Ariz. Admin. Code § 9-31-215

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-31-215 - Other Medical Professional Services

A. The following medical professional services are covered services if a member receives these services in an inpatient, outpatient, or office setting:

1. Dialysis;

2. The following family planning services if provided to delay or prevent pregnancy:

a. Medications,

b. Supplies,

c. Devices, and

d. Surgical procedures.

3. Family planning services are limited to:

a. Contraceptive counseling, medication, supplies, and associated medical and laboratory examinations, including HIV blood screening as part of a package of sexually transmitted disease tests provided with a family planning service; and

b. Natural family planning education or referral;

4. Midwifery services provided by a nurse practitioner certified in midwifery;

5. Podiatry services if ordered by a member's primary care provider as specified in A.R.S. § 36-2989;

6. Respiratory therapy;

7. Ambulatory and outpatient surgery facilities services;

8. Home health services in A.R.S. § 36-2989;

9. Private or special duty nursing services;

10. Rehabilitation services including physical therapy, occupational therapy, speech therapy, and audiology provided under this Article;

11. Total parenteral nutrition services, (which are the provision of total caloric needs by intravenous route for individuals with severe pathology of the alimentary tract);

12. Inpatient chemotherapy;

13. Outpatient chemotherapy; and

14. Hospice care under R9-22-213.

B. Prior authorization from the Administration for a member is required for services listed in subsections (A)(4) through (11) and (14); except for:

1. Dialysis shunt placement,

2. Arteriovenous graft placement for dialysis,

3. Angioplasties or thrombectomies of dialysis shunts,

4. Angioplasties or thrombectomies of arteriovenous grafts for dialysis,

5. Eye surgery for the treatment of diabetic retinopathy,

6. Eye surgery for the treatment of glaucoma,

7. Eye surgery for the treatment of macular degeneration,

8. Home health visits following an acute hospitalization (limited up to five visits),

9. Hysteroscopies, (up to two, one before and one after, when associated with a family planning diagnosis code and done within 90 days of hysteroscopic sterilization),

10. Physical therapy subject to the limitation in subsection A.A.C. R9-22-215(C),

11. Facility services related to wound debridement,

12. Apnea management and training for premature babies up to the age of 1, and

13. Other services identified by the Administration through the Provider Participation Agreement.

Ariz. Admin. Code § R9-31-215

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).