Chapter DHS 107

DHS 107.06(2)(j) (j) Supracervical hysterectomy, that is, subtotal hysterectomy, with or without removal of tubes or ovaries or both tubes and ovaries;

DHS 107.06(2)(k) (k) Uterine suspension, with or without presacral sympathectomy;

DHS 107.06(2)(L) (L) Ligation of thyroid arteries as an independent procedure;

DHS 107.06(2)(m) (m) Hypogastric or presacral neurectomy as an independent procedure;

DHS 107.06(2)(n) (n)

DHS 107.06(2)(n)1. 1. Fascia lata by stripper when used as treatment for lower back pain;

DHS 107.06(2)(n)2. 2. Fascia lata by incision and area exposure, with removal of sheet, when used as treatment for lower back pain;

DHS 107.06(2)(o) (o) Ligation of femoral vein, unilateral and bilateral, when used as treatment for post-phlebitic syndrome;

DHS 107.06(2)(p) (p) Excision of carotid body tumor without excision of carotid artery, or with excision of carotid artery, when used as treatment for asthma;

DHS 107.06(2)(q) (q) Sympathectomy, thoracolumbar or lumbar, unilateral or bilateral, when used as treatment for hypertension;

DHS 107.06(2)(r) (r) Splanchnicectomy, unilateral or bilateral, when used as treatment for hypertension;

DHS 107.06(2)(s) (s) Bronchoscopy with injection of contrast medium for bronchography or with injection of radioactive substance;

DHS 107.06(2)(t) (t) Basal metabolic rate (BMR);

DHS 107.06(2)(u) (u) Protein bound iodine (PBI);

DHS 107.06(2)(v) (v) Ballistocardiogram;

DHS 107.06(2)(w) (w) Icterus index;

DHS 107.06(2)(x) (x) Phonocardiogram with interpretation and report, and with indirect carotid artery tracings or similar study;

DHS 107.06(2)(y) (y)

DHS 107.06(2)(y)1. 1. Angiocardiography, utilizing C02 method, supervision and interpretation only;

DHS 107.06(2)(y)2. 2. Angiocardiography, either single plane, supervision and interpretation in conjunction with cineradiography or multi-plane, supervision and interpretation in conjunction with cineradiography;

DHS 107.06(2)(z) (z)

DHS 107.06(2)(z)1. 1. Angiography — coronary: unilateral, selective injection, supervision and interpretation only, single view unless emergency;

DHS 107.06(2)(z)2. 2. Angiography — extremity: unilateral, supervision and interpretation only, single view unless emergency;

DHS 107.06(2)(za) (za) Fabric wrapping of abdominal aneurysm;

DHS 107.06(2)(zb) (zb)

DHS 107.06(2)(zb)1. 1. Mammoplasty, reduction or repositioning, one-stage — bilateral;

DHS 107.06(2)(zb)2. 2. Mammoplasty, reduction or repositioning, two-stage — bilateral;

DHS 107.06(2)(zb)3. 3. Mammoplasty augmentation, unilateral and bilateral;

DHS 107.06(2)(zb)4. 4. Breast reconstruction and reduction.

DHS 107.06(2)(zc) (zc) Rhinoplasty;

DHS 107.06(2)(zd) (zd) Cingulotomy;

DHS 107.06(2)(ze) (ze) Dermabrasion;

DHS 107.06(2)(zf) (zf) Lipectomy;

DHS 107.06(2)(zg) (zg) Mandibular osteotomy;

DHS 107.06(2)(zh) (zh) Excision or surgical planning for rhinophyma;

DHS 107.06(2)(zi) (zi) Rhytidectomy;

DHS 107.06(2)(zj) (zj) Constructing an artificial vagina;

DHS 107.06(2)(zk) (zk) Repair blepharoptosis, lid retraction;

DHS 107.06(2)(zL) (zL) Any other procedure not identified in the physicians’ “current procedural terminology”, fourth edition, published by the American medical association;

DHS 107.06 Note 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.

DHS 107.06(2)(zm) (zm) Transplants;

DHS 107.06(2)(zm)1. 1. Heart;

DHS 107.06(2)(zm)2. 2. Pancreas;

DHS 107.06(2)(zm)3. 3. Bone marrow;

DHS 107.06(2)(zm)4. 4. Liver;

DHS 107.06(2)(zm)5. 5. Heart-lung; and

DHS 107.06(2)(zm)6. 6. Lung.

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) (3) Limitations on sterilization.

DHS 107.06(3)(a) (a) Conditions for coverage. Sterilization is covered only if:

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) (b) Sterilization by hysterectomy.

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)5. 5. The consent form requirements of par. (e) were met.

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.a. a. In labor or childbirth.

DHS 107.06(3)(d)7.b. b. Seeking to obtain or obtaining an abortion.

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(3)(e) (e) Consent form.

DHS 107.06(3)(e)1. 1. Consent shall be registered on a form prescribed by the department.

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)2. 2. The consent form shall be signed and dated by:

DHS 107.06(3)(e)2.a. a. The individual to be sterilized;