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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-34

Effective Date: 07/01/05

34 Approval Date: _____________/06 F. Reimbursement will not be provided for physician services performed in the inpatient setting for those surgical or diagnostic procedures listed on the mandatory outpatient surgery list unless the service is medically justified or meets one of the exceptions. G. For purposes of organ transplantation, all similarly situated individuals will be treated alike. Experimental or investigational procedures are not covered.

6.2.4.A ⌧ Surgical services (Section 2110(a)(4))

A. Medical surgical services - Medically necessary surgical services are covered. Elective surgery is defined as procedures not medically necessary to restore or materially improve a body function. Elective and cosmetic surgical procedures are not covered unless performed for physiological reasons and require preauthorization. B. See physician services above for organ transplantation. Breast reconstruction/prostheses following mastectomy and breast reduction may be covered if preauthorized following the medically necessary complete or partial removal of a breast for any medical reason. Breast reductions shall be covered, if prior authorized for all medically necessary indications. Such procedures shall be considered non-cosmetic. 6.2.5.A ⌧ Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

Clinic services means preventive, diagnostic, therapeutic, rehabilitative, or palliative items of services that are provided to outpatients by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients and are furnished by or under the direction of a physician or dentist.

6.2.6.A ⌧ Prescription drugs (Section 2110(a)(6)) A. Drugs for which Federal Financial Participation is not available pursuant to the requirements of §1927 of the Social Security Act shall not be covered. Legend drugs, with the exception of the drugs or classes of drugs provided for in Supplement 5 of the Medicaid State Plan are covered. Coverage of drugs used for weight loss requires prior authorization. Prescriptions for recipients for specific multiple source drugs shall be filled with generic drug products unless the physician or other practitioners so licensed and certified to prescribe drugs certifies “brand necessary”. The number of refills shall be limited pursuant to the Drug Control Act, Code of Virginia Title §54.1-3411.