DHS 107.06 Note
Note: For more information about prior authorization, see s.
DHS 107.02 (3).
DHS 107.06(2)(zn)
(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;
DHS 107.06(2)(zo)
(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;
DHS 107.06(3)(a)1.
1. The individual is at least 21 years old at the time consent is obtained;
DHS 107.06(3)(a)2.
2. The individual has not been declared mentally incompetent by a federal, state or local court of competent jurisdiction to consent to sterilization;
DHS 107.06(3)(a)3.
3. The individual has voluntarily given informed consent in accordance with all the requirements prescribed in subd.
4. and par.
(d); and
DHS 107.06(3)(a)4.
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.
DHS 107.06(3)(b)2.2. A hysterectomy may be a covered service if it is performed on an individual:
DHS 107.06(3)(b)2.a.
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
DHS 107.06(3)(b)2.b.
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.
DHS 107.06 Note
Note: Documentation may include an operative note, or the patient's medical history and report of physical examination conducted prior to the surgery.
DHS 107.06(3)(b)3.
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:
DHS 107.06(3)(b)3.a.
a. The individual was informed before the operation that the hysterectomy would make her permanently incapable of reproducing; or
DHS 107.06(3)(b)3.b.
b. The condition in subd.
2. was met. The physician shall supply the information specified in subd.
2. DHS 107.06(3)(c)
(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.
DHS 107.06 Note
Note: Copies of the consent form and the physician's certification form are reproduced in the Wisconsin medical assistance physician provider handbook.
DHS 107.06(3)(d)
(d) Informed consent. For purposes of this subsection, an individual has given informed consent only if all of the following occur:
DHS 107.06(3)(d)1.
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:
DHS 107.06(3)(d)1.a.
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.
DHS 107.06(3)(d)1.b.
b. A description of available alternative methods of family planning and birth control.
DHS 107.06(3)(d)1.c.
c. Information that the sterilization procedure is considered to be irreversible.
DHS 107.06(3)(d)1.d.
d. A thorough explanation of the specific sterilization procedure to be performed.
DHS 107.06(3)(d)1.e.
e. A full description of the discomforts and risks that may accompany or follow the performing of the procedure, including an explanation of the type and possible effects of any anesthetic to be used.
DHS 107.06(3)(d)1.f.
f. A full description of the benefits or advantages that may be expected as a result of the sterilization.
DHS 107.06(3)(d)1.g.
g. Advice that the sterilization will not be performed for at least 30 days, except under the circumstances specified in par.
(a) 4. DHS 107.06(3)(d)2.
2. Suitable arrangements were made to ensure that the information specified in subd.
1. was effectively communicated to any individual who is blind, deaf, or otherwise disabled.
DHS 107.06(3)(d)3.
3. An interpreter was provided if the individual to be sterilized did not understand the language used on the consent form or the language used by the person obtaining consent.
DHS 107.06(3)(d)4.
4. The individual to be sterilized was permitted to have a witness of his or her choice present when consent was obtained.
DHS 107.06(3)(d)6.
6. Any additional requirement of state or local law for obtaining consent, except a requirement for spousal consent, was followed.
DHS 107.06(3)(d)7.
7. Informed consent is not obtained while the individual to be sterilized is in any of the following situations:
DHS 107.06(3)(d)7.c.
c. Under the influence of alcohol or other substances that affect the individual's state of awareness.
DHS 107.06 Note
Note: A copy of the informed consent form can be found in the Wisconsin medical assistance physician provider handbook.
DHS 107.06(3)(e)3.
3. The person securing the consent and the physician performing the sterilization shall certify by signing the consent form that:
DHS 107.06(3)(e)3.a.
a. Before the individual to be sterilized signed the consent form, they advised the individual to be sterilized that no federally funded program benefits will be withdrawn because of the decision not to be sterilized;
DHS 107.06(3)(e)3.b.
b. They explained orally the requirements for informed consent as set forth on the consent form; and
DHS 107.06(3)(e)3.c.
c. To the best of their knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.
DHS 107.06(3)(e)4.a.a. Except in the case of premature delivery or emergency abdominal surgery, the physician shall further certify that at least 30 days have passed between the date of the individual's signature on the consent form and the date upon which the sterilization was performed, and that to the best of the physician's knowledge and belief, the individual appeared mentally competent and knowingly and voluntarily consented to be sterilized.
DHS 107.06(3)(e)4.b.
b. In the case of premature delivery or emergency abdominal surgery performed within 30 days of consent, the physician shall certify that the sterilization was performed less than 30 days but not less than 72 hours after informed consent was obtained because of premature delivery or emergency abdominal surgery. In the case of premature delivery, the physician shall state the expected date of delivery. In the case of abdominal surgery, the physician shall describe the emergency.
DHS 107.06(3)(e)5.
5. If an interpreter is provided, the interpreter shall certify that the information and advice presented orally was translated, that the consent form and its contents were explained to the individual to be sterilized and that to the best of the interpreter's knowledge and belief, the individual understood what the interpreter said.
DHS 107.06(4)(a)
(a) Physician's visits. A maximum of one physician's visit per month to a recipient confined to a nursing home is covered unless the recipient has an acute condition which warrants more frequent care, in which case the recipient's medical record shall document the necessity of additional visits. The attending physician of a nursing home recipient, or the physician's assistant, or a nurse practitioner under the supervision of a physician, shall reevaluate the recipient's need for nursing home care in accordance with s.
DHS 107.09 (4) (m).
DHS 107.06(4)(b)
(b) Services of a surgical assistant. The services of a surgical assistant are not covered for procedures which normally do not require assistance at surgery.
DHS 107.06(4)(c)
(c) Consultations. Certain consultations shall be covered if they are professional services furnished to a recipient by a second physician at the request of the attending physician. Consultations shall include a written report which becomes a part of the recipient's permanent medical record. The name of the attending physician shall be included on the consultant's claim for reimbursement. The following consultations are covered:
DHS 107.06(4)(c)1.
1. Consultation requiring limited physical examination and evaluation of a given system or systems;
DHS 107.06(4)(c)2.
2. Consultation requiring a history and direct patient confrontation by a psychiatrist;
DHS 107.06(4)(c)3.
3. Consultation requiring evaluation of frozen sections or pathological slides by a pathologist; and
DHS 107.06(4)(c)4.
4. Consultation involving evaluation of radiological studies or radiotherapy by a radiologist;
DHS 107.06(4)(cm)
(cm)
Interprofessional consultation. Interprofessional consultations shall be covered if all of the following apply:
DHS 107.06(4)(cm)1.
1. The consultation is a professional service furnished to a recipient by a certified provider at the request of the treating provider.
DHS 107.06(4)(cm)2.
2. The consultation constitutes an evaluation and management service in which the certified provider treating a recipient requests the opinion or treatment advice of a consulting provider with specific expertise to assist the treating provider in the evaluation or management of the recipient’s problem without requiring the recipient to have face-to-face contact with the consulting provider.
DHS 107.06(4)(cm)3.
3. The consulting provider provides a written report that becomes a part of the recipient's permanent medical record.
DHS 107.06(4)(d)1.1. Services pertaining to the cleaning, trimming, and cutting of toenails, often referred to as palliative care, maintenance care, or debridement, shall be reimbursed no more than one time for each 31-day period and only if the recipient's condition is one or more of the following:
DHS 107.06(4)(d)1.c.
c. Peripheral neuropathies involving the feet, which are associated with malnutrition or vitamin deficiency, carcinoma, diabetes mellitus, drugs and toxins, multiple sclerosis, uremia or cerebral palsy.
DHS 107.06(4)(d)2.
2. The cutting, cleaning and trimming of toenails, corns, callouses and bunions on multiple digits shall be reimbursed at one inclusive fee for each service which includes either one or both appendages.
DHS 107.06(4)(d)3.
3. For multiple surgical procedures performed on the foot on the same day, the physician shall be reimbursed for the first procedure at the full rate and the second and all subsequent procedures at a reduced rate as determined by the department.
DHS 107.06(4)(d)4.
4. Debridement of mycotic conditions and mycotic nails shall be a covered service in accordance with utilization guidelines established and published by the department.
DHS 107.06(4)(d)5.
5. The application of unna boots is allowed once every 2 weeks, with a maximum of 12 applications for each 12-month period.
DHS 107.06(4)(f)
(f) Services performed under a physician's supervision. Services performed under the supervision of a physician shall comply with federal and state regulations relating to supervision of covered services. Specific documentation of the services shall be included in the recipient's medical record.
DHS 107.06(4)(g)
(g) Dental services. Dental services performed by a physician shall be subject to all requirements for MA dental services described in s.
DHS 107.07.
DHS 107.06(4)(h)
(h) Obesity-related procedures. Gastric bypass or gastric stapling for obesity is limited to medical emergencies, as determined by the department.
DHS 107.06(4)(i)1.1. Abortions, both surgically-induced and drug-induced, are limited to those that comply with s.
20.927, Stats.
DHS 107.06(4)(i)2.
2. Services, including drugs, directly related to non-surgical abortions shall comply with s.
20.927, Stats., may only be prescribed by a physician, and shall comply with MA policy and procedures as described in MA provider handbooks and bulletins.
DHS 107.06(5)
(5) Non-covered services. The following services are not covered services:
DHS 107.06(5)(a)
(a) Services and items that are provided for the purpose of enhancing the prospects of fertility in males or females, within the meaning of s.
DHS 107.03 (19).
DHS 107.06(5)(d)
(d) As separate charges, preoperative and postoperative surgical care, including office visits for suture and cast removal, which commonly are included in the payment of the surgical procedure;
DHS 107.06(5)(e)
(e) As separate charges, transportation expenses incurred by a physician, to include but not limited to mileage;
DHS 107.06(5)(g)
(g) Except as provided in sub.
(3) (b) 1., a hysterectomy if it was performed solely for the purpose of rendering an individual permanently incapable of reproducing or, if there was more than one purpose to the procedure, it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing;
