Utah Administrative Code
Topic - Health
Title R414 - Integrated Healthcare
Rule R414-2A - Inpatient Hospital Services
Section R414-2A-7 - Limitations
Current through Bulletin 2024-06, March 15, 2024
Inpatient hospital care is limited to medical treatment of symptoms that lead to medical stabilization of the member. This medical stabilization care is irrespective of any underlying psychiatric diagnosis.
(1) Detoxification for a substance use disorder in a hospital shall meet the criteria in the Department's evidence-based criteria tool for inpatient detoxification. The Department does not cover any lesser level of detoxification in an inpatient hospital. The standards for the evidence-based criteria tool shall be in accordance with Section R414-1-12.
(2) Abortion procedures require prior authorization. Refer to Rule R414-1B.
(3) Sterilization and hysterectomy procedures require prior authorization and must meet the requirements of 42 CFR 441, Subpart F.
(4) Organ transplant services are governed by Rule R414-10A.
(5) Take-home supplies, dressings, non-rental durable medical equipment, and drugs are included in the inpatient reimbursement.
(6) Coverage of sleep studies requires sleep center accreditation through one of the following nationally recognized accreditation organizations:
(7) Hyperbaric oxygen therapy is limited to service in a facility in which the hyperbaric unit is accredited by the Undersea and Hyperbaric Medical Society. Hyperbaric oxygen therapy is therapy that places the member in an enclosed pressure chamber for medical treatment.
(8) Medicaid does not cover inpatient services solely for pain management. Pain management is adjunct to other Medicaid services.
(9) Inpatient rehabilitation services require prior authorization.
(10) Observation services are limited to cases where observation and evaluation is required to establish a diagnosis and determine the appropriateness of an inpatient admission or discharge. Observation is used to monitor the member's condition, complete diagnostic testing to establish a definitive diagnosis and formulate the treatment plan.
(11) Medicaid does not cover admission solely for the treatment of eating disorders.
(12) Medicaid does not cover non-physician psychosocial counseling outside of the DRG.
(13) An undocumented immigrant who does not meet United States residency requirements may only receive emergency services, including emergency labor and delivery, to treat an emergency medical condition.
(14) Inpatient hospital intensive physical rehabilitation services are not covered when the condition and prognosis meet the requirements of placement into a long-term facility, skilled nursing facility, or outpatient rehabilitation service.
(15) Medicaid does not cover admission for deconditioning in an inpatient hospital intensive physical rehabilitation facility.
(16) Inpatient hospital intensive physical rehabilitation services for a member who has suffered a stroke or other cerebral vascular accident may be provided only when admission and therapy is initiated within the first 60 days after onset of the incident.