Payment will not be made for the following physicians'
services:
(1) Procedures not listed in
the Medical Assistance program fee schedule.
(2) Medical services or surgical procedures
performed on an inpatient basis that could have been performed in the
physician's office, the clinic, the emergency room, or a short procedure unit
without endangering the life or health of the patient.
(3) Medical or surgical procedures designated
in the Medical Assistance program fee schedule as outpatient procedures,
signified by the letters OP which are performed on an inpatient basis unless
the requirements specified in Chapter 1150 (relating to noncompensable
services) are met.
(4) Dental
rehabilitation and restorative services provided on an inpatient basis.
Exception-Oral restorative services are
compensable on an inpatient basis for persons requiring extensive oral
rehabilitation or restoration who are unmanageable in a doctor's office because
of a severe physical or mental condition and require general anesthesia.
Documentation of a secondary diagnosis or the specific physical or mental
condition that made the hospitalization necessary shall be included in the
record of the patient and on the invoice submitted for payment.
(5) Diagnostic tests, for which a
patient was admitted, that may be performed on an outpatient basis; tests not
related to the diagnosis and treatment of the illness for which the patient was
admitted; tests for which there is no medical justification.
(6) Methadone maintenance.
(7) Hysterectomy performed solely for the
purpose of rendering an individual incapable of reproducing or if there was
more than one purpose to the procedure, it would not have been performed but
for the purpose of rendering the individual incapable of reproducing.
(8) Acupuncture, medically unnecessary
surgery, insertion of penile prosthesis, gastroplasty for morbid obesity,
gastric stapling or ileo-jejunal shunt-except when all other types of treatment
of morbid obesity have failed-and other procedures which are experimental or
are not in accordance with customary standards of medical practice.
(9) Services and procedures that are
available through other public agencies or private insurance plans.
(10) Services to inpatients who no longer
require acute inpatient care. However, the Department will make payment to the
hospital for skilled nursing or intermediate care provided for a patient in a
certified bed in a certified and approved hospital based skilled nursing or
intermediate care unit.
(11)
Surgical procedures and medical care provided in connection with sex
reassignment. This includes but is not limited to hormone therapy, penile
construction, revision of labia, vaginoplasty, vaginal dilation, vaginal
reconstruction, penectomy, orchiectomy, mamoplasty, mastectomy, hysterectomy,
and release of vaginal adhesions.
(12) Experimental procedures as defined in §
1141.2 (relating to
definitions).
(13) Cosmetic surgery
as defined in §
1141.2.
Exception: Cosmetic surgery is a covered
service when performed in order to improve the functioning of a malformed body
member, to correct a visible disfigurement which would affect the ability of
the person to obtain or hold employment, or as postmastectomy breast
reconstruction.
(14)
Diagnostic pathological examinations of body fluids or tissues, procedure codes
80001 through 89360 and 89900 and 99901. Except for professional components for
anatomical pathology, payment for these procedures is made only to hospital and
independent laboratories that are approved to participate in the Medical
Assistance Program.
(15) Services
and procedures related to the delivery within the antepartum period and
postpartum period when performed and billed by a midwife.
(16) Medical services or surgical procedures
performed in a short procedure unit that could have been appropriately and
safely performed in the physician's office, the clinic, or the emergency room
without endangering the life or health of the patient.
