Wisconsin Legislature: DHS 107.06(2)(r)

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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:

a. Already sterile prior to the hysterectomy and whose physician has provided written documentation, including a statement of the reason for sterility, with the claim form; or

b. Requiring a hysterectomy due to a life-threatening situation in which the physician determines that prior acknowledgment is not possible. The physician performing the operation shall provide written documentation, including a clear description of the nature of the emergency, with the claim form.

Note: Documentation may include an operative note, or the patient’s medical history and report of physical examination conducted prior to the surgery.

3. If a hysterectomy was performed for a reason stated under subd. 1. or 2. during a period of the individual’s retroactive eligibility for MA under s. DHS 103.08, the hysterectomy shall be covered if the physician who performed the hysterectomy certifies in writing that:

a. The individual was informed before the operation that the hysterectomy would make her permanently incapable of reproducing; or

b. The condition in subd. 2. was met. The physician shall supply the information specified in subd. 2.

(c) Documentation. Before reimbursement will be made for a sterilization or hysterectomy, the department shall be given documentation showing that the requirements of this subsection were met. This documentation shall include a consent form, an acknowledgment of receipt of hysterectomy information or a physician’s certification form for a hysterectomy performed without prior acknowledgment of receipt of hysterectomy information.

Note: Copies of the consent form and the physician’s certification form are reproduced in the Wisconsin medical assistance physician provider handbook.

(d) Informed consent. For purposes of this subsection, an individual has given informed consent only if all of the following occur:

1. The person who obtained consent for the sterilization procedure offered to answer any questions the individual to be sterilized may have had concerning the procedure, provided a copy of the consent form and provided orally all of the following information or advice to the individual to be sterilized:

a. Advice that the individual is free to withhold or withdraw consent to the procedure at any time before the sterilization without affecting the right to future care or treatment and without loss or withdrawal of any federally funded program benefits to which the individual might be otherwise entitled.

b. A description of available alternative methods of family planning and birth control.