DHS 107.20(4) (4) Non-covered services. The following services and materials are not covered services:

DHS 107.20(4)(a) (a) Anti-glare coating;

DHS 107.20(4)(b) (b) Spare eyeglasses or sunglasses; and

DHS 107.20(4)(c) (c) Services provided principally for convenience or cosmetic reasons, including but not limited to gradient focus, custom prosthesis, fashion or cosmetic tints, engraved lenses and anti-scratch coating.

DHS 107.20 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.20 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.21 DHS 107.21 Family planning services.

DHS 107.21(1) (1) Covered services.

DHS 107.21(1)(a) (a) General. Covered family planning services are the services included in this subsection when prescribed by a physician and provided to a recipient, including initial physical exam and health history, annual office visits and follow-up office visits, laboratory services, prescribing and supplying contraceptive supplies and devices, counseling services and prescribing medication for specific treatments. All family planning services performed in family planning clinics shall be prescribed by a physician, and furnished, directed or supervised by a physician, registered nurse, nurse practitioner, licensed practical nurse or nurse midwife under s. 441.15 (1) and (2) (b), Stats.

DHS 107.21(1)(b) (b) Physical examination. An initial physical examination with health history is a covered service and shall include the following:

DHS 107.21(1)(b)1. 1. Complete obstetrical history including menarche, menstrual, gravidity, parity, pregnancy outcomes and complications of pregnancy or delivery, and abortion history;

DHS 107.21(1)(b)2. 2. History of significant illness-morbidity, hospitalization and previous medical care, particularly in relation to thromboembolic disease, any breast or genital neoplasm, any diabetic or prediabetic condition, cephalalgia and migraine, pelvic inflammatory disease, gynecologic disease and venereal disease;

DHS 107.21(1)(b)3. 3. History of previous contraceptive use;

DHS 107.21(1)(b)4. 4. Family, social, physical health, and mental health history, including chronic illnesses, genetic aberrations and mental depression;

DHS 107.21(1)(b)5. 5. Physical examination. Recommended procedures for examination are:

DHS 107.21(1)(b)5.a. a. Thyroid palpation;

DHS 107.21(1)(b)5.b. b. Examination of breasts and axillary glands;

DHS 107.21(1)(b)5.c. c. Auscultation of heart and lungs;

DHS 107.21(1)(b)5.d. d. Blood pressure measurement;

DHS 107.21(1)(b)5.e. e. Height and weight measurement;

DHS 107.21(1)(b)5.f. f. Abdominal examination;

DHS 107.21(1)(b)5.g. g. Pelvic examination; and

DHS 107.21(1)(b)5.h. h. Examination of extremities.

DHS 107.21(1)(c) (c) Laboratory and other diagnostic services. Laboratory and other diagnostic services are covered services as indicated in this paragraph. These services may be performed in conjunction with an initial examination with health history, and are the following:

DHS 107.21(1)(c)1. 1. Routinely performed procedures:

DHS 107.21(1)(c)1.a. a. CBC, or hematocrit or hemoglobin;

DHS 107.21(1)(c)1.b. b. Urinalysis;

DHS 107.21(1)(c)1.c. c. Papanicolaou smear for females between the ages of 12 and 65;

DHS 107.21(1)(c)1.d. d. Bacterial smear or culture (gonorrhea, trichomonas, yeast, etc.) including VDRL — syphilis serology with positive gonorrhea cultures; and