Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES
PAYMENT FOR SAME DAY SURGICAL SERVICES
Section 1126.54 - Noncompensable services and items

(1) A service not designated by the Department as appropriate to be performed in an ASC or SPU.

(2) A service that does not conform to the requirements of this chapter.

(3) A sterilization performed on individuals 20 years of age or younger.

(4) A sterilization performed on individuals 21 years of age or older who have not signed the Consent Form for Sterilization at least 30 days but not more than 180 days prior to the sterilization.

(5) Abortion procedures performed on individuals if a Physician Certification for an Abortion form has not been completed.

(6) A service provided by an ambulatory surgical center that does not meet the Federal Medicare requirements at 42 CFR 416 (relating to ambulatory surgical services).

(7) Procedures and medical care performed in connection with sex reassignment.

(8) Medical, dental or surgical procedures which may be provided in a clinic or practitioner's office without undue risk to the patient.

(9) Plastic or cosmetic surgery for beautification purposes-for example, otoplasty for protruding ears or lop ears, rhinoplasty-except for internal nasal deformity-nasal reconstruction, excision of keloids, mammoplasty, silicone or silastic implants, dermabrasion, skin grafts and lipectomy. Plastic surgery is compensable if performed for the purpose of improving the functioning of a deformed body member.

(10) A dental case involving oral rehabilitation or restorative services, except for procedures performed for treatment of a secondary diagnosis, unless:

(11) Diagnostic tests and procedures that can be performed in a clinic or practitioner's office and diagnostic tests and procedures not related to the diagnosis.

(12) Services and items for which full payment equal to or in excess of the Medical Assistance fee, is available through Medicare, other financial resources or other health insurance programs.

(13) Services and items not ordinarily provided to the general public.

(14) A diagnostic or therapeutic procedure solely for experimental, research or educational purposes.

(15) A procedure that is not listed under the Medical Assistance Fee Schedule.

(16) A service that is not medically necessary.