Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 18 - PHYSICIANS' SERVICES
Section 471-18-006 - NON-COVERED SERVICES
Universal Citation: 471 NE Admin Rules and Regs ch 18 ยง 006
Current through September 17, 2024
The services outlined in this section are specifically excluded from coverage by the Department. This is not intended to be an all-inclusive, or exhaustive, list of non-covered services.
006.01 SURGICAL PROCEDURES. Nebraska Medicaid 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) Ballistocardiogram;
(G) Basal metabolic rate (BMR);
(H) Bronchoscopy, with injection of contrast
medium for bronchography or with injection of radioactive substance;
(I) Circumcision, female;
(J) Excision of carotid body tumor, with or
without excision of carotid artery, when used as a treatment for
asthma;
(K) Extra-intra cranial
arterial bypass for stroke;
(L)
Fabric wrapping of abdominal aneurysm;
(M) Fascia lata by incision and area
exposure, with removal of sheet, when used as treatment for lower back
pain;
(N) Fascia lata by stripper
when used as a treatment for lower back pain;
(O) Hypogastric or presacral neurectomy as an
independent procedure;
(P)
Hysterotomy, non-obstetrical, vaginal;
(Q) Icterus index;
(R) Ileal bypass or any other intestinal
surgery for the treatment of obesity;
(S) Kidney decapsulation, unilateral and
bilateral;
(T) Ligation of femoral
vein, unilateral and bilateral, when used as treatment for post-phlebotic
syndrome;
(S) Ligation of internal
mammary arteries, unilateral or bilateral;
(U) Ligation of thyroid arteriesas an
independent procedure;
(V)
Nephropexy: fixation or suspension of kidney as an independent procedure,
unilateral;
(W) Omentopexy for
establishing collateral circulation in portal obstruction;
(X) Perirenal insufflation;
(Y) Phonocardiogram with interpretation and
report, and with indirect carotid artery tracings or similar study;
(Z) Protein bound iodine (PBI);
(AA) Radical hemorrhoidectomy, whitehead
type, including removal of entire pile bearing area;
(BB) Refractive keratoplasty, includes
keratomileusis, keratophakia, and radial keratotomy;
(CC) Reversal of tubal ligation or
vasectomy;
(DD) Sex change
procedures;
(FF) Solid organ
transplants performed in a facility which is not included on the list of
Medicare-approved transplant programs;
(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;
or
(JJ) Uterine suspension, with or
without presacral sympathectomy.
006.02 OBSOLETE TESTS. Unless determined to be medically necessary by the physician performing the test and verified by the Department, Nebraska Medicaid does not cover the following obsolete diagnostic tests:
(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;
(Y)
Colloidal gold;
(Z) Bendien's test
for cancer and tuberculosis;
(AA)
Bolen's test for cancer; and
(BB)
Rehfuss test for gastric acidity.
006.03 SERVICES REQUIRED TO TREAT COMPLICATIONS OR CONDITIONS RESULTING FROM NON-COVERED SERVICES. Nebraska Medicaid may consider coverage of medically necessary services which are required to treat complications or conditions resulting from non-covered services. If the services are determined to be part of a previous non-covered service, such as an extension or a periodic segment of a non-covered service or follow-up care associated with it, the subsequent services will be denied.
006.04 SERVICES NOT REASONABLE AND NECESSARY. Nebraska Medicaid does not cover items and services which are not reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the function of a malformed body member.
006.05 SURGICAL ASSISTANT FEES. Nebraska Medicaid does not cover surgical assistance fees for the following. Additional assistant fees may be determined to be noncovered during the utilization review process.
(A) Laparoscopy, including laparoscopic tubal
ligation;
(B) Tonsillectomy,
adenoidectomy, myringotomy;
(C)
Conservative or closed fracture care; and
(D) Uncomplicated procedures of the
integument.
006.06 EXPERIMENTAL AND INVESTIGATIONAL SERVICES. Nebraska Medicaid 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.
006.06(A)
RELATED
SERVICES. Nebraska Medicaid does not pay for associated or
adjunctive services which are directly related to non-covered experimental or
investigational services. The Department will pay for all medically necessary
expenses incurred which are not directly related to the non-covered
experimental or investigative services. Nebraska Medicaid may cover
complications of non-covered services once the non-covered service is
completed.
006.06(B)
REQUESTS FOR MEDICAID COVERAGE. Requests for Nebraska
Medicaid coverage for new services or those which may be considered
experimental or investigational must be submitted in writing before providing
the services, or in the case of medical emergencies, before submitting a claim.
The request for coverage must include sufficient information to document the
new service is not considered investigational or experimental for Department
payment purposes. Reliable evidence must be submitted identifying the status on
the new service with regard to the criteria listed below, cost-benefit data,
short and long term outcome data, patient selection criteria which is both
disease or condition specific and age specific, information outlining the
circumstances under which the service is considered the accepted standard of
care, and any other information which would be helpful to the Department in
deciding coverage issues. Additional information may be requested by the
Department. Requests must be submitted to the Department's Medical Director.
006.06(B)(i)
INVESTIGATIONAL AND
EXPERIMENTAL CRITERIA. Services may be deemed investigational or
experimental by Nebraska Medicaid, which 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:
(1) The Food and Drug Administration (FDA),
or other governmental or regulatory authority, has not approved the service or
treatment for general marketing to the public for the proposed use;
(2) Reliable evidence does not lead to the
conclusion that there is a consensus within the medical community 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 or proposed use and age group. Also, facility
specific data, including short and long term outcomes, must be submitted to the
Department;
(3) 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
(4) The service is the
subject of an ongoing clinical trial which 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 (FDA) oversight and regardless
of whether an institutional review board (IRB) process or protocol is required
at any one particular institution.
006.06(C)
DEFINITION OF CLINICAL
TRIALS. For services not subject to Food and Drug Administration
(FDA) approval, the following definitions apply:
(i)
PHASE I. Initial
introduction of an investigational service into humans.
(ii)
PHASE II.
Controlled clinical studies conducted to evaluate the effectiveness of the
service for a particular indication or medical condition of the individual;
these studies are also designed to determine the short-term side effects and
risks associated with the new service.
(iii)
PHASE III.
Clinical studies to further evaluate the effectiveness and safety of a service
which is needed to evaluate the overall risk and benefit and to provide an
adequate basis for determining patient selection criteria for the service as
the recommended standard of care. These studies usually compare the new service
to the current recommended standard of care.
006.07 NON-COVERED PORTABLE X-RAY SERVICES. Nebraska Medicaid 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 individual or injection of a substance into the
individual or special manipulation of the individual;
(D) Procedures which require special medical
skill or knowledge possessed by a doctor of medicine or doctor of osteopathy or
which require 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.
006.08 NON-COVERED DRUG SERVICES. Payment by Nebraska Medicaid will not be approved for:
(A) Requests for quantities not in compliance
with 471 NAC 16;
(B) Experimental
drugs or non-Food and Drug Administration (FDA) approved drugs;
(C) Drugs or items when the prescribed use is
not for a medically accepted indication;
(D) Drugs or items prescribed or recommended
for weight control or appetite suppression;
(E) Liquors;
(F) Drug Efficacy Study Implementation
Program (DESI) drugs identified as less than effective (LTE) or identical,
related, or similar (IRS) with an indicator value assigned by the Food and Drug
Administration (FDA) of either five or six;
(G) Personal care items;
(H) Medical supplies and certain drugs for
nursing facility and intermediate care facility for individuals with
developmental disabilities (ICF/DD) residents, see 471 NAC 7 and 16;
(I) Over-the-counter (OTC) drugs not listed
on the Nebraska Point of Sale system or on the Department's web site;
(J) Drugs or items used for cosmetic purposes
or hair growth;
(K) Baby foods or
metabolic agents normally supplied by the Department, see 471 NAC 16 for
exceptions;
(L) Drugs distributed
or manufactured by certain drug manufacturers or labelers who have not agreed
to participate in the drug rebate program;
(M) Products used to promote
fertility;
(N) Medications
dispensed as partial month fills for nursing facility or group home residents
when dispensed by more than one pharmacy;
(O) Medications dispensed to replace products
which have been recalled by the drug manufacturer;
(P) Drugs, items, or products of
manufacturers or labelers which are identifiable as non-covered on the Nebraska
Point of Sale system or on the Department's website;
(Q) Drugs, classes of drugs, or therapeutic
categories of drugs which are Medicare Part D drugs and Medicare Part D covered
supplies or equipment, for all persons eligible for benefits under Medicare
Part D, whether or not such persons are enrolled into a Medicare Part D
plan;
(R) Drugs or classes of drugs
approved by the Food and Drug Administration (FDA) for treatment of sexual or
erectile dysfunction, or drugs or classes of drugs which are being used for the
treatment of sexual or erectile dysfunction. Drugs or classes of drugs which
are approved by the Food and Drug Administration (FDA) for treatment of sexual
or erectile dysfunction and for conditions other than treatment of sexual or
erectile dysfunction and are prescribed for those other conditions may be
covered, but Nebraska Medicaid may require prior authorization. See 471 NAC 16;
and
(S) Automatic Refills, see 471
NAC 16.
006.09 INFLUENZA INJECTIONS IN LONG-TERM CARE FACILITIES. No payment is made to a physician giving influenza injections in long-term care facilities.
006.10 INJECTABLE ESTROGENS. Nebraska Medicaid does not pay for injectable estrogens for depression or osteoporosis associated with menopause.
006.11 LIVER AND VITAMIN INJECTIONS. Nebraska Medicaid does not pay for liver and vitamin injections.
006.12 AUTOPSIES. Autopsies are a non-covered service under Nebraska Medicaid.
Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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