Alert! This chapter may be affected by an emergency rule:
h. Examination of extremities.
(c) Laboratory and other diagnostic services. Laboratory and other diagnostic services are covered services as indicated in this paragraph. These services may be performed in conjunction with an initial examination with health history, and are the following:
1. Routinely performed procedures:
a. CBC, or hematocrit or hemoglobin;
b. Urinalysis;
c. Papanicolaou smear for females between the ages of 12 and 65;
d. Bacterial smear or culture (gonorrhea, trichomonas, yeast, etc.) including VDRL — syphilis serology with positive gonorrhea cultures; and
2. Procedures covered if indicated by the recipient’s health history:
a. Skin test for TB;
b. Vaginal smears and wet mounts for suspected vaginal infection;
c. Pregnancy test;
d. Rubella titer;
e. Sickle-cell screening;
f. Post-prandial blood glucose; and
g. Blood test for cholesterol, and triglycerides when related to oral contraceptive prescription;
3. Diagnostic and other procedures not for the purpose of enhancing the prospects of fertility in males or females;
a. Endometrial biopsy when performed after a hormone blood test;
b. Laparoscopy;
c. Cervical mucus exam;
d. Vasectomies;
e. Culdoscopy; and
f. Colposcopy;
4. Procedures relating to genetics, including:
a. Ultrasound;
b. Amniocentesis;
c. Tay-Sachs screening;
d. Hemophilia screening;
e. Muscular dystrophy screening; and
f. Sickle-cell screening; and
5. Colposcopy, culdoscopy, and laparoscopy procedures which may be either diagnostic or treatment procedures.
(d) Counseling services. Counseling services in the clinic are covered as indicated in this paragraph. These services may be performed or supervised by a physician, registered nurse or licensed practical nurse. Counseling services may be provided as a result of request by a recipient or when indicated by exam procedures and health history. These services are limited to the following areas of concern:
1. Instruction on reproductive anatomy and physiology;
2. Overview of available methods of contraception, including natural family planning. An explanation of the medical ramifications and effectiveness of each shall be provided;
3. Counseling about venereal disease;
4. Counseling about sterilization accompanied by a full explanation of sterilization procedures including associated discomfort and risks, benefits, and irreversibility;
5. Genetic counseling accompanied by a full explanation of procedures utilized in genetic assessment, including information regarding the medical ramifications for unborn children and planning of care for unborn children with either diagnosed or possible genetic abnormalities;
6. Information regarding teratologic evaluations; and
7. Information and education regarding pregnancies at the request of the recipient, including pre-natal counseling and referral.
(e) Contraceptive methods. Procedures related to the prescription of a contraceptive method are covered services. The contraceptive method selected shall be the choice of the recipient, based on full information, except when in conflict with sound medical practice. The following procedures are covered:
1. Those related to intrauterine devices (IUD):
a. Furnishing and fitting of the device;
b. Localization procedures limited to sonography, and up to 2 x-rays with interpretation;
c. A follow-up office visit once within the first 90 days of insertion; and
d. Extraction;
2. Those related to diaphragms:
a. Furnishing and fitting of the device; and
b. A follow-up office visit once within 90 days after furnishing and fitting;
3. Those related to contraceptive pills:
a. Furnishing and instructions for taking the pills; and
b. A follow-up office visit once during the first 90 days after the initial prescription to assess physiological changes. This visit shall include taking blood pressure and weight, interim history and laboratory examinations as necessary.
(f) Office visits. Follow-up office visits performed by either a nurse or a physician and an annual physical exam and health history are covered services.
(g) Supplies. The following supplies are covered when prescribed:
1. Oral contraceptives;
2. Diaphragms;
3. Jellies, creams, foam and suppositories;
4. Condoms; and
5. Natural family planning supplies such as charts.
(2)Services requiring prior authorization. All sterilization procedures require prior authorization by the medical consultant to the department, as well as the informed consent of the recipient. Informed consent requests shall be in accordance with s. DHS 107.06 (3).
Note: For more information on prior authorization, see DHS 107.02 (3).
(3)Non-covered services. The following services are not covered services:
(a) The sterilization of a recipient under the age of 21 or of a recipient declared legally incapable of consenting to such a procedure;
(b) Services and items that are provided for the purpose of enhancing the prospects of fertility in males or females, including but not limited to:
1. Artificial insemination, including but not limited to intra-cervical or intra-uterine insemination;
2. Infertility counseling;
3. Infertility testing, including but not limited to tubal patency, semen analysis or sperm evaluation;
4. Reversal of female sterilizations, including but not limited to tubouterine implantation, tubotubal anastomoses or fimbrioplasty;
5. Fertility-enhancing drugs provided for the treatment of infertility;
6. Reversal of vasectomies;
7. Office visits, consultations and other encounters to enhance fertility; and
8. Other fertility-enhancing services and items;
(c) Impotence devices and services, including but not limited to penile prostheses and external devices and to insertion surgery and other related services;
(d) Testicular prosthesis; and
(e) Services that are not covered under ss. DHS 107.03 and 107.06 (5).
Note: For more information on non-covered services, see s. DHS 107.03.
History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; r. and recr. (1) (c) 3., (3), r. (1) (d) 4., renum. (1) (d) 5. to 8. to be (1) (d) 4. to 7; Register, January, 1997, No. 493, eff. 2-1-97.
DHS 107.22Early and periodic screening, diagnosis and treatment (EPSDT) services.
(1)Covered services. Early and periodic screening and diagnosis to ascertain physical and mental defects, and the provision of treatment as provided in sub. (4) to correct or ameliorate the defects shall be covered services for all recipients under 21 years of age when provided by an EPSDT clinic, a physician, a private clinic, an HMO or a hospital certified under s. DHS 105.37.
(2)EPSDT health assessment and evaluation package. The EPSDT health assessment and evaluation package shall include at least those procedures and tests required by 42 CFR 441.56. The package shall include the following:
(a) A comprehensive health and developmental history;
(b) A comprehensive unclothed physical examination;
(c) A vision test appropriate for the person being assessed;
(d) A hearing test appropriate for the person being assessed;
(e) Dental assessment and evaluation services furnished by direct referral to a dentist for children beginning at 3 years of age;
(f) Appropriate immunizations; and
(g) Appropriate laboratory tests.
(3)Supplemental tests. Selection of additional tests to supplement the health assessment and evaluation package shall be based on the health needs of the target population. Consideration shall be given to the prevalence of specific diseases and conditions, the specific racial and ethnic characteristics of the population, and the existence of treatment programs for each condition for which assessment and evaluation is provided.
(4)Other needed services. In addition to diagnostic and treatment services covered by Wisconsin MA under applicable provisions of this chapter, any services described in the definition of “medical assistance” under federal law, 42 USC 1396d(a), when provided to EPSDT patients, are covered if the EPSDT health assessment and evaluation indicates that they are needed. Prior authorization under s. DHS 107.02 (3) is required for coverage of services under this subsection.
(5)Reasonable standards of practice. Services under this section shall be provided in accordance with reasonable standards of medical and dental practice determined by the department after consultation with the medical society of Wisconsin and the Wisconsin dental association.
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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.