DHS 107.03(9) (9)Any service requiring prior authorization for which prior authorization is denied, or for which prior authorization was not obtained prior to the provision of the service except in emergency circumstances;
DHS 107.03(10) (10)Services subject to review and approval pursuant to s. 150.21, Stats., but which have not yet received approval;
DHS 107.03(11) (11)Psychiatric examinations and evaluations ordered by a court following a person's conviction of a crime, pursuant to s. 972.15, Stats.;
DHS 107.03(12) (12)Consultations between or among providers, except as specified in s. DHS 107.06 (4) (e);
DHS 107.03(13) (13)Medical services for adult inmates of the correctional institutions listed in s. 302.01, Stats.;
DHS 107.03(14) (14)Medical services for a child placed in a detention facility;
DHS 107.03(15) (15)Expenditures for any service to an individual who is an inmate of a public institution or for any service to a person 21 to 64 years of age who is a resident of an institution for mental diseases (IMD), unless the person is 21 years of age, was a resident of the IMD immediately prior to turning 21 and has been continuously a resident since then, except that expenditures for a service to an individual on convalescent leave from an IMD may be reimbursed by MA.
DHS 107.03(16) (16)Services provided to recipients when outside the United States, except Canada or Mexico;
DHS 107.03(17) (17)Separate charges for the time involved in completing necessary forms, claims or reports;
DHS 107.03(18) (18)Services provided by a hospital or professional services provided to a hospital inpatient are not covered services unless billed separately as hospital services under s. DHS 107.08 or 107.13 (1) or as professional services under the appropriate provider type. No recipient may be billed for these services as non-covered;
DHS 107.03(19) (19)Services, drugs and items that are provided for the purpose of enhancing the prospects of fertility in males or females, including but not limited to the following:
DHS 107.03(19)(a) (a) Artificial insemination, including but not limited to intra-cervical and intra-uterine insemination;
DHS 107.03(19)(b) (b) Infertility counseling;
DHS 107.03(19)(c) (c) Infertility testing, including but not limited to tubal patency, semen analysis or sperm evaluation;
DHS 107.03(19)(d) (d) Reversal of female sterilization, including but not limited to tubouterine implantation, tubotubal anastomoses or fimbrioplasty;
DHS 107.03(19)(e) (e) Fertility-enhancing drugs used for the treatment of infertility;
DHS 107.03(19)(f) (f) Reversal of vasectomies;
DHS 107.03(19)(g) (g) Office visits, consultations and other encounters to enhance the prospects of fertility; and
DHS 107.03(19)(h) (h) Other fertility-enhancing services and items;
DHS 107.03(20) (20)Surrogate parenting and related services, including but not limited to artificial insemination and subsequent obstetrical care;
DHS 107.03(21) (21)Ear lobe repair;
DHS 107.03(22) (22)Tattoo removal;
DHS 107.03(23) (23)Drugs, including hormone therapy, associated with transsexual surgery or medically unnecessary alteration of sexual anatomy or characteristics;
DHS 107.03(24) (24)Transsexual surgery;
DHS 107.03(25) (25)Impotence devices and services, including but not limited to penile prostheses and external devices and to insertion surgery and other related services; and
DHS 107.03(26) (26)Testicular prosthesis.
DHS 107.03 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. (15), eff. 8-1-88; r. and recr. (15), Register, December, 1988, No. 396, eff. 1-1-89; emerg. am. (15), eff. 6-1-89; am. (15), Register, February, 1990, No. 410, eff. 3-1-90; am. (10), (12), (16) and (17), cr. (18), Register, September, 1991, No. 429, eff. 10-1-91; am. (17) and (18), cr. (19) to (26), Register, January, 1997, No. 493, eff. 2-1-97; correction in (13) made under s. 13.93 (2m) (b) 7., Stats., Register, October, 2000, No. 538.
DHS 107.035 DHS 107.035Definition and identification of experimental services.
DHS 107.035(1)(1)Definition. “Experimental in nature," as used in s. DHS 107.03 (4) and this section, means a service, procedure or treatment provided by a particular provider which the department has determined under sub. (2) not to be a proven and effective treatment for the condition for which it is intended or used.
DHS 107.035(2) (2)Departmental review. In assessing whether a service provided by a particular provider is experimental in nature, the department shall consider whether the service is a proven and effective treatment for the condition which it is intended or used, as evidenced by:
DHS 107.035(2)(a) (a) The current and historical judgment of the medical community as evidenced by medical research, studies, journals or treatises;
DHS 107.035(2)(b) (b) The extent to which medicare and private health insurers recognize and provide coverage for the service;
DHS 107.035(2)(c) (c) The current judgment of experts and specialists in the medical specialty area or areas in which the service is applicable or used; and
DHS 107.035(2)(d) (d) The judgment of the MA medical audit committee of the state medical society of Wisconsin or the judgment of any other committee which may be under contract with the department to perform health care services review within the meaning of s. 146.37, Stats.
DHS 107.035(3) (3)Exclusion of coverage. If on the basis of its review the department determines that a particular service provided by a particular provider is experimental in nature and should therefore be denied MA coverage in whole or in part, the department shall send written notice to physicians or other affected certified providers who have requested reimbursement for the provision of the experimental service. The notice shall identify the service, the basis for its exclusion from MA coverage and the specific circumstances, if any, under which coverage will or may be provided.
DHS 107.035(4) (4)Review of exclusion from coverage. At least once a year following a determination under sub. (3), the department shall reassess services previously designated as experimental to ascertain whether the services have advanced through the research and experimental stage to become established as proven and effective means of treatment for the particular condition or conditions for which they are designed. If the department concludes that a service should no longer be considered experimental, written notice of that determination shall be given to the affected providers. That notice shall identify the extent to which MA coverage will be recognized.
DHS 107.035 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86.
DHS 107.04 DHS 107.04Coverage of out-of-state services. All non-emergency out-of-state services require prior authorization, except where the provider has been granted border status pursuant to s. DHS 105.48.
DHS 107.04 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520.
DHS 107.05 DHS 107.05Coverage of emergency services provided by a person not a certified provider. Emergency services necessary to prevent the death or serious impairment of the health of a recipient shall be covered services even if provided by a person not a certified provider. A person who is not a certified provider shall submit documentation to the department to justify provision of emergency services, according to the procedures outlined in s. DHS 105.03. The appropriate consultant to the department shall determine whether a service was an emergency service.
DHS 107.05 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.
DHS 107.06 DHS 107.06Physician services.
DHS 107.06(1)(1)Covered services. Physician services covered by the MA program are, except as otherwise limited in this chapter, any medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a physician's office, in a hospital, in a nursing home, in a recipient's residence or elsewhere, and performed by or under the direct, on-premises supervision of a physician within the scope of the practice of medicine and surgery as defined in s. 448.01 (9), Stats. These services shall be in conformity with generally accepted good medical practice.
DHS 107.06(2) (2)Services requiring prior authorization. The following physician services require prior authorization in order to be covered under the MA program:
DHS 107.06(2)(a) (a) All covered physician services if provided out-of-state under non-emergency circumstances by a provider who does not have border status. Transportation to and from these services shall also require prior authorization, which shall be obtained by the transportation provider;
DHS 107.06(2)(b) (b) All medical, surgical, or psychiatric services aimed specifically at weight control or reduction, and procedures to reverse the result of these services;
DHS 107.06(2)(c) (c) Surgical or other medical procedures of questionable medical necessity but deemed advisable in order to correct conditions that may reasonably be assumed to significantly interfere with a recipient's personal or social adjustment or employability, an example of which is cosmetic surgery;
DHS 107.06(2)(d) (d) Prescriptions for those drugs listed in s. DHS 107.10 (2);
DHS 107.06(2)(e) (e) Ligation of internal mammary arteries, unilateral or bilateral;
DHS 107.06(2)(f) (f) Omentopexy for establishing collateral circulation in portal obstruction;
DHS 107.06(2)(g)1.1. Kidney decapsulation, unilateral and bilateral;
DHS 107.06(2)(g)2. 2. Perirenal insufflation; and
DHS 107.06(2)(g)3. 3. Nephropexy: fixation or suspension of kidney (independent procedure), unilateral;
DHS 107.06(2)(h) (h) Female circumcision;
DHS 107.06(2)(i) (i) Hysterotomy, non-obstetrical or vaginal;
DHS 107.06(2)(j) (j) Supracervical hysterectomy, that is, subtotal hysterectomy, with or without removal of tubes or ovaries or both tubes and ovaries;
DHS 107.06(2)(k) (k) Uterine suspension, with or without presacral sympathectomy;
DHS 107.06(2)(L) (L) Ligation of thyroid arteries as an independent procedure;
DHS 107.06(2)(m) (m) Hypogastric or presacral neurectomy as an independent procedure;
DHS 107.06(2)(n)1.1. Fascia lata by stripper when used as treatment for lower back pain;
DHS 107.06(2)(n)2. 2. Fascia lata by incision and area exposure, with removal of sheet, when used as treatment for lower back pain;
DHS 107.06(2)(o) (o) Ligation of femoral vein, unilateral and bilateral, when used as treatment for post-phlebitic syndrome;
DHS 107.06(2)(p) (p) Excision of carotid body tumor without excision of carotid artery, or with excision of carotid artery, when used as treatment for asthma;
DHS 107.06(2)(q) (q) Sympathectomy, thoracolumbar or lumbar, unilateral or bilateral, when used as treatment for hypertension;
DHS 107.06(2)(r) (r) Splanchnicectomy, unilateral or bilateral, when used as treatment for hypertension;
DHS 107.06(2)(s) (s) Bronchoscopy with injection of contrast medium for bronchography or with injection of radioactive substance;
DHS 107.06(2)(t) (t) Basal metabolic rate (BMR);
DHS 107.06(2)(u) (u) Protein bound iodine (PBI);
DHS 107.06(2)(v) (v) Ballistocardiogram;
DHS 107.06(2)(w) (w) Icterus index;
DHS 107.06(2)(x) (x) Phonocardiogram with interpretation and report, and with indirect carotid artery tracings or similar study;
DHS 107.06(2)(y)1.1. Angiocardiography, utilizing C02 method, supervision and interpretation only;
DHS 107.06(2)(y)2. 2. Angiocardiography, either single plane, supervision and interpretation in conjunction with cineradiography or multi-plane, supervision and interpretation in conjunction with cineradiography;
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)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;
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.