471 Neb. Admin. Code, ch. 10, § 005

Current through September 17, 2024

Section 471-10-005 - NON-COVERED SERVICES

The following services are not intended to be an all-inclusive, or exhaustive, list of non-covered services.

005.01SURGICAL PROCEDURES. The Department does not cover:

(A) Acupuncture;

(B) Angiocardiography, single plane, supervision and interpretation in conjunction with cineradiography or multi-plane, supervision and interpretation in conjunction with cineradiography;

(C) Angiocardiography, utilizing CO₂ method, supervision and interpretation only;

(D) Angiography, coronary, unilateral selective injection supervision and interpretation only, single view unless emergency;

(E) Angiography, extremity, unilateral, supervision and interpretation only, single view unless emergency;

(F) Artificial Heart Transplant;

(G) Ballistocardiogram;

(H) Basal metabolic rate (BMR);

(I) Bronchoscopy, with injection of contrast medium for bronchography or with injection of radioactive substance;

(J) Circumcision, female;

(K) Excision of carotid body tumor, with or without excision of carotid artery, when used as a treatment for asthma;

(L) Extra-intra cranial arterial bypass for stroke;

(M) Fabric wrapping of abdominal aneurysm;

(N) Fascia lata by incision and area exposure, with removal of sheet, when used as treatment for lower back pain;

(O) Fascia lata by stripper when used as a treatment for lower back pain;

(P) Hypogastric or presacral neurectomy (independent procedure);

(Q) Hysterotomy, non-obstetrical, vaginal;

(R) Icterus index;

(S) Ileal bypass or any other intestinal surgery for the treatment of obesity;

(T) Kidney decapsulation, unilateral and bilateral;

(U) Ligation of femoral vein, unilateral and bilateral, when used as treatment for post-phlebotic syndrome;

(V) Ligation of internal mammary arteries, unilateral or bilateral;

(W) Ligation of thyroid arteries (independent procedure);

(X) Nephropexy: fixation or suspension of kidney (independent procedure), unilateral;

(Y) Omentopexy for establishing collateral circulation in portal obstruction;

(Z) Perirenal insufflation;

(AA) Phonocardiogram with interpretation and report, and with indirect carotid artery tracings or similar study;

(BB) Protein bound iodine (PBI);

(CC) Radical hemorrhoidectomy, whitehead type, including removal of entire pile bearing area;

(DD) Refractive keratoplasty including keratomileusis, keratophakia, and radial keratotomy;

(EE) Reversal of tubal ligation or vasectomy;

(FF) Sex change procedures;

(GG) Splanchicectomy, unilateral or bilateral, when used as a treatment for hypertension;

(HH) Supracervical hysterectomy: subtotal hysterectomy, with or without tubes or ovaries, one or both;

(II) Sympathectomy, thoracolumbar or lumbar, unilateral or bilateral, when used as a treatment for hypertension; and

(JJ) Uterine suspension, with or without presacral sympathectomy.

005.02OBSOLETE TESTS. Obsolete tests may be covered only if the physician who performs the test justifies the medical necessity for the test. The Department will determine that satisfactory medical necessity exists from the physician's justification. The Department does not routinely cover the following diagnostic tests because they are obsolete and have been replaced by more advanced procedures:

(A) Amylase, blood isoenzymes, electrophoretic;

(B) Chromium, blood;

(C) Guanase, blood;

(D) Zinc sulphate turbidity, blood;

(E) Skin test, cat scratch fever;

(F) Skin test, lymphopathia venereum;

(G) Circulation time, one test;

(H) Cephalin flocculation;

(I) Congo red, blood;

(J) Hormones, adrenocorticotropin quantitative animal tests;

(K) Hormones, adrenocorticotropin quantitative bioassay;

(L) Thymol turbidity, blood;

(M) Skin test, actinomycosis;

(N) Skin test, brucellosis;

(O) Skin test, leptospirosis;

(P) Skin test, psittacosis;

(Q) Skin test, trichinosis;

(R) Calcium, feces, 24-hour quantitative;

(S) Starch; feces, screening;

(T) Chymotrypsin, duodenal contents;

(U) Gastric analysis pepsin;

(V) Gastric analysis, tubeless;

(W) Calcium saturation clotting time;

(X) Capillary fragility test (Rumpel-Leede);

(Y) Colloidal gold;

(Z) Bendien's test for cancer and tuberculosis;

(AA) Bolen's test for cancer; and

(BB) Rehfuss test for gastric acidity.

005.03SERVICES REQUIRED TO TREAT COMPLICATIONS OR CONDITIONS RESULTING FROM NON-COVERED SERVICES. The Department may consider payment for medically necessary services that are required to treat complications or conditions resulting from non-covered services.

005.04EXPERIMENTAL AND INVESTIGATIONAL SERVICES. The Department does not cover medical services which are considered investigational or experimental or which are not generally employed by the medical profession. While the circumstances leading to participation in an experimental or investigational program may meet the definition of medical necessity, the Department prohibits payment for these services.

005.04(A)RELATED SERVICES. The Department does not pay for associated or adjunctive services that are directly related to non-covered experimental/investigational services.

005.04(B)COVERAGE REQUESTS FOR NEW SERVICES. Requests for Nebraska Medicaid coverage for new services or those which may be considered experimental or investigational must be submitted to the Department before providing the services, or in the case of true medical emergencies, before submitting a claim. The request for coverage must include sufficient information to document that the new service is not considered investigational or experimental for Nebraska Medicaid payment purposes. Reliable evidence must be submitted identifying the status with regard to the criteria below, cost-benefit data, short and long term outcome data, patient selection criteria that is both disease/condition specific and age specific, information outlining under what circumstances the service is considered the accepted standard of care, and any other information that would be helpful to the Department in deciding coverage issues. Additional information may be requested by the Department.

005.04(C)INVESTIGATIONAL OR EXPERIMENTAL CRITERIA. Services are deemed investigational or experimental by the Medical Director, who may convene ad hoc advisory groups of experts to review requests for coverage. A service is deemed investigational or experimental if it meets any one of the following criteria:

(i) There is no Food and Drug Administration (FDA) or other governmental or regulatory approval given, when appropriate, for general marketing to the public for the proposed use;

(ii) Reliable evidence does not permit a conclusion based on consensus that the service is a generally accepted standard of care employed by the medical profession as a safe and effective service for treating or diagnosing the condition or illness for which its use is proposed. Reliable evidence includes peer reviewed literature with statistically significant data regarding the service for the specific disease, proposed use, and age group. Also, facility specific data, including short and long term outcomes, must be submitted to the Department;

(iii) The service is available only through an Institutional Review Board (IRB) research protocol for the proposed use or subject to such an Institutional Review Board (IRB) process; or

(iv) The service is the subject of an ongoing clinical trial(s) that meets the definition of a Phase I, Phase II, or Phase III Clinical Trial, regardless of whether the trial is actually subject to Food and Drug Administration oversight and regardless of whether an Institutional Review Board (IRB) process or protocol is required at any one particular institution.

005.05CUSTODIAL OR RESPITE CARE. The Department does not cover hospital services that are custodial or respite care.

005.06PRIVATE DUTY NURSING. The services of a private-duty nurse or other private-duty attendant are not covered as a hospital service.

005.07PROSTHETICS. The Department does not cover external powered prosthetic devices.

005.08FACILITY BASED PHYSICIAN CLINICS. Physician clinic services provided in a hospital, or a facility under the hospital's licensure, are considered to be a physician's service and are reimbursed accordingly.

005.09TOBACCO CESSATION SERVICES. Tobacco cessation services are not covered as a hospital service.

005.10HOSPITAL ACQUIRED CONDITIONS. The Department will not make payment for conditions which are a result of avoidable inpatient hospital complications and medical errors that are identifiable, preventable, and serious in their consequences to patients. This means that the Department will, at a minimum, identify as a hospital acquired conditions (HAC), those diagnoses codes that have been identified as Medicare hospital acquired conditions (HAC) when not present on hospital admission.

005.11HEALTH CARE-ACQUIRED CONDITIONS. A health care-acquired condition (HCAC) means a condition occurring in any inpatient hospital setting, identified as a hospital- acquired condition (HAC) by Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients. The Department will not make payment for conditions which are a result of avoidable inpatient hospital complications and medical errors that are identifiable, preventable, and serious in their consequences to patients.

005.12NON-COVERED PORTABLE X-RAY SERVICES. The Department does not cover the following portable x-ray services:

(A) Procedures involving fluoroscopy;

(B) Procedures involving the use of contrast media;

(C) Procedures requiring the administration of a substance to the patient or injection of a substance into the patient or special manipulation of the patient;

(D) Procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor of osteopathy or which require that medical judgment be exercised;

(E) Procedures requiring special technical competency or special equipment or materials;

(F) Routine screening procedures; and

(G) Procedures which are not of a diagnostic nature.

471 Neb. Admin. Code, ch. 10, § 005

Amended effective 11/9/2020

Amended effective 6/6/2022