DHS 107.05DHS 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. DHS 107.05 HistoryHistory: 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(1)(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. DHS 107.06(2)(2) Services requiring prior authorization. The following physician services require prior authorization in order to be covered under the MA program: DHS 107.06(2)(a)(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; DHS 107.06(2)(b)(b) All medical, surgical, or psychiatric services aimed specifically at weight control or reduction, and procedures to reverse the result of these services; DHS 107.06(2)(c)(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; DHS 107.06(2)(e)(e) Ligation of internal mammary arteries, unilateral or bilateral; DHS 107.06(2)(f)(f) Omentopexy for establishing collateral circulation in portal obstruction; DHS 107.06(2)(g)3.3. Nephropexy: fixation or suspension of kidney (independent procedure), unilateral; 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)(m)(m) Hypogastric or presacral neurectomy as an independent procedure; 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;