Current through Register Vol. 24-18, September 15, 2024
(1)
The medicaid agency evaluates a request for noncovered services in this chapter
under WAC
182-501-0160. In addition to
noncovered services found in WAC
182-501-0070, except as provided
in subsection (2) of this section, the agency does not cover:
(a) Acupuncture, massage, or massage
therapy;
(b) Any service
specifically excluded by statute;
(c) Care, testing, or treatment of
infertility or sexual dysfunction. This includes procedures for donor ovum,
donor sperm, gestational carrier, and reversal of vasectomy or tubal
ligation;
(d) Hysterectomy
performed solely for the purpose of sterilization;
(e) Cosmetic treatment or surgery, except as
provided in WAC
182-531-0100
(4)(x);
(f) Experimental or investigational services,
procedures, treatments, devices, drugs, or application of associated services,
except when the individual factors of an individual client's condition justify
a determination of medical necessity under WAC
182-501-0165;
(g) Hair transplantation;
(h) Marital counseling or sex
therapy;
(i) More costly services
when the medicaid agency determines that less costly, equally effective
services are available;
(j)
Vision-related services as follows:
(i)
Services for cosmetic purposes only;
(ii) Group vision screening for eyeglasses;
and
(iii) Refractive surgery of any
type that changes the eye's refractive error. The intent of the refractive
surgery procedure is to reduce or eliminate the need for eyeglass or contact
lens correction. This refractive surgery does not include intraocular lens
implantation following cataract surgery;
(k) Payment for body parts, including organs,
tissues, bones and blood, except as allowed in WAC
182-531-1750;
(l) Physician-supplied medication, except
those drugs which the client cannot self-administer and therefore are
administered by the physician in the physician's office;
(m) Physical examinations or routine
checkups, except as provided in WAC
182-531-0100;
(n) Foot care, unless the client meets
criteria and conditions outlined in WAC
182-531-1300, as follows:
(i) Routine foot care including, but not
limited to:
(A) Treatment of tinea
pedis;
(B) Cutting or removing
warts, corns and calluses; and
(C)
Trimming, cutting, clipping, or debriding of nails.
(ii) Nonroutine foot care including, but not
limited to, treatment of:
(A) Flat
feet;
(B) High arches (cavus
foot);
(C) Onychomycosis;
(D) Bunions and tailor's bunion (hallux
valgus);
(E) Hallux
malleus;
(F) Equinus deformity of
foot, acquired;
(G) Cavovarus
deformity, acquired;
(H) Adult
acquired flatfoot (metatarsus adductus or pes planus);
(I) Hallux limitus.
(iii) Any other service performed in the
absence of localized illness, injury, or symptoms involving the foot;
(o) Except as provided in WAC
182-531-1600, weight reduction
and control services, procedures, treatments, devices, drugs, products, gym
memberships, equipment for the purpose of weight reduction, or the application
of associated services;
(p)
Nonmedical equipment;
(q)
Nonemergent admissions and associated services to out-of-state hospitals or
noncontracted hospitals in contract areas; and
(r) Early elective deliveries as defined in
WAC 182-500-0030.
(2) The medicaid agency covers excluded
services listed in (1) of this subsection if those services are mandated under
and provided to a client who is eligible for one of the following:
(a) The EPSDT program;
(b) A Washington apple health program for
qualified medicare beneficiaries (QMBs); or
(c) A waiver program.
WSR 11-14-075, recodified as §182-531-0150, filed
6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090. WSR 11-14-055, §
388-531-0150, filed 6/29/11, effective 7/30/11; WSR 10-19-057, §
388-531-0150, filed 9/14/10, effective 10/15/10. Statutory Authority:
RCW
74.08.090,
74.09.520. WSR 05-12-022, §
388-531-0150, filed 5/20/05, effective 6/20/05; WSR 01-01-012, §
388-531-0150, filed 12/6/00, effective
1/6/01.
