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 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(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 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;