Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 26 - COVERED SERVICES
Section 26-23 - Physician Services
Universal Citation: WY Code of Rules 26-23
Current through September 21, 2024
(a) Covered services. Medically necessary professional services furnished by or under the supervision of a licensed Physician, except as otherwise specified by this Chapter.
(b) Excluded or limited services.
(i) Anesthesia services shall be
limited as follows:
(A) An anesthesiologist
shall not receive Medicaid reimbursement for a consultation in addition to any
other anesthesia services for the same surgery.
(B) Anesthesia services shall not be covered
when performed in conjunction with:
(I) A
non-covered surgical procedure; or
(II) A procedure requiring client consent if
proper consent was not obtained.
(ii) The following allergy and clinical
immunotherapy services are excluded:
(A)
Sublingual, intracutaneous and subcutaneous provocative and neutralization
testing; and
(B) Neutralization
therapy for food allergies.
(iii) Cosmetic surgery:
(A) Services intended solely to improve an
individual's physical appearance and which do not restore bodily function or
correct a physical deformity are excluded.
(B) Reconstructive surgery procedures which
are intended to improve bodily functions and the appearance of a body area
which has been altered by disease, trauma, congenital or developmental
anomalies, or previous surgical procedures shall be covered only if authorized
prior to the procedure.
(iv) Dermatology. The following shall be
excluded:
(A) Removal of lesions not suspected
to be precancerous, unless medically necessary to restore a bodily function;
and
(B) Services performed
primarily for cosmetic reasons.
(v) Medical supplies. Expendable medical
supplies normally used in a physician's office shall be included in the
Medicaid payment for the office visit or test performed. The actual cost of
special expendable supplies prescribed for home use by a client may be
separately billed to Medicaid.
(vi)
Prolonged care shall be limited to a total of three (3) hours per day unless
there is documentation in the medical records that additional prolonged care
was medically necessary.
(vii)
Sterilizations shall not be covered unless the requirements of 42 C.F.R. §
441 are satisfied.
(viii)
Therapeutic injections shall not be covered unless:
(A) The drug cannot be administered
orally;
(B) The drug cannot be
self-administered; and
(C) The drug
is reasonable and medically necessary.
(c) Service Limitations. Unless pre-approved, Medicaid reimbursement for client visits to a physician, ophthalmologist, physician assistant, nurse practitioner, or optometrist and to the outpatient department of a hospital shall be limited to a total of twelve (12) visits per calendar year. The limitations of this subsection shall not apply to:
(i) A client seeking emergency services who
is diagnosed with an emergent condition;
(ii) A client seeking family planning clinic
services;
(iii) A client who is
under age twenty-one (21);
(iv) A
pregnant woman;
(v) Items and
services furnished directly by the Indian Health Services, an Indian Tribe,
Tribal Organization, or Urban Indian Organization, or through a referral under
a purchase order contract health services (as described in 42 C.F.R., Ch. I,
Subch. M, Pt. 136, Subpart C) to an American Indian or Alaskan Native who is
enrolled as a member of a Federally-Recognized Tribe or otherwise meets the
definition of a "Indian" as Section 4 of the Indian Healthcare Improvement Act
( 25 U.S.C. § 1608);
(vi) A
resident of a nursing facility; or
(vii) A client who is also eligible for
Medicare and where Medicare has reimbursed the provider for the
claim.
Disclaimer: These regulations may not be the most recent version. Wyoming may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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