Utah Admin. Code R414-10-5 - Service Coverage and Limitations

(1) This section contains general information on coverage and limitations for physician services.

(a) Physician services may be provided only within the parameters of accepted medical practice and are subject to limitations and exclusions established by the Department on the basis of medical necessity, appropriateness, and utilization control considerations.

(b) Medicaid covers cosmetic or reconstructive procedures pursuant to Section R414-1-29.

(c) Medicaid covers experimental or medically unproven physician services pursuant to Rule R414-1A.

(d) Program limitations and non-covered services are maintained in the Coverage and Reimbursement Code Lookup and updated by notification through the Medicaid Information Bulletin. Medicaid does not cover the following types of services:

(i) services rendered during a period in which an individual is ineligible for Medicaid;

(ii) medically unnecessary or unreasonable services;

(iii) services that fail to meet existing standards of professional practice;

(iv) services rendered without required prior authorization;

(v) services, elective in nature, based on patient request or individual preference rather than medical necessity;

(vi) services claimed fraudulently;

(vii) services that represent abuse or overuse;

(viii) services rejected or disallowed by Medicare when the rejection is based on any of the reasons listed in this section;

(ix) services for which third party payers are primarily responsible for coverage, such as Medicare, private health insurance, and liability insurance pursuant to Rule R527-936. Medicaid may make a partial payment up to the Medicaid maximum if a third party does not reach the payment limit;

(x) related services, supplies, or institutional costs during a post-operative recovery period, if the service or procedure is not covered for any of the reasons specified in this section, or due to policy exclusion; and

(xi) paternity tests.

(e) Medicaid covers treatment for alcoholism or drug dependency in an inpatient setting pursuant to Subsection R414-2A-7(1).

(2) Medicaid does not cover the following family planning services:

(a) surgical procedures for the reversal of previous elective sterilization on both males and females;

(b) infertility studies;

(c) in-vitro fertilization;

(d) artificial insemination; and

(e) surrogate motherhood, including services, tests, and related charges.

(3) Medicaid may only cover anesthesia services performed by a licensed, qualified provider.

(4) Medicaid does not cover anesthesia standby services.

(5) Medicaid covers the following surgical global services and procedures:

(a) preoperative examination, initiation of the hospital record, and development of a treatment program either in the physician's office on the day before admission, in the hospital, or in the physician's office on the same day as hospital admission;

(b) the operation;

(c) any topical, local, or regional anesthesia; and

(d) the normal, uncomplicated follow-up care covering the period of hospitalization and office follow-up for progress checks or any service directly related to the surgical procedure.

(6) The following criteria apply to global services.

(a) A physician may not bill for an office visit the day before surgery, for preadmission or admission workup, or for subsequent hospital care while the patient is being prepared, hospitalized, or under care for a global surgical service.

(b) Only the consulting physician may bill for consultation services when consultation and no other service is provided. When a consulting physician admits and follows a patient, independently or concurrently with the primary physician, the consulting physician may only use admission codes and subsequent care codes.

(c) Office visits after hospitalization that relate to the same diagnosis are part of the global service. The only exception to either inpatient or office service is for service related to complications, exacerbations, or recurrence of other diseases or problems requiring additional or separate service.

(d) Complications, exacerbations, recurrence, or the presence of other diseases or injuries, which require services concurrent with the initial surgical procedure during the listed period of normal follow-up care, may warrant additional charges only when the record shows extensive documentation and justification of additional services.

(e) When an additional surgical procedure is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods continue concurrently to their normal terminations.

(f) Preoperative examination and planning are covered as separate services only under the following circumstances.

(i) When the preoperative visit is the initial visit for the physician and prolonged detention or evaluation is required to establish a diagnosis to determine the need for a specific surgical procedure, or to prepare the patient.

(ii) When the preoperative visit is a consultation and the consulting physician does not assume care of the patient.

(iii) When diagnostic procedures are not part of the basic surgical procedure.

(7) Medicaid does not cover early elective delivery, whether vaginal or caesarean, before 39 weeks.

(8) The following references apply to abortion, sterilization, and hysterectomy.

(a) For information on abortion policy, see Rule R414-1B.

(b) Sterilization and hysterectomy procedures must meet the requirements of 42 CFR 441 Subpart F.

(9) Organ transplant services must meet the requirements of Rule R414-10A.

(10) Medicaid may cover the following psychiatric services as a medical benefit:

(a) physician-ordered psychiatric services for a patient hospitalized in a non-psychiatric unit of a hospital;

(b) mental health services that target the diagnosis or treatment of developmental disability or organic disorder; and

(c) psychosocial evaluations requested before organ transplantations, psychiatric evaluations before other medical services or surgical procedures, and evaluations for individuals with conditions that require chronic pain management services.

(11) Medicaid covers the following pain management services:

(a) pain management for delivery and acute post-operative pain; and

(b) treatment for chronic pain.

(12) Medicaid may cover prescription medications subject to the requirements of Rule R414-60.

Notes

Utah Admin. Code R414-10-5

Amended by Utah State Bulletin Number 2017-14, effective 7/1/2017 Amended by Utah State Bulletin Number 2021-23, effective 11/15/2021 Amended by Utah State Bulletin Number 2022-06, effective 3/1/2022