Page 104

Official source

UNOFFICIAL 1737-104 (J) Jejuno-ileal by-pass procedures for morbid obesity; (K) Ear piercing; (23) In vitro fertilization procedures; (24) Medications, devices, or agents for the treatment of erectile dysfuction in males; (25) Swimming lessons, summer camp, gym membership, weight control classes, or smoking cessation classes; (26) Personal use of physical therapy equipment that is customarily used by a physical therapist in a physical therapy treatment or modality including, but not limited to, tilt tables, whirlpools, mats, play equipment, or exercise equipment; (27) Modifications to motor vehicles; and (28) Equipment to access motor vehicles or modifications to access motor vehicles.

loading…

Page 104

Official source

UNOFFICIAL 1737-104 (J) Jejuno-ileal by-pass procedures for morbid obesity; (K) Ear piercing; (23) In vitro fertilization procedures; (24) Medications, devices, or agents for the treatment of erectile dysfuction in males; (25) Swimming lessons, summer camp, gym membership, weight control classes, or smoking cessation classes; (26) Personal use of physical therapy equipment that is customarily used by a physical therapist in a physical therapy treatment or modality including, but not limited to, tilt tables, whirlpools, mats, play equipment, or exercise equipment; (27) Modifications to motor vehicles; and (28) Equipment to access motor vehicles or modifications to access motor vehicles.

(c)The UCC shall apply these exclusions in facilities and…#

(c) The UCC shall apply these exclusions in facilities and for recipients under its review. In other cases authorization of the department shall be obtained before performing any of the above procedures where exclusions are allowed.

(d)A medical service, supply, or durable medical equipment…#

(d) A medical service, supply, or durable medical equipment excluded from coverage may be approved on a case by case basis by the deparment if there is sufficient justification to support the medical necessity, as determined by its medical consultant.

(e)All other forms or types of health care services and…#

(e) All other forms or types of health care services and supplies not specifically mentioned in this chapter shall not be included in the program. Questions regarding a form or type of health care service or supply shall be directed to the medical consultant.

(f)New tests, procedures, equipment, supplies, and other…#

(f) New tests, procedures, equipment, supplies, and other services for which payment has not been claimed previously shall not be considered for inclusion until information satisfactory and acceptable to the program has been received and approval given. This particularly applies to tests and procedures not included in the HCPCS code, where several procedures are being clumped under one heading, or a single procedure is divided into several components. [Eff 08/01/94; am 03/30/96; am 11/25/96; am 02/10/97; am 07/06/99; am 06/19/00; am 10/26/01; 09/17/07 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §456.3)