long bone fractures, failed fusion, or congenital
psuedoathroses.
005.11
BIOFEEDBACK THERAPY. Nebraska Medicaid covers
biofeedback therapy only when it is reasonable and necessary for the individual
for muscle re-education of specific muscle groups or for treating pathological
muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness,
and more conventional treatments have not been successful. This therapy is not
covered for treatment of ordinary muscle tension states, for psychosomatic
conditions, or for psychiatric conditions.
005.12
SLEEP DISORDER
CLINICS. Sleep disorder clinics are facilities in which certain
conditions are diagnosed through the study of sleep. Nebraska Medicaid covers
diagnostic and therapeutic services of a sleep disorder clinic under the
following conditions.
005.12(A)
DIAGNOSTIC SERVICES. Diagnostic testing which is
duplicative of previous testing done by the attending physician to the extent
the results are still pertinent is not covered. Individuals who undergo
diagnostic testing are not considered inpatients; however, if required as part
of the diagnostic testing, the overnight stay is considered an integral part of
these tests. All reasonable and necessary diagnostic tests given for narcolepsy
and sleep apnea are covered when the following criteria are met:
(i) The clinic must be affiliated with a
hospital;
(ii) The individual must
be referred to the sleep disorder clinic by a physician. The clinic must
maintain a record of the attending physician's orders; and
(iii) The need for diagnostic testing must be
confirmed by medical evidence, such as physician examinations and laboratory
tests.
005.12(B)
THERAPEUTIC SERVICES. Nebraska Medicaid may cover
therapeutic services provided they are standard and accepted services, and are
reasonable and medically necessary for the individual. Sleep disorder clinics
must provide therapeutic services in the hospital outpatient setting.
Therapeutic services may be provided for:
(i)
Insomnia which is not associated with psychiatric disorders;
(ii) Nocturnal myoclonus, also known as
muscle jerks;
(iii) Sleep
apnea;
(iv) Drug
dependency;
(v) Shift work and
schedule disturbances;
(vi)
Restless leg syndrome;
(vii)
Hypersomnia, also known as excessive daytime sleepiness;
(viii) Somnambulism;
(ix) Night terrors or dream anxiety
attacks;
(x) Enuresis;
and
(xi)
Bruxism.
005.13
SURGERY. Nebraska Medicaid covers surgical procedures,
including 14 days of post-operative care. When multiple procedures are
performed at the same time, the primary procedure and any secondary procedures
are covered and reimbursed in accordance with this chapter. Incidental
procedures through the same incision are not considered separate secondary
procedures for reimbursement.
005.13(A)
ASSISTANT SURGEON. Nebraska Medicaid covers the
services of an assistant surgeon when reasonable and medically
necessary.
005.13(B)
NEW OR UNUSUAL SURGICAL PROCEDURES. Nebraska Medicaid
may cover new or unusual surgical procedures. In all cases, the Department will
determine the necessity or usefulness of the procedure pursuant to a prior
authorization request.
005.13(C)
SECOND SURGICAL OPINION. Nebraska Medicaid provides
coverage for individuals who desire a second physician's opinion concerning
proposed surgery.
005.13(D)
SERVICES PERFORMED IN AN AMBULATORY SURGICAL CENTER.
In addition to the federally identified ambulatory surgical center services,
Nebraska Medicaid covers the certain state-defined services provided in an
ambulatory surgical center. Payment for facility services provided in
connection with the state-defined procedures will not exceed payment for the
corresponding group of Medicare-covered ambulatory surgical center procedures.
Federally identified ambulatory surgical center services are defined in 471 NAC
26.
005.14
HOSPITAL VISITS. Nebraska Medicaid covers only one
visit per day by the same physician, or physicians of the same specialty from
the same group practice, unless the primary physician states on Form CMS-1500:
Health Insurance Claim Form, or electronically, more than one visit was
necessary because of serious illness or change in condition, and approval is
given by the Department.
005.14(A)
SURVEILLANCE AND UTILIZATION REVIEW CRITERIA. The
Department may contract with a medical review organization to review inpatient
hospital services. The physician must comply with all medical review
requirements. For hospitalizations not subject to medical review, the
Department's in-house utilization review will prevail. If a hospitalization is
denied or reduced based on utilization review, the physician's claim may also
be denied or reduced accordingly.
005.15
EMERGENCY ROOM
SERVICES. At least one of the following conditions must be met
before the Department approves payment for use of an emergency room:
(1) The individual is evaluated or treated
for an emergency medical condition. The facility must review emergency room
services and determine whether services provided in the emergency room
constitute an emergency and bill accordingly;
(2) If the individual's evaluation or
treatment in the emergency room results in an approved inpatient hospital
admission, the emergency room charges must be displayed on the inpatient claim
as ancillary charges and included in the inpatient per diem; or
(3) The individual is referred by his or her
physician for treatment in an emergency room.
005.15(A)
NON-EMERGENT
SERVICES. When the facility or the Department determines service
are non-emergent, the room fee for non-emergent services provided in an
emergency room will be disallowed to 50 percent of what would otherwise be
allowed. When these conditions are met, the physician's fee will be disallowed
to the rate of a comparable office service. All other Nebraska Medicaid
allowable charges incurred in this type of visit will be paid according to 471
NAC 10.
005.16
PRENATAL, DELIVERY, AND POSTPARTUM CARE. Nebraska
Medicaid covers physicians' services related to pregnancy. Routine prenatal
care, delivery, six weeks' postpartum care, and routine urinalysis are
reimbursed as a package service. The physician may claim, as independent
procedures, those laboratory and medical services which are not related to the
pregnancy, or which are not included as part of the package service. Postpartum
services are covered through the applicable postpartum period defined in 477
NAC 1, for women who were eligible for, applied for, and received medical
assistance on the day the pregnancy ends. After the infant is delivered, the
infant is treated as a separate patient for reimbursement purposes.
005.16(A)
NURSE MIDWIFE
SERVICES. Nebraska Medicaid covers nurse midwife services which
are medically necessary and provided in accordance with the practice as defined
by law. Nebraska Medicaid does not cover routine office visits to a physician
when a nurse midwife is providing complete obstetrical care, unless
documentation of medical necessity for the physician's office visit is
submitted. Nebraska Medicaid covers pre-natal care, delivery, and post-partum
care as a package service. Auxiliary services, such as pre-natal classes and
home visits, are not paid separately.
005.17
ANTIGENS.
Nebraska Medicaid may make payment for a reasonable supply of antigens which
have been prepared for and administered to a particular individual even though
the antigens have not been administered to the individual by the same physician
who prepared them if:
(A) The antigens are
prepared by a physician who is a doctor of medicine or osteopathy;
and
(B) The physician who prepared
the antigens has examined the individual and determined a plan of treatment and
a dosage regimen.
005.18
DIALYSIS. Nebraska Medicaid follows Medicare's
guidelines for coverage of dialysis.
005.19
FAMILY PLANNING
SERVICES. Nebraska Medicaid covers family planning services,
including consultation and procedures, provided upon the request of the
individual. The individual must be allowed to exercise freedom of choice in
choosing a method of family planning. Family planning services performed in
family planning clinics must be prescribed by a physician, and must be and
furnished, directed, or supervised by a physician or registered nurse. Family
planning services must:
(A) Be provided
without regard to age, sex, or marital status. There can be no discrimination
in the provision of services and information; and
(B) The scope of available services and
information must include medical, social, and educational services and
information, including initial physical examination and health history, annual
and follow-up visits, laboratory services, prescribing and supplying
contraceptive supplies and devices, counseling services, and prescribing
medication for specific treatment.
005.20
FRACTURE
CARE. Coverage of initial fracture care includes the application
and removal of the first cast or traction device.
005.21
DRUGS.
005.21(A)
COVERED
DRUGS. Nebraska Medicaid covers outpatient prescription drugs in
accordance with the Omnibus Budget Reconciliation Act of 1990 (OBRA '90)
(Public
Law 101-508) including legend drugs, compounded
prescriptions, and over-the-counter (OTC) drugs indicated as covered on the
Nebraska Point of Sale System or listed on the Department's website.
005.21(A)(i)
PREFERRED DRUG LIST
(PDL). Nebraska Medicaid will include on the preferred drug list
prescribed drugs which are found to be therapeutically equivalent to or
superior to other drugs within a therapeutic class, and the net cost of the
drugs are equal to or less than other drugs within a therapeutic class after
consideration of applicable rebates or discounts negotiated by the Department
or it's designated contractor. Medications designated as non-preferred on the
preferred drug list will be subject to prior authorization. The Pharmaceutical
and Therapeutics Committee will develop criteria for use of medications with
non-preferred status. The Department will maintain an updated preferred drug
list in electronic format and will make the list available to the public on the
Department's internet web site.
005.21(A)(ii)
COMPOUNDED
PRESCRIPTIONS. Any mixture of drugs which results in a
commercially available over-the-counter (OTC) preparation is not considered a
compounded prescription.
005.21(A)(iii)
OVER THE COUNTER
(OTC) DRUGS. Nebraska Medicaid covers only over-the-counter (OTC)
drugs indicated as covered on the Nebraska Point of Sale System or listed on
the Department's website. Over-the-counter (OTC) drugs must be prescribed by a
licensed practitioner.
005.21(B)
BRAND NECESSARY
CERTIFICATION OF DRUGS. The Federal Upper Limit (FUL) or State
Maximum Allowable Cost (SMAC) limitations will not apply in any case where the
prescribing physician certifies a specific brand is medically necessary. In
these cases, the usual and customary charge, or National Average Drug
Acquisition Cost (NADAC) will be the maximum allowable cost. The prescriber
must certify on Form MC-6: Physician's Certification Form that a brand name is
medically necessary.
005.21(C)
INJECTIONS. In addition to the limitations in 471 NAC
16, injections administered by the physician in the clinical setting are not
reimbursable through the outpatient drug program. Medications used in this
manner are considered medical services and are to be purchased, used, and
billed to the Department by the physician or clinic.
005.22
PRACTITIONER-ADMINISTERED
MEDICATIONS. Practitioner administered injectable medications will
be reimbursed at average sales prices (ASP) plus 6%, consistent with the
Medicare Drug Fee Schedule. Injectable medications not available on the
Medicare Drug Fee Schedule will be reimbursed at whole acquisition cost (WAC)
plus 6.8%, or manual pricing based on the provider's actual acquisition cost.
Practitioner administered injectable medications, including specialty drugs,
purchased through the Federal Public Health Service's 340B Drug Pricing Program
will be reimbursed at the 340B actual acquisition cost and no more than the
340B ceiling price. When billing for medications administered during the course
of a clinic visit, the physician must use the appropriate Health Care Common
Procedure Coding System (HCPCS) procedure code for the medication, the correct
number of units per the Health Care Common Procedure Coding System (HCPCS)
description, the National Drug Code (NDC) of the drug administered, the
National Drug Code (NDC) 'unit of measure' and the number National Drug Code
(NDC) units. A Current Procedural Terminology (CPT) code for the administration
must also be submitted. When billing for medication which does not have a
specific Level I or II code, the physician must use a miscellaneous Health Care
Common Procedure Coding System (HCPCS) code with the name and National Drug
Code (NDC) number identifying the drug and include the dosage given. If this
information is not with the claim, the Department may return the claim to the
physician for completion or pay the claim at the lowest dosage manufactured for
the specific drug. Payment for service is as described in this chapter.
005.22(A)
ALLERGY
INJECTIONS. See payment limitations in this chapter.
005.22(B)
VITAMIN 8-12
INJECTIONS. Nebraska Medicaid covers vitamin B-12 injections as
specific or effective treatment for:
(i)
Gastrectomy;
(ii) Idiopathic
steatorrhea;
(iii)
Ileostomy;
(iv) Internal
cancers;
(v) Macrocytic
anemia;
(vi) Megaloblastic
anemia;
(vii) During or after
radiation therapy;
(viii) Certain
neuropathies;
(ix) Pernicious
anemia; and
(x) Post-surgical and
mechanical disorders.
005.23
CHEMOTHERAPY.
Nebraska Medicaid covers chemotherapy which has been provided and billed in
accordance with this chapter.
005.24
IMMUNIZATIONS. Nebraska Medicaid covers routine
immunizations for children, adolescent, and adults that are medically necessary
according to the Advisory Committee on Immunization Practices' guidelines that
are effective the date the service is provided. Immunizations are available to
children and adolescents from birth through age 20 under the Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) program. Vaccines for those
individuals age 18 and younger are available through the Vaccine for Children
(VFC) program. The Department will not reimburse for a physician's private
stock vaccine when the vaccine is available through the Vaccine for Children
(VFC) program.
005.25
LABORATORY SERVICES. Laboratory services may be
provided in a physician's or group of physicians' private office, in a licensed
and certified independent clinical laboratory, or in a hospital whose
certification covers services performed in the laboratory.
005.25(A)
PHYSICIAN'S OFFICE
LABORATORY. A laboratory which a physician or a group of
physicians maintains for performing diagnostic tests in connection with their
own or the group practice is not considered an independent clinical
laboratory.
005.25(B)
LICENSED AND CERTIFIED INDEPENDENT CLINICAL
LABORATORIES. A laboratory which is operated by or under the
supervision of a hospital or the organized medical staff of the hospital which
does not meet the definition of a hospital is considered to be an independent
laboratory. A laboratory serving hospital inpatients and outpatients and
operated on the premises of a hospital which meets the definition of a hospital
is presumed to be subject to the supervision of the hospital or its organized
medical staff and is not classified as an independent clinical laboratory. The
hospital's certification covers the services performed in this laboratory.
Nebraska Medicaid may cover laboratory tests which have been referred by one
independent laboratory to another. Nebraska Medicaid does not cover handling
services for tests referred to a second laboratory. A specimen collection fee
is not covered for samples where the cost of collecting the specimen is
minimal, such as a throat culture, a routine capillary puncture, or a pap
smear.
005.26
RADIOLOGY SERVICES. Claims for radiology procedures
must have at least a provisional diagnosis or statement of symptoms. The
Department will not accept claims with a diagnosis of 'routine radiology'.
These services may be provided in a physician's or group of physicians' private
office or a hospital whose certification covers the radiological services
provided.
005.26(A)
PHYSICIAN'S
PRIVATE OFFICE. Nebraska Medicaid covers the total radiology
procedure when both the technical and professional components of medically
necessary radiological procedures are performed in a physician's private
office.
005.26(B)
HOSPITAL RADIOLOGY SERVICES. When a physician orders
medically necessary radiological services performed in a hospital, Nebraska
Medicaid covers those services under 471 NAC 10. The Department does not
reimburse the private physician for interpreting radiology procedures performed
outside their office.
005.26(C)
MAMMOGRAMS. Nebraska Medicaid covers mammograms when
provided based on a medically necessary diagnosis. In the absence of a
diagnosis, Nebraska Medicaid covers mammograms provided according to the
American Cancer Society's periodicity schedule.
005.26(D)
ULTRASOUND DIAGNOSTIC
PROCEDURES. Nebraska Medicaid covers ultrasound diagnostic
procedures listed by Medicare under Category I. The Department may review
claims for these procedures to ensure the techniques are medically appropriate
and the general indications of Medicare's categories are met. Claims for uses
other than those listed under Medicare's Category I will be reviewed before
payment. Nebraska Medicaid does not cover ultrasound procedures listed by
Medicare under Category II.
005.26(E)
COMPUTERIZED TOMOGRAPHY
(CT) SCANS. Nebraska Medicaid covers diagnostic examinations of
the head and of certain other parts of the body performed by computerized
tomography (CT) scanners when medical and scientific literature and opinion
support the use of a scan for the condition, the scan is reasonable and
necessary for the individual, and the scan is performed on a model of
computerized tomography (CT) equipment which meets Medicare's criteria for
coverage.
005.26(E)(i)
REASONABLE
AND NECESSARY. To be determined reasonable and necessary for the
individual, the use of the computerized tomography (CT) scan must be medically
appropriate considering the individual's symptoms and preliminary diagnosis.
The Department may determine the use of a computerized tomography (CT) scan as
the initial diagnostic test was not reasonable and necessary because it was not
supported by the individual's symptoms and complaints stated on the claim form
or electronic format. The Department reviews claims for computerized tomography
(CT) scans for evidence of abuse, such as the absence of reasonable indications
for the scans, an excessive number of scans, or unnecessarily expensive types
of scans.
005.26(F)
PORTABLE X-RAY SERVICES. Nebraska Medicaid covers
diagnostic x-ray services provided by a certified portable x-ray provider when
provided in a place of residence used as the individual's home and in
nonparticipating institutions. These services must be performed under the
general supervision of a physician and certain conditions relating to health
and safety must be met. Nebraska Medicaid also covers diagnostic portable x-ray
services when provided in participating skilled nursing facilities (SNF) under
circumstances in which they cannot be covered as skilled nursing facility (SNF)
services, such as those services not provided by the participating institution
either directly or under arrangements which allow the institution to bill for
the services. If portable x-ray services are provided in a participating
hospital under arrangement, the hospital will bill for the service.
005.26(F)(i)
COVERED PORTABLE
X-RAY SERVICES. Nebraska Medicaid covers the following portable
x-ray services:
(1) Skeletal films involving
arms, legs, pelvis, vertebral column, and skull;
(2) Chest films which do not involve the use
of contrast media and are not used for routine screening or physical
examinations; and
(3) Abdominal
films which do not involve the use of contrast media.
005.26(F)(ii)
ELECTROCARDIOGRAMS. The taking of an electrocardiogram
tracing by an approved provider of portable x-ray services may be covered as an
'other diagnostic test'.
005.27
HOSPITAL DIAGNOSTIC AND
THERAPEUTIC SERVICES. Hospital diagnostic and therapeutic services
are procedures performed to determine the nature and severity of an illness or
injury, or procedures used to treat disease or disorders. Hospital diagnostic
and therapeutic services include both inpatient and outpatient hospital
services. Hospital diagnostic and therapeutic services are comprised of two
distinct elements: the professional component and the technical component.
Nebraska Medicaid may designate other services as having professional and
technical components when the services are identified.
005.27(A)
PROFESSIONAL
COMPONENT. The professional component of hospital diagnostic and
therapeutic services includes those physician's services directly related to
the medical care of the individual. A physician includes not only a specialist
but also a physician who normally performs or supervises these services for all
inpatients and outpatients of a hospital, even though the physician does not
otherwise specialize in this field.
005.27(A)(i)
COVERAGE
CONDITIONS. To be covered as a professional component, the
physician's services must:
(1) Be personally
provided to an individual by a physician;
(2) Contribute directly to the diagnosis or
treatment of an individual;
(3)
Ordinarily require performance by a physician;
(4) Be medically necessary; and
(5) For anesthesiology, laboratory, or
radiology services, meet the requirements previously set forth in this
chapter.
005.27(B)
TECHNICAL
COMPONENT. The technical component of hospital diagnostic and
therapeutic services is covered in accordance with 471 NAC 10.
005.27(C)
PRE-ADMISSION
TESTING. Nebraska Medicaid does not cover preadmission testing
performed in a physician's office which is performed solely to satisfy hospital
pre-admission requirements.
005.27(D)
RADIOLOGY AND
PATHOLOGY. Nebraska Medicaid covers medically necessary
radiological and pathological services provided to inpatients and outpatients.
Nebraska Medicaid covers only those services which are directly related to the
individual's diagnosis.
005.27(D)(i)
OUTPATIENT DIAGNOSTIC SERVICES PROVIDED BY
ARRANGEMENT. Nebraska Medicaid covers medically necessary
diagnostic services provided to an outpatient by arrangement.
005.27(D)(ii)
LABORATORY AND
PATHOLOGY.005.27(D)(ii)(1)
PROFESSIONAL COMPONENT. Nebraska Medicaid covers as a
physician's service the professional component of laboratory services provided
by a physician to an individual only if the services meet the conditions of
coverage previously outlined and are:
(a)
Anatomical pathology services; or
(b) Consultative pathology services, which
must:
(i) Be requested by the individual's
attending physician;
(ii) Relate to
a test result which lies outside the clinically significant normal or expected
range in view of the individual's condition;
(iii) Result in a written narrative report
included in the individual's medical record; and
(iv) Require the exercise of medical judgment
by the consulting physician; or
(v)
Services performed by a physician in personal administration of test devices,
isotopes, or other materials to an individual.
005.27(D)(ii)(2)
TECHNICAL
COMPONENT. Clinical laboratory services do not require performance
by a physician and are considered the technical component. There is no
professional component for these services.
005.27(D)(ii)(3)
ANATOMICAL
PATHOLOGY SERVICES. Anatomical pathology services are services
which ordinarily require a physician's interpretation. If these services are
provided to hospital inpatients or outpatients, the professional and technical
components must be separately identified for billing and payment.
005.27(D)(ii)(4)
CLINICAL
LABORATORY CONSULTATION. Nebraska Medicaid covers a physician
clinical laboratory consultation if the service:
(a) Is requested by the individual's
attending physician;
(b) Relates to
a test result which lies outside the clinically significant normal or expected
range for the individual's condition;
(c) Results in a written narrative report
which is included in the individual's record; and
(d) Requires the exercise of medical
judgement by the consulting physician.
005.27(D)(iii)
RADIOLOGY. All radiology services have a technical
component and a professional component. The professional and technical
component of hospital services must be separately identified for billing and
payment.
005.27(D)(iii)(1)
PROFESSIONAL COMPONENT. The professional component of
radiology services provided by a physician to an individual is covered as a
physician's service when the services meet the previously outlined conditions
of coverage and the services are identifiable, direct, and discrete diagnostic
or therapeutic services to an individual, such as interpretation of x-ray
plates, angiograms, myelograms, pyelograms, or ultrasound procedures.
005.27(D)(iii)(2)
TECHNICAL
COMPONENT. The technical component of hospital diagnostic and
therapeutic services is covered in accordance with 471 NAC
10.
005.28
NON-PHYSICIAN CARE
PROVIDERS. Nebraska Medicaid covers services provided by
non-physician care providers who have fulfilled all state and federal
licensing, certification, and training requirements, under the following
conditions:
(A) The non-physician care
provider must meet the following definition: An individual trained to assist or
act in the place of a physician, such as physician assistant, medical specialty
assistant, medical services assistant, clinical associate, surgical assistant,
or graduate physician assistant who has completed a committee on allied health
education and accreditation (CAHEA) accredited surgical residency
program;
(B) The service provided
by the non-physician care provider must be within the scope of practice as
defined by state law; and
(C) The
non-physician care provider must provide the services under a practice
agreement between the non-physician care provider and their supervising
physician, and must be approved by the Board of Medicine and Surgery in the
Nebraska Department of Health and Human Services or the appropriate licensing
agency in the state in which they provide the services.
005.29
PHYSICIAN SERVICES IN
SKILLED NURSING FACILITIES (SNF), INTERMEDIATE CARE FACILITIES (ICF) AND
INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES
(ICF/DD). The physician must complete, sign and date Form DM-5:
Physician's Confidential Report prior to admission in a skilled nursing
facility (SNF), intermediate care facility (ICF) or intermediate care facility
for individuals with developmental disabilities (ICF/DD). Form DM-5:
Physician's Confidential Report serves as the certification required by federal
regulations. If the admission is a facility-to-facility transfer, local office
staff will obtain a copy of the individual's annual history and physical, if it
is current to the individual's condition within 30 days before the transfer and
attach it to the signed and dated Form DM-5: Physician's Confidential Reports.
The physician must examine the individual before completing the certification,
within the following time frames:
(1)
SKILLED NURSING FACILITIES (SNF). The individual must
have a physical examination no later than two business days after admission
unless an examination was performed within five days before admission;
and
(2)
INTERMEDIATE
CARE FACILITIES (ICF). The individual must have a recent physical
examination within 30 days before admission or the date eligibility was
determined, or no later than two business days after admission or the date
eligibility was determined.
005.29(A)
ANNUAL PHYSICAL
EXAMINATION. Nebraska Medicaid requires all long term care
facility residents have an annual physical examination. The physician, based on
their authority to prescribe continued treatment, determines the extent of the
examination for individuals based on medical necessity. Nebraska Medicaid does
not cover routine laboratory and radiology services which are not directly
related to the individual's diagnosis and treatment; however, for the annual
physical exam, a complete blood count (CBC) and urinalysis are not considered
routine and are reimbursed based on the physician's orders when noted on the
claim that these services were performed for an annual physical exam for a
nursing home resident. The results of the examination must be recorded in the
individual's medical record.
005.29(B)
PHYSICIANS' SERVICES
FOR SKILLED NURSING FACILITY (SNF) RESIDENTS.
005.29(B)(i)
PHYSICIANS'
VISITS. The physician must see the skilled nursing facility (SNF)
resident whenever necessary, but at least once every 30 days for the first 90
days following admission. After the 90th day following admission, an alternate
schedule for physician's visits not to exceed 60 days may be adopted if the
attending physician determines, and justifies in the individual's medical
record, the individual's condition does not require visits at 30-day intervals.
The facility's Utilization Review Committee will approve the alternate
schedule. At the time of each visit, the physician must document the visit in
the individual's medical record and write and sign a progress note on the
individual's condition.
005.29(B)(ii)
REVIEW OF PLAN OF
CARE. The physician and facility staff involved in the (SNF)
resident's care will review each plan of care every 60 days. This should be
done in conjunction with a physician's visit or recertification.
005.29(B)(iii)
RECERTIFICATION. For skilled nursing facility (SNF)
residents, the physician or the physician's assistant will recertify in writing
the individual's continued need for the current level of care every 30 days for
the first 90 days, every 60 days thereafter, and at any time the individual
requires a different level of care. The physician's assistant or nurse
practitioner may recertify the individual's need under the general supervision
of a physician when the physician formally delegates this function to the
physician's assistant. The physician, the physician's assistant, or nurse
practitioner must sign, or stamp and initial, the recertification clearly
identifying themselves. The recertification must also be dated at the time it
is signed. Facility staff must maintain the recertification in the individual's
medical record in the facility or building where the individual resides.
005.29(B)(iii)(1)
ON-SITE
RECERTIFICATION. The physician must record recertification
accomplished by on-site visits to the facility in the individual's
record.
005.29(C)
PHYSICIANS' SERVICES
FOR RESIDENTS OF INTERMEDIATE CARE FACILITIES (ICF'S) AND INTERMEDIATE CARE
FACILITIES FOR THE DEVELOPMENTALLY DISABLED (ICF/DD'S).
005.29(C)(i)
PHYSICIAN'S
VISITS. The physician must see the intermediate care facility
(ICF) resident whenever necessary, but at least once every 60 days, unless the
physician determines the frequency is not necessary and establishes an
alternate schedule not to exceed one year and records the reason in the medical
record. The physician must actually see the individual to claim the service. At
the time of each visit, the physician must document the visit in the
individual's medical record and write and sign a progress note on the
individual's condition.
005.29(C)(ii)
REVIEW PLAN OF
CARE. The interdisciplinary team, which includes the physician,
must review each intermediate care facility (ICF) plan of care every 90 days.
This should be done in conjunction with recertification and is not reimbursed
separately.
005.29(C)(iii)
RECERTIFICATION. The physician must recertify in
writing the individual's continued need for the intermediate care facilities
for the developmentally disabled (ICF/DD) level of care at least once every 365
days, and at any time the individual requires a different level of care. The
extended recertification period in no way indicates one year is the appropriate
length of stay for an individual in an intermediate care facility for the
developmentally disabled (ICF/DD). The interagency team responsible for the
individual's care determines the individual's length of stay. The physician's
assistant or nurse practitioner may recertify the individual's need under the
general supervision of a physician when the physician formally delegates this
function to the physician's assistant or nurse practitioner. The physician, the
physician's assistant, or nurse practitioner must sign, or stamp and initial,
the recertification clearly identifying themselves. The physician, physician's
assistant, or nurse practitioner must date the recertification at the same time
it is signed. Facility staff must maintain the recertification in the
individual's medical record in the facility or building where the individual
resides.
005.29(C)(iii)(1)
ON-SITE
RECERTIFICATION. The physician must record recertification
accomplished by on-site visits to the facility in the individual's
record.
005.30
TELEPHONE
CONSULTATIONS. Nebraska Medicaid does not cover telephone calls to
or from an individual, pharmacy, nursing home, or hospital. Nebraska Medicaid
may cover telephone consultations with another physician if the name of the
consulting physician is indicated on or in the claim.
005.31
MEDICAL
TRANSPLANTS. Nebraska Medicaid covers transplants, including donor
services which are medically necessary and defined as non-experimental by
Medicare. Nebraska Medicaid may cover transplantation services when performed
in a facility approved by Centers for Medicaid and Medicare (CMS) as meeting
coverage criteria. Nebraska Medicaid is the payor of last resort, see 471 NAC
3. Nebraska Medicaid requires prior authorization of all transplant services
before the services are provided. An exception may be made for emergency
situations, in which case verbal approval is obtained and the notification of
authorization is sent later.
005.31(A)
SERVICES FOR A MEDICAID-ELIGIBLE DONOR. Nebraska
Medicaid covers medically necessary services, including laboratory tests
directly related to the transplant, for the Nebraska Medicaid-eligible donor to
a Nebraska Medicaid-eligible individual. The services must be directly related
to the transplant.
005.31(B)
SERVICES FOR A MEDICAID-INELIGIBLE DONOR. Nebraska
Medicaid covers medically necessary services, including laboratory tests
directly related to the transplant, for a Nebraska Medicaid-ineligible donor to
a Nebraska Medicaid-eligible individual. The services must be directly related
to the transplant and must directly benefit the Nebraska Medicaid transplant
recipient. Coverage of treatment for complications related to the donor is
limited to those which are reasonably medically foreseeable.
005.31(C)
AMBULATORY ROOM AND
BOARD. Nebraska Medicaid may cover ambulatory room and board
services for transplant patients for the individual and an attendant, if
necessary.
005.32
ITINERANT PHYSICIAN VISITS. Nebraska Medicaid covers
non-emergency physician visits provided in a hospital outpatient setting if the
services are:
(A) Provided by an out-of-town
specialist who has a contractual agreement with the hospital. Medicaid does not
consider general practitioners or family practitioners to be specialists;
and
(B) Determined to have been
provided in the most appropriate place of service in accordance with 471 NAC
2.
005.33
NURSE PRACTITIONER SERVICES. Nebraska Medicaid covers
nurse practitioner services, in accordance with the scope of practice
applicable to their specific licensure designation.
005.34
DURABLE MEDICAL EQUIPMENT
AND SUPPLIES. With certain exceptions, Nebraska Medicaid does not
enroll hospitals, hospital pharmacies, long term care facilities,
rehabilitation services or centers, or physicians as providers of durable
medical equipment and medical supplies.
005.34(A)
INFANT APNEA
MONITORS. Nebraska Medicaid covers rental of home infant apnea
monitors for infants with medical conditions which require monitoring due to a
specific medical diagnosis only if prescribed by and used under the supervision
of a physician. Proper infant evaluation by the physician and parent or
caregiver training must occur before placement of infant apnea monitor. In
addition to the regulations outlined herein, apnea monitoring services must be
provided in accordance with 471 NAC 7.
005.34(A)(i)
DOCUMENTATION
REQUIRED AFTER INITIAL RENTAL PERIOD. Monitor rental exceeding the
original two-month prescription period requires an updated physician's
narrative report of patient progress and a statement of continued need to
accompany the claim. A new progress report is required every two months. The
report must include:
(1) The number of apnea
episodes during the previous prescription period;
(2) The results of any tests performed during
the previous prescription period;
(3) Additional length of time needed;
and
(4) Any additional information
the physician may wish to provide.
005.34(A)(ii)
PNEUMOCARDIOGRAMS. Pneumocardiograms are covered only
when physician ordered to determine when the infant may be removed from the
monitor. Payment for rental of an electrocardiogram (ECG) respirator recorder
includes all accessories required to obtain a valid pneumocardiogram. Coverage
of durable medical equipment does not include analysis and interpretation of
tests, which is covered for the physician performing the
service.
005.34(B)
HOME PHOTOTHERAPY. Nebraska Medicaid covers rental of
home phototherapy (bilirubin) equipment for infants who require phototherapy
when neonatal hyperbilirubinemia is the infant's sole clinical problem and only
if prescribed by and used under the supervision of a physician. Prior
authorization is not required for this service. In addition to the regulations
outlined herein, home phototherapy services must be provided in accordance with
471 NAC 7.
005.34(B)(i)
LIMITATIONS ON COVERAGE OF HOME PHOTOTHERAPY SERVICES.
Coverage of the rental of home phototherapy equipment does not include
physician's professional services or laboratory and radiology services related
to home phototherapy.
005.34(C)
AMBULATORY UTERINE
MONITORS. Nebraska Medicaid covers rental of ambulatory uterine
monitors. The monitor must be prescribed by and used under the supervision of a
physician and provided by a medical supplier. Prior authorization is not
required for this service. In addition to the regulations outlined herein,
ambulatory uterine monitor services must be provided in accordance with 471 NAC
7.
005.34(C)(i)
LIMITATIONS ON
COVERAGE OF AMBULATORY UTERINE MONITORS. Nebraska Medicaid covers
all equipment, supplies, and services necessary for the effective use of the
monitor. This does not include medications or physician's professional
services. Rental is allowable only when the individual is at home and
appropriately using the monitor.
005.35
ANESTHESIOLOGY.
005.35(A)
PROFESSIONAL
COMPONENT. Nebraska Medicaid covers, as a physician's service, the
professional component of anesthesiology services provided by a physician to an
individual if the conditions in this chapter are met.
005.35(B)
MEDICAL DIRECTION OF
FOUR OR FEWER CONCURRENT PROCEDURES. The professional component
for the physician's medical direction of concurrent anesthesiology services
provided by qualified anesthetists, such as certified registered nurse
anesthetists (CRNA), is covered as a physician's service when the services meet
the requirements previously designated as conditions of coverage and the
following additional requirements:
(1) For
each individual, the physician:
(a) Performs
and documents a pre-anesthetic examination and evaluation;
(b) Prescribes the anesthesia plan;
(c) Personally participates in the most
demanding procedures in the anesthesia plan, including induction and
emergence;
(d) Ensures any
procedures in the anesthesia plan that he or she does not perform are performed
by a qualified individual;
(e)
Monitors the course of anesthesia administration at frequent
intervals;
(f) Remains physically
present and available for immediate diagnosis and treatment of emergencies;
and
(g) Provides indicated
post-anesthesia care; and
(2) The physician directs no more than four
anesthesia procedures concurrently, and does not provide any other services
while directing the concurrent procedures.
005.35(B)(i)
OTHER SERVICES
PROVIDED WHILE DIRECTING CONCURRENT PROCEDURES. A physician who is
directing concurrent anesthesia services for four or fewer surgical patients
must not ordinarily be involved in providing additional services to other
patients. The following situations are examples of services which do not
constitute a separate service for determining medical direction:
(a) Addressing an emergency of short duration
in the immediate area;
(b)
Administering an epidural or caudal anesthetic to ease labor pain;
(c) Periodic, rather than continuous,
monitoring of an obstetrical patient;
(d) Receiving patients entering the operating
suite for the next surgery;
(e)
Checking or discharging patients in the recovery room; and
(f) Handling scheduling matters.
005.35(B)(i)(1)
SERVICES
CONSIDERED A TECHNICAL COMPONENT. If the physician leaves the
immediate area of the operating suite for longer than short durations, devotes
extensive time to an emergency case, or is otherwise not available to respond
to the immediate needs of surgical patients, the physician's services to the
surgical patient are supervisory in nature and are considered a technical
component; therefore, these services must be billed as the technical component
by the hospital.
005.35(C)
SUPERVISION OF MORE
THAN FOUR CONCURRENT PROCEDURES. If the physician is involved in
providing supervision for more than four concurrent procedures or is performing
other services while directing concurrent procedures, the concurrent anesthesia
services are covered as the technical component of the hospital services. The
physician must ensure that a qualified individual performs any procedure in
which the physician does not personally participate. The physician's personal
services up to and including induction are considered the professional
component.
005.35(D)
STANDBY ANESTHESIA SERVICES. A physician's standby
anesthesia services are covered when the physician is physically present in the
operating suite, monitoring the individual's condition, making medical
judgments regarding the individual's anesthesia needs, and is ready to furnish
anesthesia services to a specific individual who is known to be in potential
need of services.
005.35(E)
SERVICES OF CERTIFIED REGISTERED NURSE ANESTHETISTS
(CRNA). When anesthesia services are provided by an
anesthesiologist and a certified registered nurse anesthetist (CRNA) at the
same time, Nebraska Medicaid will cover only those services provided by the
anesthesiologist. In the event multiple surgical procedures are performed at
the same time, Nebraska Medicaid only covers the certified registered nurse
anesthetist (CRNA) services for the major procedure. Nebraska Medicaid does not
cover certified registered nurse anesthetist (CRNA) services for secondary
procedures.
005.36
FEEDING AND SWALLOWING CLINIC SERVICES. This service
is covered for those individuals with dysphagia, a medical condition which
makes feeding and swallowing difficult. The service is covered when the
individual is referred by a physician for a medical evaluation. The purpose of
the evaluation is to assess the individual's current status and potential for
improvement and to develop a plan of care for the individual.
005.36(A)
DEFINITIONS. For the purposes of feeding and
swallowing clinic services, the following definitions will apply:
005.36(A)(i)
SWALLOWING DISORDERS
ASSESSMENT, COMPREHENSIVE. This includes, at a minimum,
comprehensive evaluation by the occupational therapist, speech pathologist,
nurse, and nutritionist. The need for a psychology evaluation is determined by
intake information; if necessary, the psychology evaluation is billed
separately.
005.36(A)(ii)
SWALLOWING DISORDER ASSESSMENT, EXTENDED. This
includes, at a minimum, a comprehensive evaluation by the occupational
therapist and extended evaluations by the speech pathologist, nurse, and
nutritionist. The need for a psychology evaluation is determined by intake
information; if necessary, the psychology evaluation is billed
separately.
005.36(A)(iii)
SWALLOWING DISORDER ASSESSMENT, BRIEF. The brief
assessment includes approximately two hours of time for the occupational
therapist, speech pathologist, and nutritionist.
005.36(A)(iv)
FOLLOW-UP VISIT,
BRIEF. This includes a visit with two or more team
members.
005.36(A)(v)
FOLLOW-UP VISIT, EXTENDED. This includes a visit which
involves four or more team members.
005.36(B)
INITIAL
EVALUATION. An initial evaluation must be performed by an
interdisciplinary team (IDT), which, at a minimum, must include a nurse,
occupational therapist, speech pathologist, nutritionist, psychologist, and
radiologist. The interdisciplinary team (IDT) must be under the direction of a
physician. After the initial visit, the interdisciplinary team (IDT) formulates
a formal written report and sends copies to the individual or family, the
referring physician, and others designated by the individual or family and by
the Department. The team contacts the referring physician and, if appropriate,
other medical professionals, to provide immediate feedback to the team on
primary findings and recommendations.
005.36(C)
FOLLOW-UP
VISITS. Follow-up visits must be available in a frequency adequate
to meet patient needs and program objectives.
005.36(D)
FOLLOW-UP
CALLS. Follow-up telephone calls are made after the initial
evaluation and are included in the cost of the evaluation, as follows:
(i) Within 48 hours after the evaluation, a
team member calls the individual or family to answer questions and provide
clarification, if needed, for any information presented during the initial
visit;
(ii) Two to four weeks after
the initial visit, a follow-up call is made to ask about progress and problems
in following the plan of care; and
(iii) Ongoing telephone communication is
maintained with the individual or family and referring physician to facilitate
implementation of the plan of care.
005.37
COMPREHENSIVE
INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER.
Nebraska Medicaid covers comprehensive interdisciplinary treatment for an
infant or child with a severe feeding disorder when it impacts the infant's or
child's ability to consume sufficient oral nutrition to maintain adequate
growth or weight.
005.37(A)
DEFINITIONS. For the purposes of comprehensive
interdisciplinary treatment for a severe feeding disorder service, the
following definitions will apply:
005.37(A)(i)
DAY TREATMENT. Daily therapy, which occurs Monday
through Friday, from approximately 8:30 am to 5:00 pm.
005.37(A)(ii)
OUTPATIENT. Therapy one to two times per week for one
to three hours per day.
005.38
TOBACCO
CESSATION. Nebraska Medicaid covers tobacco cessation services as
practitioner and pharmacy services, for individuals 18 years of age or older,
under the following conditions:
(A) Tobacco
cessation services must be ordered by a physician or mid-level practitioner,
and provided in accordance with the provider requirements listed in 471 NAC
16;
(B) Up to two tobacco cessation
sessions may be covered in a 12-month period. A session is defined as medical
encounters and drug products as listed below. Individual access to the Nebraska
Tobacco Free Quitline will be unlimited;
(C) Practitioner office visits:
(i) Individuals must see their medical care
provider for evaluation particularly for any contraindications for drug
products and to obtain prescriptions if tobacco cessation products are
needed;
(ii) In addition to the
evaluation, a total of four tobacco cessation counseling visits with a medical
care provider or tobacco cessation counselor are covered for each tobacco
cessation session. This may be a combination of intermediate or intensive
tobacco cessation counseling visits;
(D) Tobacco cessation products are covered by
Nebraska Medicaid as a pharmacy service for those 18 years of age or older who
require this particular assistance;
(i)
Coverage of products used for tobacco cessation is limited to a maximum 90
days' supply in one tobacco cessation session. Up to two 90-day supplies may be
covered in a 12 month period, beginning with the date the first prescription
for the products is dispensed; and
(ii) Tobacco cessation products will only be
covered when individuals are currently enrolled with, and actively
participating in, the Nebraska Tobacco Free Quitline. Disenrollment or lack of
active participation in the Nebraska Tobacco Free Quitline will result in
discontinuation of Nebraska Medicaid coverage of tobacco cessation drug
products; and
(E)
Nebraska Tobacco Free Quitline: Referral to the Quitline may be made by a
medical professional or a self-referral.
005.39
ENDOMETRIAL
ASPIRATION. Nebraska Medicaid covers vacutage type or other
endometrial aspiration or curettage. The provider must submit the pathologist's
report on the tissue with all claims for this service. For diagnoses of absent,
delayed, or late menstruation, the physician must administer a pregnancy test
to verify the individual is not pregnant. When requested, the provider must
submit copies of individuals' medical records to the Department.
005.40
MEDICAL NUTRITION THERAPY
FOR INDIVIDUALS AGE 21 AND OLDER. Medical nutrition therapy is
available to individuals with medical needs which require nutritional
assessment, intervention, and continued monitoring. Nebraska Medicaid covers
one-on-one medical nutrition therapy provided by a licensed medical nutritional
therapist for individuals age 21 and older under the following guidelines:
(A) The service is covered when the
individual is referred by a physician or nurse practitioner. A nutritional
assessment is done by an individual's primary care provider. The diagnostic
finding from the exam must indicate a nutritional problem or condition of such
severity that nutritional counseling beyond that normally expected as part of
the standard medical management is warranted.
(B) Individuals must meet at least one of the
following medical conditions:
(i) Type I or
Type II diabetes;
(ii) Current
kidney disease; or
(iii) A kidney
transplant in the last 36 months.
(C) Individuals receiving dialysis in a
dialysis facility receive medical nutrition therapy as part of their overall
dialysis care, medical nutrition therapy is not separately billable.
(D) Medical nutrition therapy includes the
assessment, intervention, and counseling provided to prevent, improve, or
resolve identified nutritional problems. Coverage of medical nutrition therapy
allows for:
(i) Three hours in the first
year;
(ii) Two hours in subsequent
years; and
(iii) Additional hours
are considered to be medically necessary and covered if the treating physician
determines there is a change in medical condition, diagnosis, or treatment
regimen which requires a change in medical nutrition therapy and orders
additional hours during that episode of care. The Department may request
periodic review of the services.
