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 NoteNote: 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 NoteNote: 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 NoteNote: Documentation may include an operative note, or the patient’s medical history and report of physical examination conducted prior to the surgery.