Orthopedic shoes and supportive devices such as arch supports, shoe inlays and pads;
Services directed toward the care and correction of “flat feet";
Sterilization of a mentally incompetent or institutionalized person, or of a person who is less than 21 years of age;
Inpatient laboratory tests not ordered by a physician or other responsible practitioner, except in emergencies;
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;
Non-emergency gastric bypass or gastric stapling for obesity; and
DHS 107.06 Note
For more information on non-covered services, see s. DHS 107.03
DHS 107.06 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
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.
A nurse anesthetist shall perform services in the presence of a supervising anesthesiologist or performing physician.
An anesthesiology assistant shall perform services only in the presence of a supervising anesthesiologist.
DHS 107.065 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
Covered services; dentists and physicians.
Except as provided under subs. (2)
, 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)
General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation.
DHS 107.07 Note
Orthodontia may be covered under early and periodic screening, diagnosis and treatment (EPSDT) services. Please see s. DHS 107.22 (4)
(1m) Covered services; dental hygienists.
Except as provided under subs. (2)
, 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)
All of the following dental services require prior authorization in order to be reimbursed under MA:
Surgical extractions of teeth and tooth roots for orthodontia, or for asymptomatic impacted teeth.
Other repair procedures including osteoplasty, alveoloplasty, and sialolithotomy.
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.
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.
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)
(3) Other limitations.
All of the following limitations apply to the coverage of dental services under this section:
The MA program may impose reasonable limitations on reimbursement of the services listed in subs. (1)
regarding any of the following:
Frequency of service per time period, including coverage of services in emergency situations only.
Required documentation, including pathology report or operative report.
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.
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.
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.
A non-covered service specified under sub. (4)
may be reimbursed if the department's dental consultant requests that the service be performed in order to review the request for prior authorization.
(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:
General services for purely aesthetic or cosmetic purposes.
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.
Equivalent services or separate components of a service performed on the same day.
Tests and laboratory examinations, other than for diagnostic casts when required by the department.
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.
Endodontic filling materials that are not approved for use by the American Dental Association.