Wisconsin Legislature: DHS 107.06(5)(w)

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

EmR2421

5. The application of unna boots is allowed once every 2 weeks, with a maximum of 12 applications for each 12-month period.

(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.

(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.

(h) Obesity-related procedures. Gastric bypass or gastric stapling for obesity is limited to medical emergencies, as determined by the department.

(i) Abortions.

1. Abortions, both surgically-induced and drug-induced, are limited to those that comply with s. 20.927, Stats.

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.

(5) Non-covered services. The following services are not covered services:

(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).

(b) Abortions performed which do not comply with s. 20.927, Stats.;

(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;

(e) As separate charges, transportation expenses incurred by a physician, to include but not limited to mileage;

(f) Dab’s and Wynn’s solution;

(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;

(h) Ear piercing;

(i) Electrolysis;

(j) Tattooing;

(k) Hair transplants;

(L) Vitamin C injections;

(m) Lincocin (lincomycin) injections performed on an outpatient basis;

(n) Orthopedic shoes and supportive devices such as arch supports, shoe inlays and pads;

(o) Services directed toward the care and correction of “flat feet”;

(p) Sterilization of a mentally incompetent or institutionalized person, or of a person who is less than 21 years of age;

(q) Inpatient laboratory tests not ordered by a physician or other responsible practitioner, except in emergencies;

(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;

(s) Liver injections;

(t) Acupuncture;

(u) Phonocardiogram with interpretation and report;

(v) Vector cardiogram;

(w) Non-emergency gastric bypass or gastric stapling for obesity; and

(x) Separate charges for pump technician services.

Note: For more information on non-covered services, see s. DHS 107.03.

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 Anesthesiology services.

(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.

(2) Other limitations.

(a) A nurse anesthetist shall perform services in the presence of a supervising anesthesiologist or performing physician.

(b) An anesthesiology assistant shall perform services only in the presence of a supervising anesthesiologist.

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 Dental services.

(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.:

(a) Diagnostic services.

(b) Preventive services.

(d) Endodontic services.

(e) Periodontic services.

(f) Removable prosthodontic services.

(g) Fixed prosthodontic services.

(h) Oral and maxillofacial surgery services.

(j) All of the following other services:

1. Unclassified treatment.

2. Palliative emergency treatment.

3. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation.

4. Hospital calls.

Note: Orthodontia may be covered under early and periodic screening, diagnosis and treatment (EPSDT) services. Please see s. DHS 107.22 (4).

(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.:

(a) Oral screening and preliminary examination.

(b) Prophylaxis.

(d) Pit and fissure sealants.

(e) Scaling and root planing.

(f) Full mouth debridement.

(g) Periodontal maintenance.

(2) Services requiring prior authorization.

(a) All of the following dental services require prior authorization in order to be reimbursed under MA:

1. Molar root canal therapy for recipients ages 21 and over.

2. All of the following periodontal services:

a. Grafts, mucogingival and osseous surgical periodontal services.

b. Provisional splinting.

c. Gingivectomy and gingivoplasty.

d. Scaling and root planing.

e. Periodontal maintenance.

3. All of the following removable prosthodontic services:

a. Complete dentures.

b. Partial dentures.

4. All of the following oral and maxillofacial surgery services:

a. Surgical extractions of teeth and tooth roots for orthodontia, or for asymptomatic impacted teeth.

b. Temporomandibular joint surgery.

c. Repairs of orthognathic deformities.

d. Other repair procedures including osteoplasty, alveoloplasty, and sialolithotomy.

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.

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.

(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).

(3) Other limitations. All of the following limitations apply to the coverage of dental services under this section:

(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:

1. Frequency of service per time period, including coverage of services in emergency situations only.

2. Allowable age of recipient who may receive a service.

3. Required documentation, including pathology report or operative report.

(b) Specific limitations.