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;
DHS 107.06(5)(m)
(m) Lincocin (lincomycin) injections performed on an outpatient basis;
DHS 107.06(5)(n)
(n) Orthopedic shoes and supportive devices such as arch supports, shoe inlays and pads;
DHS 107.06(5)(o)
(o) Services directed toward the care and correction of “flat feet";
DHS 107.06(5)(p)
(p) Sterilization of a mentally incompetent or institutionalized person, or of a person who is less than 21 years of age;
DHS 107.06(5)(q)
(q) Inpatient laboratory tests not ordered by a physician or other responsible practitioner, except in emergencies;
DHS 107.06(5)(r)
(r) Hospital care following admission on a Friday or Saturday, except for emergencies, accident care or obstetrical cases, unless the hospital can demonstrate to the satisfaction of the department that the hospital provides all of its services 7 days a week;
DHS 107.06(5)(w)
(w) Non-emergency gastric bypass or gastric stapling for obesity; and
DHS 107.06 Note
Note: For more information on non-covered services, see s.
DHS 107.03.
DHS 107.06 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; cr. (2) (cm), (4) (h) and (5) (y), am. (4) (a) 3.
Register, February, 1988, No. 386, eff. 3-1-88; am. (4) (a) 1. c., p. and q., cr. (4) (a) 1. r.,
Register, April, 1988, No. 388, eff. 7-1-88; r. (2) (cm) and (5) (y), r. and recr. (4) (h),
Register, December, 1988, No. 396, eff. 1-1-89; r. (2) (zh), (zk), (zo), (zp) and (4) (a), renum. (2) (zi) to (zw) to be (zh) to (zs) and am. renum. (4) (b) to (h) to be (4) (a) to (g), cr. (2) (zt), r. (4) (a),
Register, September, 1991, No. 429, eff. 10-1-91; r. and recr. (2) (h) and (5) (a), r. (2) (zb), (zc), zl), (zn), (zp), (zq) and (zs), renum. (2) (zd), (ze) to (zk), (zm), (zo), (zr) and (zt) to be(zb), (zc) to (zi), (zj), (zk), (zL) and (zm) and am.(2) (zc) and (zm), am. (5) (w) and (x), cr. (2) (zn) and (zo), (4) (h) and (i),
Register, January, 1997, No. 493, eff. 2-1-97; correction in (4) (a) made under s. 13.93 (2m) (b) 7., Stats.,
Register, April, 1999, No. 520; correction in (3) (b) 3. (intro.) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636; republication of (3) (e) 5. to reinsert text inadvertently dropped in 1991,
Register February 2019 No. 758;
CR 20-039: r. (4) (e)
Register October 2021 No. 790, eff. 11-1-21;
CR 20-068: am. (3) (d) (intro), 1. a. to f., 2. to 6., 7. (intro.), a., b.
Register December 2021 No. 792, eff. 1-1-22;
CR 22-043: am. (1), cr. (4) (cm), r. (5) (c)
Register May 2023 No. 809, eff. 6-1-23;
CR 23-046: r. (3) (b) 1. Register April 2024 No. 820, eff. 5-1-24. DHS 107.065(1)(1)
Covered services. Anesthesiology services covered by the MA program are any medically necessary medical services applied to a recipient to induce the loss of sensation of pain associated with surgery, dental procedures or radiological services. These services are performed by an anesthesiologist certified under s.
DHS 105.05, or by a nurse anesthetist or an anesthesiology assistant certified under s.
DHS 105.055. Anesthesiology services shall include preoperative, intraoperative and postoperative evaluation and management of recipients as appropriate.
DHS 107.065(2)(a)
(a) A nurse anesthetist shall perform services in the presence of a supervising anesthesiologist or performing physician.
DHS 107.065(2)(b)
(b) An anesthesiology assistant shall perform services only in the presence of a supervising anesthesiologist.
DHS 107.065 History
History: Cr.
Register, September, 1991, No. 429, eff. 10-1-91; correction in (1) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 107.07(1)(1)
Covered services; dentists and physicians. Except as provided under subs.
(2),
(3),
(4) and
(4m), all of the following dental services are covered services when provided by or under the supervision of a dentist or physician within the scope of practice of dentistry as defined in s.
447.01 (8), Stats.:
DHS 107.07(1)(j)3.
3. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation.
DHS 107.07 Note
Note: Orthodontia may be covered under early and periodic screening, diagnosis and treatment (EPSDT) services. Please see s.
DHS 107.22 (4).
DHS 107.07(1m)
(1m) Covered services; dental hygienists. Except as provided under subs.
(2),
(3),
(4), and
(4m), all of the following dental services are covered services when provided by a dental hygienist who is individually certified under ch.
DHS 105 within the scope of dental hygiene as defined in s.
447.01 (3), Stats.:
DHS 107.07(2)(a)(a) All of the following dental services require prior authorization in order to be reimbursed under MA:
DHS 107.07(2)(a)4.a.
a. Surgical extractions of teeth and tooth roots for orthodontia, or for asymptomatic impacted teeth.
DHS 107.07(2)(a)4.d.
d. Other repair procedures including osteoplasty, alveoloplasty, and sialolithotomy.
DHS 107.07(2)(a)6.
6. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation for recipients age 21 and over, where the treatment is not provided in a hospital or in an emergency situation.
DHS 107.07(2)(a)7.
7. Surgical or other dental services, including fixed prosthodontics in order to correct conditions that may reasonably be assumed to significantly interfere with a recipient's personal or social adjustment or employability.
DHS 107.07(2)(b)
(b) A provider who submits a request for prior authorization of dental services to the department shall identify the recipient's birth date and the items enumerated in s.
DHS 107.02 (3) (d).
DHS 107.07(3)
(3) Other limitations. All of the following limitations apply to the coverage of dental services under this section:
DHS 107.07(3)(a)
(a)
General limitations. The MA program may impose reasonable limitations on reimbursement of the services listed in subs.
(1) and
(1m) regarding any of the following:
DHS 107.07(3)(a)1.
1. Frequency of service per time period, including coverage of services in emergency situations only.
DHS 107.07(3)(a)3.
3. Required documentation, including pathology report or operative report.
DHS 107.07(3)(b)1.1. Reimbursement for dentures and partial dentures includes 6 months postdelivery care. If a prior authorization request for these services is approved, the recipient shall be eligible on the date the authorized treatment is started, which is the date the final impressions were taken. Once started, the service shall be reimbursed to completion, regardless of the recipient's eligibility.
DHS 107.07(3)(b)2.
2. Temporomandibular joint surgery is a covered service only when performed after all professionally accepted non-surgical medical or dental treatment has been provided, and the necessary non-surgical medical or dental treatment has been determined unsuccessful by the department's dental consultant.
DHS 107.07(3)(b)3.
3. The diagnostic work-up for orthodontic services shall be performed and submitted with the prior authorization request. If the request is approved, the recipient is required to be eligible on the date the authorized orthodontic treatment is started as demonstrated by the placement of bands for comprehensive orthodontia. Once started, the service shall be reimbursed to completion, regardless of the recipient's eligibility.
DHS 107.07(3)(b)4.
4. A non-covered service specified under sub.
(4) or
(4m) may be reimbursed if the department's dental consultant requests that the service be performed in order to review the request for prior authorization.
