DHS 107.06(5)(n) (n) Orthopedic shoes and supportive devices such as arch supports, shoe inlays and pads;
DHS 107.06(5)(o) (o) Services directed toward the care and correction of “flat feet";
DHS 107.06(5)(p) (p) Sterilization of a mentally incompetent or institutionalized person, or of a person who is less than 21 years of age;
DHS 107.06(5)(q) (q) Inpatient laboratory tests not ordered by a physician or other responsible practitioner, except in emergencies;
DHS 107.06(5)(r) (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;
DHS 107.06(5)(s) (s) Liver injections;
DHS 107.06(5)(t) (t) Acupuncture;
DHS 107.06(5)(u) (u) Phonocardiogram with interpretation and report;
DHS 107.06(5)(v) (v) Vector cardiogram;
DHS 107.06(5)(w) (w) Non-emergency gastric bypass or gastric stapling for obesity; and
DHS 107.06(5)(x) (x) Separate charges for pump technician services.
DHS 107.06 Note Note: For more information on non-covered services, see s. DHS 107.03.
DHS 107.06 History 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.
DHS 107.065 DHS 107.065Anesthesiology services.
DHS 107.065(1)(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.
DHS 107.065(2) (2)Other limitations.
DHS 107.065(2)(a) (a) A nurse anesthetist shall perform services in the presence of a supervising anesthesiologist or performing physician.
DHS 107.065(2)(b) (b) An anesthesiology assistant shall perform services only in the presence of a supervising anesthesiologist.
DHS 107.065 History 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 DHS 107.07Dental services.
DHS 107.07(1)(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.:
DHS 107.07(1)(a) (a) Diagnostic services.
DHS 107.07(1)(b) (b) Preventive services.
DHS 107.07(1)(c) (c) Restorative services.
DHS 107.07(1)(d) (d) Endodontic services.
DHS 107.07(1)(e) (e) Periodontic services.
DHS 107.07(1)(f) (f) Removable prosthodontic services.
DHS 107.07(1)(g) (g) Fixed prosthodontic services.
DHS 107.07(1)(h) (h) Oral and maxillofacial surgery services.
DHS 107.07(1)(j) (j) All of the following other services:
DHS 107.07(1)(j)1. 1. Unclassified treatment.
DHS 107.07(1)(j)2. 2. Palliative emergency treatment.
DHS 107.07(1)(j)3. 3. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation.
DHS 107.07(1)(j)4. 4. Hospital calls.
DHS 107.07 Note Note: Orthodontia may be covered under early and periodic screening, diagnosis and treatment (EPSDT) services. Please see s. DHS 107.22 (4).
DHS 107.07(1m) (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.:
DHS 107.07(1m)(a) (a) Oral screening and preliminary examination.
DHS 107.07(1m)(b) (b) Prophylaxis.
DHS 107.07(1m)(c) (c) Topical application of fluoride.
DHS 107.07(1m)(d) (d) Pit and fissure sealants.
DHS 107.07(1m)(e) (e) Scaling and root planing.
DHS 107.07(1m)(f) (f) Full mouth debridement.
DHS 107.07(1m)(g) (g) Periodontal maintenance.
DHS 107.07(2) (2)Services requiring prior authorization.
DHS 107.07(2)(a)(a) All of the following dental services require prior authorization in order to be reimbursed under MA:
DHS 107.07(2)(a)1. 1. Molar root canal therapy for recipients ages 21 and over.
DHS 107.07(2)(a)2. 2. All of the following periodontal services:
DHS 107.07(2)(a)2.a. a. Grafts, mucogingival and osseous surgical periodontal services.
DHS 107.07(2)(a)2.b. b. Provisional splinting.
DHS 107.07(2)(a)2.c. c. Gingivectomy and gingivoplasty.
DHS 107.07(2)(a)2.d. d. Scaling and root planing.
DHS 107.07(2)(a)2.e. e. Periodontal maintenance.
DHS 107.07(2)(a)3. 3. All of the following removable prosthodontic services:
DHS 107.07(2)(a)3.a. a. Complete dentures.
DHS 107.07(2)(a)3.b. b. Partial dentures.
DHS 107.07(2)(a)4. 4. All of the following oral and maxillofacial surgery services:
DHS 107.07(2)(a)4.a. a. Surgical extractions of teeth and tooth roots for orthodontia, or for asymptomatic impacted teeth.
DHS 107.07(2)(a)4.b. b. Temporomandibular joint surgery.
DHS 107.07(2)(a)4.c. c. Repairs of orthognathic deformities.
DHS 107.07(2)(a)4.d. d. Other repair procedures including osteoplasty, alveoloplasty, and sialolithotomy.
DHS 107.07(2)(a)6. 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.
DHS 107.07(2)(a)7. 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.
DHS 107.07(2)(b) (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).
DHS 107.07(3) (3)Other limitations. All of the following limitations apply to the coverage of dental services under this section:
DHS 107.07(3)(a) (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:
DHS 107.07(3)(a)1. 1. Frequency of service per time period, including coverage of services in emergency situations only.
DHS 107.07(3)(a)2. 2. Allowable age of recipient who may receive a service.
DHS 107.07(3)(a)3. 3. Required documentation, including pathology report or operative report.
DHS 107.07(3)(b) (b) Specific limitations.
DHS 107.07(3)(b)1.1. Reimbursement for dentures and partial dentures includes 6 months postdelivery care. If a prior authorization request for these services is approved, the recipient shall be eligible on the date the authorized treatment is started, which is the date the final impressions were taken. Once started, the service shall be reimbursed to completion, regardless of the recipient's eligibility.
DHS 107.07(3)(b)2. 2. Temporomandibular joint surgery is a covered service only when performed after all professionally accepted non-surgical medical or dental treatment has been provided, and the necessary non-surgical medical or dental treatment has been determined unsuccessful by the department's dental consultant.
DHS 107.07(3)(b)3. 3. The diagnostic work-up for orthodontic services shall be performed and submitted with the prior authorization request. If the request is approved, the recipient is required to be eligible on the date the authorized orthodontic treatment is started as demonstrated by the placement of bands for comprehensive orthodontia. Once started, the service shall be reimbursed to completion, regardless of the recipient's eligibility.
DHS 107.07(3)(b)4. 4. A non-covered service specified under sub. (4) or (4m) may be reimbursed if the department's dental consultant requests that the service be performed in order to review the request for prior authorization.
DHS 107.07(4) (4)Non-covered services; dentists and physicians. The following dental services are not covered under MA whether or not the service is performed by a dentist; physician; or a person under the supervision of a dentist or physician:
DHS 107.07(4)(a) (a) General services for purely aesthetic or cosmetic purposes.
DHS 107.07(4)(b) (b) General services performed by means of a telephone call between a provider and a recipient, including those in which the provider provides advice or instructions to or on behalf of the recipient, or between dentists, physicians or a dentist and physician on behalf of the recipient.
DHS 107.07(4)(c) (c) Equivalent services or separate components of a service performed on the same day.
DHS 107.07(4)(d) (d) Tests and laboratory examinations, other than for diagnostic casts when required by the department.
DHS 107.07(4)(e) (e) Oral hygiene instruction or training in preventive dental care as a separate procedure, including tooth brushing technique, flossing or use of special oral hygiene aids, tobacco cessation counseling, or nutritional counseling.
DHS 107.07(4)(f) (f) The following restorative services:
DHS 107.07(4)(f)1. 1. Labial veneer.
DHS 107.07(4)(f)2. 2. Temporary crowns.
DHS 107.07(4)(f)3. 3. Cement bases as a separate item.
DHS 107.07(4)(f)4. 4. Endodontic filling materials that are not approved for use by the American Dental Association.
DHS 107.07(4)(g) (g) Pulp cappings.
DHS 107.07(4)(h) (h) The following removable prosthodontic services:
DHS 107.07(4)(h)1. 1. Overlay dentures.
DHS 107.07(4)(h)2. 2. Overlay partial dentures.
DHS 107.07(4)(h)3. 3. Duplicate dentures and adjustments.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.