Nebraska Administrative Code, Chapter 18, Section 471-18-006 - NON-COVERED SERVICES | Nebraska Administrative Code

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.

Nebraska Administrative CodeTopic - HEALTH AND HUMAN SERVICES SYSTEMTitle 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICESChapter 18 - PHYSICIANS' SERVICESSection 471-18-006 - NON-COVERED SERVICES

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