(1) The Utah Cancer Control Program provides
reimbursement to providers for services rendered to individuals who meet the
eligibility requirements. The Utah Cancer Control Program provides limited
cancer screening and cardiovascular health services as described in this rule.
The Department provides reimbursement coverage under the program only for
services for each program:
(a) as provided by
Public Law
101-354,
42 U.S.C.
Section 300 k, which established the National
Breast and Cervical Cancer Early Detection Program (NBCCEDP) and by ongoing CDC
program guidance;
(2)
Within available funding, the Department provides the following services under
the Utah Cancer Control Program;
(a) The
Breast and Cervical Cancer Control Program pays for the following services
related to breast cancer:
(i) Screening:
Clinical Breast Exam and screening mammography.
(ii) Diagnostic: diagnostic unilateral and
bilateral mammograms; ultrasound; stereotactic localization for breast biopsy,
each lesion; radiological supervision and interpretation; preoperative
placement of needle localization wire, breast radiological supervision, and
interpretation; radiological examination and surgical specimen; ultrasonic
guidance for needle biopsy, radiological supervision, and interpretation; fine
needle aspiration with or without imaging guidance; aspiration of cyst of
breast; biopsy of breast; incisional biopsy of breast; percutaneous, needle
core, using imaging guidance; percutaneous, automated vacuum assisted or
rotating biopsy device, using imaging guidance; excision of cyst, fibroadenoma,
or other benign or malignant tumor aberrant breast tissue, duct lesion or
nipple lesion; excision of breast lesion identified by pre-operative placement
of radiological marker-single lesion; pre-operative placement of needle
localization wire; and image guided placement metallic localization clip,
percutaneous, during breast biopsy.
(iii) Surgical: surgical service, such as a
breast biopsy, as an outpatient procedure and anesthesia.
(iv) Pathology: immediate cytohistologic
study to determine adequacy of specimen of fine needle aspiration (FNA),
interpretation and report of FNA, breast biopsy interpretation, and excision of
breast lesion.
(b) The
Breast and Cervical Cancer Control Program pays for the following services
related to cervical cancer:
(i) Screening:
clinical Pap test and HPV Test.
(ii) Diagnostic: colposcopy with or without
biopsy; colposocopy of the cervix with loop electrode biopsy of the cervix;
colposocpy with loop electrode conization of the cervix; biopsy, single or
multiple, or local excision of lesion, with or without fulguration; excision,
endocervical curettage; conization of cervix; Loop Electrode Excision; and
endometrial sampling with or without biopsy, without cervical
dilation.
(iii) Pathology:
cytopathology; cytopathology, cervical or vaginal, requiring interpretation by
physician; colposcopy biopsy interpretation; and surgical pathology, first
tissue block, with frozen section, single specimen.
(iv) Office Visits: new patient office visit
and established patient office visit for both breast and cervical
clients.
(v) The program does not
pay for any services once a woman is diagnosed with breast cancer or cervical
cancer, including cervical precancerous lesions.
(c) The WISEWOMAN Program, known as BeWise,
pays for the following services:
(i) A basic
metabolic profile; comprehensive metabolic panel; lipid panel; total
cholesterol; quantative, blood, and reagent strip glucose tests; hemoglobin,
glycated (HbA1c), which is used in lieu of other glucose testing for those with
previous diagnosis of diabetes; HDL cholesterol test; office visit for new
patient--problem focus 10, 20, or 30 minutes face-to-face; office visit for
established patient, 5, 10, or 15 minutes face-to-face; routine venipuncture;
preventive medicine counseling or risk factor reduction intervention(s)
provided to an individual 15, 30, 45, or 60 minutes; and preventive medicine
counseling or risk factor reduction intervention(s) provided to individuals in
a group setting, 30 or 60 minutes.
(ii) The program does not pay for treatment
services such as medication, medical nutrition therapy, and other highly
specialized counseling such as diabetes-education programs.
(d) The Colorectal Cancer Control
Program pays for the following:
(i) Screening
Tests and Procedures: colonoscopy every ten years, biopsy/polypectomy during
colonoscopy, moderate sedation for colonoscopy, the use of propofol only if
prior approval is obtained, and office visits related to the tests listed
above.
(ii) Diagnostic Follow-up
Services: office visits related to screening and diagnostic tests, total colon
exam with colonoscopy, biopsy/polypectomy during colonoscopy, moderate sedation
for colonoscopy, the use of propofol only if prior approval is obtained, and
pathology fees.
(iii) Surveillance:
surveillance colonoscopies will be reimbursed at appropriate intervals as
determined by the recommending clinician, the program, or the program's Medical
Advisory Board (MAB).
(iv) The
program does not pay for CT Colonography, or virtual colonoscopy, as a primary
screening test; Computed Tomography Scans, known as CTs or CAT scans, requested
for staging or other purposes; surgery or surgical staging, unless specifically
required and approved by the program's MAB to provide a histological diagnosis
of cancer; any treatment related to the diagnosis of colorectal cancer; any
care or services for complications that result from screening or diagnostic
tests provided by the program; evaluation of symptoms for clients who present
for CRC screening but are found to have gastrointestinal symptoms; diagnostic
services for clients who had an initial positive screening test performed
outside of the program; management of medical conditions, including
Inflammatory Bowel Disease using surveillance colonoscopies and medical therapy
for management; genetic testing for clients who present with a history
suggestive of a hereditary non-polyposis colorectal cancer (HNPCC) or familial
adenomatous polyposis (FAP); and the use of propofol as anesthesia during
endoscopy, unless specifically required and approved by the program's MAB in
cases where the client cannot be sedated with standard moderate
sedation.
(3)
The Department may adjust the services available to meet current needs and
fluctuations in available funding.
(4) The Utah Cancer Control Program is not
health insurance. A relationship with the Department as the insurer and the
client as the insured is not created under this program.