Payment will be approved for all medically necessary services
and supplies provided by the physician including services rendered in the
physician's office or clinic, the home, in a hospital, nursing home or
Payment shall be made for all services rendered by a doctor
of medicine or osteopathy within the scope of this practice and the limitations
of state law subject to the following limitations and exclusions:
Payment will not be made for:
a. Drugs dispensed by a physician or other
legally qualified practitioner (dentist, podiatrist, optometrist, physician
assistant, or advanced registered nurse practitioner) unless it is established
that there is no licensed retail pharmacy in the community in which the legally
qualified practitioner's office is maintained. Rate of payment shall be
established as in subrule 78.2(2), but no professional fee shall be paid.
Payment will not be made for biological supplies and drugs provided free of
charge to practitioners by the state department of public health.
c. Treatment of certain foot conditions as
specified in 78.5(2)"a," "b," and"c."
f. Unproven or experimental medical and
surgical procedures. The criteria in effect in the Medicare program shall be
utilized in determining when a given procedure is unproven or experimental in
g. Charges for surgical
procedures on the "Outpatient/Same Day Surgery List" produced by the IME
medical services unit or associated inpatient care charges when the procedure
is performed in a hospital on an inpatient basis unless the physician has
secured approval from the hospital's utilization review department prior to the
patient's admittance to the hospital. Approval shall be granted only when
inpatient care is deemed to be medically necessary based on the condition of
the patient or when the surgical procedure is not performed as a routine,
primary, independent procedure. The "Outpatient/Same Day Surgery List" shall be
published by the department in the provider manuals for hospitals and
physicians. The "Outpatient/Same Day Surgery List" shall be developed by the
IME medical services unit and shall include procedures which can safely and
effectively be performed in a doctor's office or on an outpatient basis in a
hospital. The IME medical services unit may add, delete, or modify entries on
the "Outpatient/Same Day Surgery List."
h. Elective, non-medically necessary cesarean
section (C-section) deliveries.
Drugs and supplies may be covered when
prescribed by a legally qualified practitioner as provided in this rule.
a. Drugs are covered as provided by rule
are payable when ordered by a legally qualified practitioner for a specific
rather than incidental use, subject to the conditions specified in rule
441-78.10(249A). When a member is receiving care in a nursing facility or
residential care facility, payment will be approved only for the following
supplies when prescribed by a legally qualified practitioner:
(1) Colostomy and ileostomy
(2) Colostomy and
ileostomy care dressings, liquid adhesive and adhesive tape.
(3) Disposable irrigation trays or
catheterization trays or sets.
Indwelling Foley catheter.
Disposable saline enemas.
Diabetic supplies including needles and syringes, blood glucose test strips,
and diabetic urine test supplies.
c. Prescription records are required for all
drugs as specified in Iowa Code sections
the purposes of the medical assistance program, prescriptions for medical
supplies are required and shall be subject to the same provisions.
e. In order to be paid for the administration
of a vaccine covered under the Vaccines for Children (VFC) Program, a physician
must enroll in the VFC program. Payment for the vaccine will be approved only
if the VFC program stock has been depleted.
Payment will be approved for injections
provided they are reasonable, necessary, and related to the diagnosis and
treatment of an illness or injury. When billing for an injection, the legally
qualified practitioner must specify the brand name of the drug and the
manufacturer, the strength of the drug, the amount administered, and the charge
of each injection. When the strength and dosage of the drug is not included,
payment will be made based on the customary dosage. The following exclusions
a. Payment will not be
approved for injections when they are considered by standards of medical
practice not to be specific or effective treatment for the particular condition
for which they are administered.
Payment will not be approved for an injection when administered for a reason
other than the treatment of a particular condition, illness, or injury. When
injecting an amphetamine or legend vitamin, prior approval must be obtained as
specified in 78.1(2)"a" (3).
c. Payment will not be approved when
injection is not an indicated method of administration according to accepted
standards of medical practice.
Allergenic extract materials provided the patient for self-administration shall
not exceed a 90-day supply.
Payment will not be approved when an injection is determined to fall outside of
what is medically reasonable or necessary based on basic standards of medical
practice for the required level of care for a particular condition.
f. Payment for vaccines available through the
Vaccines for Children (VFC) Program will be approved only if the VFC program
stock has been depleted.
will not be approved for injections of "covered Part D drugs" as defined by
42 U.S.C. Section
"Part D eligible individual" as defined in
42 U.S.C. Section
including an individual who is not enrolled in a Part D plan.
For the purposes of this
program, cosmetic, reconstructive, or plastic surgery is surgery which can be
expected primarily to improve physical appearance or which is performed
primarily for psychological purposes or which restores form but which does not
correct or materially improve the bodily functions. When a surgical procedure
primarily restores bodily function, whether or not there is also a concomitant
improvement in physical appearance, the surgical procedure does not fall within
the provisions set forth in this subrule. Surgeries for the purpose of sex
reassignment are not considered as restoring bodily function and are excluded
Coverage under the program
is generally not available for cosmetic, reconstructive, or plastic surgery.
However, under certain limited circumstances payment for otherwise covered
services and supplies may be provided in connection with cosmetic,
reconstructive, or plastic surgery as follows:
(1) Correction of a congenital anomaly;
(2) Restoration of body form
following an accidental injury; or
(3) Revision of disfiguring and extensive
scars resulting from neoplastic surgery.
(4) Generally, coverage is limited to those
cosmetic, reconstructive, or plastic surgery procedures performed no later than
12 months subsequent to the related accidental injury or surgical trauma.
However, special consideration for exception will be given to cases involving
children who may require a growth period.
Cosmetic, reconstructive, or plastic
surgery performed in connection with certain conditions is specifically
excluded. These conditions are:
congenital anomalies, such as absent tooth buds, malocclusion, and similar
(2) Procedures related
to transsexualism, hermaphroditism, gender identity disorders, or body
reconstructive, or plastic surgery procedures performed primarily for
psychological reasons or as a result of the aging process.
(4) Breast augmentation mammoplasty, surgical
insertion of prosthetic testicles, penile implant procedures, and surgeries for
the purpose of sex reassignment.
c. When it is determined that a cosmetic,
reconstructive, or plastic surgery procedure does not qualify for coverage
under the program, all related services and supplies, including any
institutional costs, are also excluded.
Following is a partial list of cosmetic,
reconstructive, or plastic surgery procedures which are not covered under the
program. This list is for example purposes only and is not considered all
(1) Any procedure performed for
personal reasons, to improve the appearance of an obvious feature or part of
the body which would be considered by an average observer to be normal and
acceptable for the patient's age or ethnic or racial background.
(2) Cosmetic, reconstructive, or plastic
surgical procedures which are justified primarily on the basis of a
psychological or psychiatric need.
(3) Augmentation mammoplasties.
(4) Face lifts and other procedures related
to the aging process.
mammoplasties, unless there is medical documentation of intractable pain not
amenable to other forms of treatment as the result of increasingly large
Panniculectomy and body sculpture procedures.
(7) Repair of sagging eyelids, unless there
is demonstrated and medically documented significant impairment of
(8) Rhinoplasties, unless
there is evidence of accidental injury occurring within the past six months
which resulted in significant obstruction of breathing.
(9) Chemical peeling for facial
(10) Dermabrasion of the
(11) Revision of scars
resulting from surgery or a disease process, except disfiguring and extensive
scars resulting from neoplastic surgery.
(12) Removal of tattoos.
(13) Hair transplants.
(15) Sex reassignment.
(16) Penile implant procedures.
(17) Insertion of prosthetic
is available for otherwise covered services and supplies required in the
treatment of complications resulting from a noncovered incident or treatment,
but only when the subsequent complications represent a separate medical
condition such as systemic infection, cardiac arrest, acute drug reaction, or
similar conditions. Coverage shall not be extended for any subsequent care or
procedure related to the complication that is essentially similar to the
initial noncovered care. An example of a complication similar to the initial
period of care would be repair of facial scarring resulting from dermabrasion
legally qualified practitioner's prescription for medical equipment,
appliances, or prosthetic devices shall include the patient's diagnosis and
prognosis, the reason the item is required, and an estimate in months of the
duration of the need. Payment will be made in accordance with rule
Payment will be
approved for the examination to establish the need for orthopedic shoes in
accordance with rule 441-78.15
(7) No payment shall be made for the services
of a private duty nurse.
Payment for mileage shall be the same as that in effect in part B of
Payment will be
approved for visits to patients in nursing facilities subject to the following
a. Payment will be approved for
only one visit to the same patient in a calendar month. Payment for further
visits will be made only when the need for the visits is adequately documented
by the physician.
b. When only one
patient is seen in a single visit the allowance shall be based on a follow-up
home visit. When more than one patient is seen in a single visit, payment shall
be based on a follow-up office visit. In the absence of information on the
claim, the carrier will assume that more than one patient was seen, and payment
approved on that basis.
will be approved for mileage in connection with nursing home visits when:
(1) It is necessary for the physician to
travel outside the home community, and
(2) There are not physicians in the community
in which the nursing home is located.
d. Payment will be approved for tasks related
to a resident receiving nursing facility care which are performed by a nurse
practitioner, clinical nurse specialist, or physician assistant as specified in
441-paragraph 81.13(13)"e." On-site supervision of the
physician is not required for these services.
(10) Payment will be approved in independent
laboratory when it has been certified as eligible to participate in
(12) Payment will be made on the same basis
as in Medicare for services associated with treatment of chronic renal disease
including physician's services, hospital care, renal transplantation, and
hemodialysis, whether performed on an inpatient or outpatient basis. Payment
will be made for deductibles and coinsurance for those persons eligible for
Payment will be made
to the physician for services rendered by auxiliary personnel employed by the
physician and working under the direct personal supervision of the physician,
when such services are performed incident to the physician's professional
a. Auxiliary personnel are nurses,
psychologists, social workers, audiologists, occupational therapists and
auxiliary person is considered to be an employee of the physician if the
(1) Is able to control the manner
in which the work is performed, i.e., is able to control when, where and how
the work is done. This control need not be actually exercised by the
(2) Sets work
(3) Establishes job
(4) Withholds taxes
from the wages of the auxiliary personnel.
Direct personal supervision in the office
setting means the physician must be present in the same office suite, not
necessarily the same room, and be available to provide immediate assistance and
Direct personal supervision outside the office setting, such
as the member's home, hospital, emergency room, or nursing facility, means the
physician must be present in the same room as the auxiliary person.
Advanced registered nurse practitioners certified under board
of nursing rules in 655-Chapter 7 performing services within their scope of
practice are exempt from the direct personal supervision requirement for the
purpose of reimbursement to the employing physicians. In these exempted
circumstances, the employing physicians must still provide general supervision
and be available to provide immediate needed assistance by telephone. Advanced
registered nurse practitioners who prescribe drugs and medical devices are
subject to the guidelines in effect for physicians as specified in rule
A physician assistant licensed under board of physician
assistants' professional licensure rules in 645-Chapters 326 to 329 is exempt
from the direct personal supervision requirement except as expressly required
by Iowa Code chapter 148C or required by rules in 645-Chapters 326 to 329. A
physician shall be accessible at all times for consultation with a physician
assistant unless the physician assistant is providing emergency medical
services pursuant to 645-paragraph 327.1(2)"n." Physician
assistants who prescribe drugs and medical devices are subject to the
guidelines in effect for physicians as specified in rule 441-78.1
incident to the professional services of the physician means the service
provided by the auxiliary person must be related to the physician's
professional service to the member. If the physician has not or will not
perform a personal professional service to the member, the clinical records
must document that the physician assigned treatment of the member to the
Payment will be made for persons aged 20 and under for nutritional counseling
provided by a licensed dietitian employed by or under contract with a physician
for a nutritional problem or condition of a degree of severity that nutritional
counseling beyond that normally expected as part of the standard medical
management is warranted. For persons eligible for the WIC program, a WIC
referral is required. Medical necessity for nutritional counseling services
exceeding those available through WIC shall be documented.
(15) The certification of inpatient hospital
care shall be the same as that in effect in part A of Medicare. The hospital
admittance record is sufficient for the original certification.
No payment will be made for
sterilization of an individual under the age of 21 or who is mentally
incompetent or institutionalized. Payment will be made for sterilization
performed on an individual who is aged 21 or older at the time the informed
consent is obtained and who is mentally competent and not institutionalized
when all the conditions in this subrule are met.
The following definitions are pertinent to
(1) Sterilization means any
medical procedure, treatment, or operation performed for the purpose of
rendering an individual permanently incapable of reproducing and which is not a
necessary part of the treatment of an existing illness or medically indicated
as an accompaniment of an operation on the genital urinary tract. Mental
illness or retardation is not considered an illness or injury.
(2) Hysterectomy means a medical procedure or
operation to remove the uterus.
Mentally incompetent individual means a person who has been declared mentally
incompetent by a federal, state or local court of jurisdiction for any purpose,
unless the individual has been declared competent for purposes which include
the ability to consent to sterilization.
(4) Institutionalized individual means an
individual who is involuntarily confined or detained, under a civil or criminal
statute, in a correctional or rehabilitative facility, including a mental
hospital or other facility for the care and treatment of mental illness, or an
individual who is confined under a voluntary commitment in a mental hospital or
other facility for the care and treatment of mental illness.
The sterilization shall be
performed as the result of a voluntary request for the services made by the
person on whom the sterilization is performed. The person's consent for
sterilization shall be documented on:
470-0835 or 470-0835(S), Consent Form, or
(2) An official sterilization consent form
from another state's Medicaid program that contains all information found on
the Iowa form and complies with all applicable federal regulations.
c. The person shall be advised
prior to the receipt of consent that no benefits provided under the medical
assistance program or other programs administered by the department may be
withdrawn or withheld by reason of a decision not to be sterilized.
d. The person shall be informed that the
consent can be withheld or withdrawn any time prior to the sterilization
without prejudicing future care and without loss of other project or program
The person shall be
given a complete explanation of the sterilization. The explanation shall
(1) A description of available
alternative methods and the effect and impact of the proposed sterilization
including the fact that it must be considered to be an irreversible
(2) A thorough
description of the specific sterilization procedure to be performed and
description of the attendant discomforts and risks including the type and
possible effects of any anesthetic to be used.
(4) An offer to answer any inquiries the
person to be sterilized may have concerning the procedure to be performed. The
individual shall be provided a copy of the informed consent form in addition to
the oral presentation.
f. At least 30 days and not more than 180
days shall have elapsed following the signing of the informed consent except in
the case of premature delivery or emergency abdominal surgery which occurs not
less than 72 hours after the informed consent was signed. The informed consent
shall have been signed at least 30 days before the expected delivery date for
information in paragraphs"b" through "f"
shall be effectively presented to a blind, deaf, hard-of-hearing, or otherwise
disabled individual and an interpreter shall be provided when the individual to
be sterilized does not understand the language used on the consent form or used
by the person obtaining consent. The individual to be sterilized may have a
witness of the individual's choice present when consent is obtained.
The consent form described in paragraph
shall be attached to the claim for payment and
shall be signed by:
(1) The person to be
(2) The interpreter,
when one was necessary,
(4) The person who
provided the required information.
Informed consent shall not be obtained
while the individual to be sterilized is:
In labor or childbirth, or
Seeking to obtain or obtaining an abortion, or
(3) Under the influence of alcohol or other
substance that affects the individual's state of awareness.
Payment will be made for a
medically necessary hysterectomy only when it is performed for a purpose other
than sterilization and only when one or more of the following conditions is
(1) The individual or representative has
signed an acknowledgment that she has been informed orally and in writing from
the person authorized to perform the hysterectomy that the hysterectomy will
make the individual permanently incapable of reproducing, or
(2) The individual was already sterile before
the hysterectomy, the physician has certified in writing that the individual
was already sterile at the time of the hysterectomy and has stated the cause of
the sterility, or
hysterectomy was performed as a result of a life-threatening emergency
situation in which the physician determined that prior acknowledgment was not
possible and the physician includes a description of the nature of the
Abortions. Payment for an abortion or
related service is made when Form 470-0836 is completed for the applicable
circumstances and is attached to each claim for services. Payment for an
abortion is made under one of the following circumstances:
a. The physician certifies that the pregnant
woman's life would be endangered if the fetus were carried to term.
b. The physician certifies that the fetus is
physically deformed, mentally deficient or afflicted with a congenital illness
and the physician states the medical indication for determining the fetal
c. The pregnancy was the
result of rape reported to a law enforcement agency or public or private health
agency which may include a family physician within 45 days of the date of
occurrence of the incident. The report shall include the name, address, and
signature of the person making the report. Form 470-0836 shall be signed by the
person receiving the report of the rape.
d. The pregnancy was the result of incest
reported to a law enforcement agency or public or private health agency
including a family physician no later than 150 days after the date of
occurrence. The report shall include the name, address, and signature of the
person making the report. Form 470-0836 shall be signed by the person receiving
the report of incest.
(18) Payment and procedure for obtaining
eyeglasses, contact lenses, and visual aids, shall be the same as described in
441-78.6(249A). (Cross reference 78.28(4))
(19) Preprocedure review by the IME medical
services unit will be required if payment under Medicaid is to be made for
certain frequently performed surgical procedures which have a wide variation in
the relative frequency the procedures are performed. Preprocedure surgical
review applies to surgeries performed in hospitals (outpatient and inpatient)
and ambulatory surgical centers. Approval by the IME medical services unit will
be granted only if the procedures are determined to be medically necessary
based on the condition of the patient and the criteria established by the IME
medical services unit and the department. If not so approved by the IME medical
services unit, payment will not be made under the program to the physician or
to the facility in which the surgery is performed. The criteria are available
from the IME medical services unit.
Payment will be made only for the
following organ and tissue transplant services:
(1) Kidney, cornea, skin, and bone
(2) Allogeneic stem
cell transplants for the treatment of aplastic anemia, severe combined
immunodeficiency disease (SCID), Wiskott-Aldrich syndrome, follicular lymphoma,
Fanconi anemia, paroxysmal nocturnal hemoglobinuria, pure red cell aplasia,
amegakaryocytosis/congenital thrombocytopenia, beta thalassemia major, sickle
cell disease, Hurler's syndrome (mucopolysaccharidosis type 1 [MPS-1]),
adrenoleukodystrophy, metachromatic leukodystrophy, refractory anemia,
agnogenic myeloid metaplasia (myelofibrosis), familial erythrophagocytic
lymphohistiocytosis and other histiocytic disorders, acute myelofibrosis,
Diamond-Blackfan anemia, epidermolysis bullosa, or the following types of
leukemia: acute myelocytic leukemia, chronic myelogenous leukemia, juvenile
myelomonocytic leukemia, chronic myelomonocytic leukemia, acute myelogenous
leukemia, and acute lymphocytic leukemia.
(3) Autologous stem cell transplants for
treatment of the following conditions: acute leukemia; chronic lymphocytic
leukemia; plasma cell leukemia; non-Hodgkin's lymphomas; Hodgkin's lymphoma;
relapsed Hodgkin's lymphoma; lymphomas presenting poor prognostic features;
follicular lymphoma; neuroblastoma; medulloblastoma; advanced Hodgkin's
disease; primitive neuroendocrine tumor (PNET); atypical/rhabdoid tumor (ATRT);
Wilms' tumor; Ewing's sarcoma; metastatic germ cell tumor; or multiple
Liver transplants for
persons with extrahepatic biliary atresia or any other form of end-stage liver
disease, except that coverage is not provided for persons with a malignancy
extending beyond the margins of the liver.
Liver transplants require preprocedure review by the IME
medical services unit. (Cross references 78.1(19) and
Covered liver transplants are payable only when performed in
a facility that meets the requirements of 78.3(10).
Heart transplants for persons with
inoperable congenital heart defects, heart failure, or related conditions.
Artificial hearts and ventricular assist devices as a temporary life-support
system until a human heart becomes available for transplants are covered.
Artificial hearts and ventricular assist devices as a permanent replacement for
a human heart are not covered. Heart-lung transplants are covered where
bilateral or unilateral lung transplantation with repair of a congenital
cardiac defect is contraindicated.
Heart transplants, heart-lung transplants, artificial hearts,
and ventricular assist devices described above require preprocedure review by
the IME medical services unit. (Cross references 78.1(19) and
78.28(1)"f") Covered heart transplants are payable only when
performed in a facility that meets the requirements of 78.3(10).
(6) Lung transplants. Lung
transplants for persons having end-stage pulmonary disease. Lung transplants
require preprocedure review by the IME medical services unit. (Cross references
78.1(19) and 78.28(1)"f") Covered transplants are payable only
when performed in a facility that meets the requirements of 78.3(10).
Heart-lung transplants are covered consistent with criteria in subparagraph (5)
Pancreas transplants for
persons with type I diabetes mellitus, as follows:
1. Simultaneous pancreas-kidney transplants
and pancreas after kidney transplants are covered.
Pancreas transplants alone are covered for
persons exhibiting any of the following:
* A history of frequent, acute, and severe metabolic
complications (e.g., hypoglycemia, hyperglycemia, or ketoacidosis) requiring
* Clinical problems with exogenous insulin therapy that are
so severe as to be incapacitating.
* Consistent failure of insulin-based management to prevent
The pancreas transplants listed under this subparagraph
require preprocedure review by the IME medical services unit. (Cross references
78.1(19) and 78.28(1)"f")
Covered transplants are payable only when performed in a
facility that meets the requirements of 78.3(10).
Transplantation of islet cells or partial pancreatic tissue
is not covered.
b. Donor expenses incurred directly in
connection with a covered transplant are payable. Expenses incurred for
complications that arise with respect to the donor are covered only if they are
directly and immediately attributed to surgery. Expenses of searching for a
donor are not covered.
transplants must be medically necessary and meet other general requirements of
this chapter for physician and hospital services.
d. Payment will not be made for any
transplant not specifically listed in paragraph"a."
Utilization review shall be conducted of Medicaid members who access more than
24 outpatient visits in any 12-month period from physicians, advanced
registered nurse practitioners, federally qualified health centers, other
clinics, and emergency rooms. For the purposes of utilization review, the term
"physician" does not include a psychiatrist. Refer to rule
(249A) for further
information concerning the member lock-in program.
Risk assessment. Risk assessment, using
Form 470-2942, Medicaid Prenatal Risk Assessment, shall be completed at the
initial visit during a Medicaid member's pregnancy.
a. If the risk assessment reflects a low-risk
pregnancy, the assessment shall be completed again at approximately the
twenty-eighth week of pregnancy.
If the risk assessment reflects a high-risk pregnancy, referral shall be made
for enhanced services. Enhanced services include health education, social
services, nutrition education, and a postpartum home visit. Additional
reimbursement shall be provided for obstetrical services related to a high-risk
pregnancy. (See description of enhanced services at subrule
varnish. Payment shall be made for application of an FDA-approved topical
fluoride varnish, as defined by the current version of the Code on Dental
Procedures and Nomenclature (CDT) published by the American Dental Association,
for the purpose of preventing the worsening of early childhood caries in
children aged 0 to 36 months of age, when rendered by physicians or other
appropriately licensed practitioners under the supervision of or in
collaboration with a physician and who are acting within the scope of their
practice, licensure, and other applicable state law, subject to the following
provisions and limitations:
a. Application of
topical fluoride varnish must be provided in conjunction with an early and
periodic screening, diagnosis, and treatment (EPSDT) examination which includes
a limited oral screening.
Separate payment shall be available only for application of topical fluoride
varnish, which shall be at the same rate of reimbursement paid to dentists for
providing this service. Separate payment for the limited oral screening shall
not be available, as this service is already part of and paid under the EPSDT
legal guardians, or other authorized caregivers of children receiving
application of topical fluoride varnish as part of an EPSDT screening
examination shall be informed by the physician or auxiliary staff employed by
and under the physician's supervision that this application is not a substitute
for comprehensive dental care.
Physicians rendering the services under this subrule shall make every
reasonable effort to refer or facilitate referral of these children for
comprehensive dental care rendered by a dental professional.
Prior authorization for
medication-assisted treatment shall be governed pursuant to subrule 78.28(2).
This rule is intended to implement Iowa Code section