N.Y. Comp. Codes R. & Regs. tit. 10 § 85.2

Current through Register Vol. 46, No. 50, December 11, 2024

Section 85.2 - Standards for surgical intervention

(a) To be covered benefit under medical assistance for the needy as provided in section 365-a (a)(5)(b) of the Social Services Law, specified surgical procedures shall meet the standards for intervention established in this section. The specified procedures are:

(1) cataract surgery to restore vision.

(2) eye muscle surgery to correct strabismus and to prevent functional loss when binocular vision still exists.

(3) myringotomy, with or without tube insertion to preserve hearing.

(4) tubal ligation or vasectomy to interdict conception.

(5) termination of pregnancy.

(b) The patient's surgeon shall ensure that the aplicable standards for any of the specific procedures specified in subdivision (a) of this section are met and documented within the hospital medical record of the patient. Such medical record shall be accessible to the commissioner, or his designee, for review.

(c) The first three days of inpatient care, services and supplies for persons admitted to inpatient hospital care under this section shall be deemed a covered benefit under medical assistance for the needy. To be a covered benefit after the third day of inpatient care, there shall be a determination of benefit coverability prior to the end of the third day by a person designated by the Commissioner of Health. Such initial determination shall be for a specified period of time not to exceed the 50th percentile of length of stay norms for comparable patients which have been authorized by the Commissioner of Health or the 20th day of stay, whichever is less. If the stay is for rehabilitation of physical disability as described in section 85.5(a) of this Part, such specified period of time shall not exceed the 40th day of stay. Determination of coverability shall be based upon the performance of one or more of the procedures which meet the standards for surgical intervention listed in subdivision (a) of this section and the need for treatment on an inpatient hospital basis as documented in the patient's medical record. Subsequent to this initial determination of coverability, extensions of benefit coverability shall be subject to length of stay limitations of sections 85.5 and 85.7 of this Part.

(d) A determination of benefit coverability under this section shall be made by a designated physician or non-physician under a designated physician's supervision. A determination of non-coverability shall be made only by a designated physician. If such non-coverability determination is made, any care, supplies or services provided beyond three days shall not be a covered benefit under medical assistance for the needy.

(e) Notice of determination shall be given to the patient's surgeon, the hospital administrator and, if there is a determination of non-coverability, to the patient. The hospital shall keep any such notification on file, accessible for review by representatives of the State or the local social services district. The patient's surgeon or hospital administrator may within three days of the date of such notification, appeal a determination of non-coverability in writing to the physician or physicians designated by the commissioner for such purpose. Notification of decision on appeal shall be given to the patient's surgeon, the hospital administrator and the patient. If the determination of non-coverability is affirmed on appeal, any inpatient care, supplies or services provided beyond three days shall not be a covered benefit.

(f) If the person designated by the Commissioner of Health decides in the course of making determinations of coverability under this section or it is determined from other sources that a physician, physicians or the hospital are admitting patients under this section for the performance of procedures which do not meet the standards established in this section, the designated person shall give written notification to the physician(s) and the hospital that if such admissions continue, the initial three day period of stay will no longer be deemed a covered benefit. If patients are thereafter admitted for medical conditions which do not meet the standards established in this section to be a covered benefit, the designated person shall notify the physician(s) and the hospital that the first three days of inpatient stay will be subject to a determination of coverability. Such determination of coverability shall be made prior to the end of the third day of inpatient hospital stay in accordance with the procedures in subdivisions (a) through (e) of this section. If there is a determination of non-coverability, any inpatient hospital care, supplies or services provided shall not be a covered benefit under medical assistance for the needy.

N.Y. Comp. Codes R. & Regs. Tit. 10 § 85.2