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;
CR 20-039: am. (12)
Register October 2021 No. 790, eff. 11-1-21;
CR 22-043: am. (1)
Register May 2023 No. 809, eff. 6-1-23.
DHS 107.035
DHS 107.035 Definition 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 107.04 Coverage 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 107.05 Coverage 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(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 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)(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)3.
3. Nephropexy: fixation or suspension of kidney (independent procedure), unilateral;
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)(m)
(m) Hypogastric or presacral neurectomy as an independent procedure;
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)(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)(zL)
(zL) Any other procedure not identified in the physicians' “current procedural terminology", fourth edition, published by the American medical association;
DHS 107.06 Note
Note: 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 Note
Note: 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;
DHS 107.06(3)(a)1.
1. The individual is at least 21 years old at the time consent is obtained;
DHS 107.06(3)(a)2.
2. The individual has not been declared mentally incompetent by a federal, state or local court of competent jurisdiction to consent to sterilization;
DHS 107.06(3)(a)3.
3. The individual has voluntarily given informed consent in accordance with all the requirements prescribed in subd.
4. and par.
(d); and
DHS 107.06(3)(a)4.
4. At least 30 days, but not more than 180 days, have passed between the date of informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery. An individual may be sterilized at the time of a premature delivery or emergency abdominal surgery if at least 72 hours have passed since he or she gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery.
DHS 107.06(3)(b)2.2. A hysterectomy may be a covered service if it is performed on an individual:
DHS 107.06(3)(b)2.a.
a. Already sterile prior to the hysterectomy and whose physician has provided written documentation, including a statement of the reason for sterility, with the claim form; or
