Wisconsin Legislature: DHS 107.06(2)(h)

Alert! This chapter may be affected by an emergency rule:

EmR2421

(26) Testicular prosthesis.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. (15), eff. 8-1-88; r. and recr. (15), Register, December, 1988, No. 396, eff. 1-1-89; emerg. am. (15), eff. 6-1-89; am. (15), Register, February, 1990, No. 410, eff. 3-1-90; am. (10), (12), (16) and (17), cr. (18), Register, September, 1991, No. 429, eff. 10-1-91; am. (17) and (18), cr. (19) to (26), Register, January, 1997, No. 493, eff. 2-1-97; correction in (13) made under s. 13.93 (2m) (b) 7., Stats., Register, October, 2000, No. 538; CR 20-039: am. (12) Register October 2021 No. 790, eff. 11-1-21; CR 22-043: am. (1) Register May 2023 No. 809, eff. 6-1-23.

DHS 107.035 Definition and identification of experimental services.

(1) Definition. “Experimental in nature,” as used in s. DHS 107.03 (4) and this section, means a service, procedure or treatment provided by a particular provider which the department has determined under sub. (2) not to be a proven and effective treatment for the condition for which it is intended or used.

(2) Departmental review. In assessing whether a service provided by a particular provider is experimental in nature, the department shall consider whether the service is a proven and effective treatment for the condition which it is intended or used, as evidenced by:

(a) The current and historical judgment of the medical community as evidenced by medical research, studies, journals or treatises;

(b) The extent to which medicare and private health insurers recognize and provide coverage for the service;

(c) The current judgment of experts and specialists in the medical specialty area or areas in which the service is applicable or used; and

(d) The judgment of the MA medical audit committee of the state medical society of Wisconsin or the judgment of any other committee which may be under contract with the department to perform health care services review within the meaning of s. 146.37, Stats.

(3) Exclusion of coverage. If on the basis of its review the department determines that a particular service provided by a particular provider is experimental in nature and should therefore be denied MA coverage in whole or in part, the department shall send written notice to physicians or other affected certified providers who have requested reimbursement for the provision of the experimental service. The notice shall identify the service, the basis for its exclusion from MA coverage and the specific circumstances, if any, under which coverage will or may be provided.

(4) Review of exclusion from coverage. At least once a year following a determination under sub. (3), the department shall reassess services previously designated as experimental to ascertain whether the services have advanced through the research and experimental stage to become established as proven and effective means of treatment for the particular condition or conditions for which they are designed. If the department concludes that a service should no longer be considered experimental, written notice of that determination shall be given to the affected providers. That notice shall identify the extent to which MA coverage will be recognized.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.

DHS 107.04 Coverage of out-of-state services. All non-emergency out-of-state services require prior authorization, except where the provider has been granted border status pursuant to s. DHS 105.48.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520.

DHS 107.05 Coverage of emergency services provided by a person not a certified provider. Emergency services necessary to prevent the death or serious impairment of the health of a recipient shall be covered services even if provided by a person not a certified provider. A person who is not a certified provider shall submit documentation to the department to justify provision of emergency services, according to the procedures outlined in s. DHS 105.03. The appropriate consultant to the department shall determine whether a service was an emergency service.

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.06 Physician services.

(1) Covered services. Physician services covered by the MA program are, except as otherwise limited in this chapter, any medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a physician’s office, in a hospital, in a nursing home, in a recipient’s residence or elsewhere, and performed by or under the direct supervision of a physician within the scope of the practice of medicine and surgery as defined in s. 448.01 (9), Stats. These services shall be in conformity with generally accepted good medical practice.

(2) Services requiring prior authorization. The following physician services require prior authorization in order to be covered under the MA program:

(a) All covered physician services if provided out-of-state under non-emergency circumstances by a provider who does not have border status. Transportation to and from these services shall also require prior authorization, which shall be obtained by the transportation provider;

(b) All medical, surgical, or psychiatric services aimed specifically at weight control or reduction, and procedures to reverse the result of these services;

(c) Surgical or other medical procedures of questionable medical necessity but deemed advisable in order to correct conditions that may reasonably be assumed to significantly interfere with a recipient’s personal or social adjustment or employability, an example of which is cosmetic surgery;

(d) Prescriptions for those drugs listed in s. DHS 107.10 (2);

(e) Ligation of internal mammary arteries, unilateral or bilateral;

(f) Omentopexy for establishing collateral circulation in portal obstruction;

(g)

1. Kidney decapsulation, unilateral and bilateral;

2. Perirenal insufflation; and

3. Nephropexy: fixation or suspension of kidney (independent procedure), unilateral;

(h) Female circumcision;

(i) Hysterotomy, non-obstetrical or vaginal;

(j) Supracervical hysterectomy, that is, subtotal hysterectomy, with or without removal of tubes or ovaries or both tubes and ovaries;

(k) Uterine suspension, with or without presacral sympathectomy;

(L) Ligation of thyroid arteries as an independent procedure;

(m) Hypogastric or presacral neurectomy as an independent procedure;

(n)

1. Fascia lata by stripper when used as treatment for lower back pain;

2. Fascia lata by incision and area exposure, with removal of sheet, when used as treatment for lower back pain;

(o) Ligation of femoral vein, unilateral and bilateral, when used as treatment for post-phlebitic syndrome;

(p) Excision of carotid body tumor without excision of carotid artery, or with excision of carotid artery, when used as treatment for asthma;

(q) Sympathectomy, thoracolumbar or lumbar, unilateral or bilateral, when used as treatment for hypertension;

(r) Splanchnicectomy, unilateral or bilateral, when used as treatment for hypertension;

(s) Bronchoscopy with injection of contrast medium for bronchography or with injection of radioactive substance;

(t) Basal metabolic rate (BMR);

(u) Protein bound iodine (PBI);

(v) Ballistocardiogram;

(w) Icterus index;

(x) Phonocardiogram with interpretation and report, and with indirect carotid artery tracings or similar study;

(y)

1. Angiocardiography, utilizing C02 method, supervision and interpretation only;

2. Angiocardiography, either single plane, supervision and interpretation in conjunction with cineradiography or multi-plane, supervision and interpretation in conjunction with cineradiography;

(z)

1. Angiography — coronary: unilateral, selective injection, supervision and interpretation only, single view unless emergency;

2. Angiography — extremity: unilateral, supervision and interpretation only, single view unless emergency;

(za) Fabric wrapping of abdominal aneurysm;

(zb)

1. Mammoplasty, reduction or repositioning, one-stage — bilateral;

2. Mammoplasty, reduction or repositioning, two-stage — bilateral;

3. Mammoplasty augmentation, unilateral and bilateral;

4. Breast reconstruction and reduction.

(zc) Rhinoplasty;

(zd) Cingulotomy;

(ze) Dermabrasion;

(zf) Lipectomy;

(zg) Mandibular osteotomy;

(zh) Excision or surgical planning for rhinophyma;

(zi) Rhytidectomy;

(zj) Constructing an artificial vagina;

(zk) Repair blepharoptosis, lid retraction;

(zL) Any other procedure not identified in the physicians’ “current procedural terminology”, fourth edition, published by the American medical association;

Note: The referenced publication is on file and may be reviewed in the department’s division of health care financing. Interested persons may obtain a copy by writing American Medical Association, 535 N. Dearborn Avenue, Chicago, Illinois 60610.

(zm) Transplants;

1. Heart;

2. Pancreas;

3. Bone marrow;

4. Liver;

5. Heart-lung; and

6. Lung.

Note: For more information about prior authorization, see s. DHS 107.02 (3).

(zn) Drugs identified by the department that are sometimes used to enhance the prospects of fertility in males or females, when proposed to be used for treatment of a non-fertility related condition;

(zo) Drugs identified by the department that are sometimes used to treat impotence, when proposed to be used for treatment of a non-impotence related condition;

(3) Limitations on sterilization.

(a) Conditions for coverage. Sterilization is covered only if:

1. The individual is at least 21 years old at the time consent is obtained;

2. The individual has not been declared mentally incompetent by a federal, state or local court of competent jurisdiction to consent to sterilization;

3. The individual has voluntarily given informed consent in accordance with all the requirements prescribed in subd. 4. and par. (d); and

4. At least 30 days, but not more than 180 days, have passed between the date of informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery. An individual may be sterilized at the time of a premature delivery or emergency abdominal surgery if at least 72 hours have passed since he or she gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery.

(b) Sterilization by hysterectomy.

2. A hysterectomy may be a covered service if it is performed on an individual: