California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51305 - Physician Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Outpatient physician services are covered if they are medically necessary to
					 protect life, to prevent significant illness or significant disability, or to
					 alleviate severe pain, subject to the limitations specified below.
(b) Outpatient surgical procedures, other
					 than those needed for diagnostic purposes or those rendered as emergency
					 services pursuant to Section
					 51056; procedures considered to be
					 elective; and specified outpatient medical procedures, including but not
					 limited to, Hyperbaric Oxygen Therapy, Pheresis, Psoriasis Day Care and Cardiac
					 Catheterization, require prior authorization. Authorization may be granted only
					 when fully documented medical justification is provided that the services are
					 medically necessary. Services not requiring prior authorization are subject to
					 other utilization controls, as specified in this chapter. Utilization controls
					 shall be imposed on medical/surgical procedures in accordance with the
					 standards set forth in Section
					 51159. Identification of those
					 procedures requiring prior authorization shall be transmitted to all affected
					 providers of service in bulletins authorized by the Department.
(c) Surgical procedures typically performed
					 on an inpatient basis which can be performed safely on an outpatient or
					 ambulatory basis will not be reimbursed in an inpatient setting. Exceptions may
					 be authorized by a field office medical consultant if there is adequate
					 documentation of the medical need for inpatient care. In selecting procedures
					 which should normally be performed in an outpatient setting, the Department
					 shall consider patient safety, quality of medical care, common practice in the
					 medical community, and cost of the procedure. Lists of surgical procedures
					 identified by the Department for performance on an outpatient or ambulatory
					 basis will be transmitted to all interested providers of service in bulletins
					 authorized by the Department.
(d) A
					 maximum of eight injections for allergy desensitization, hyposensitization, or
					 immunotherapy by injection of an antigen to stimulate production of protective
					 antibodies may be provided in any 120-day period without prior authorization.
					 Prior authorization shall be required when more than eight of the above allergy
					 injections are provided in a 120-day period except those provided on an
					 emergency basis.
(1) Services rendered on an
					 emergency basis are exempt from authorization. The emergency services shall
					 meet the definition in Section
					 51056 and the provider shall
					 comply with the requirements of that section.
(2) A total treatment plan shall be developed
					 for allergy services which require prior authorization. The treatment plan may
					 be authorized for a period up to 120 days and shall include the following:
(A) The principal diagnosis and significant
					 associated diagnosis.
(B) Clinical
					 information adequate to describe the physiological and functional limitations,
					 including the date of onset of the illness(es).
(C) Prognosis.
(D) Specific services to be
					 rendered.
(E) The therapeutic goals
					 to be achieved and the anticipated time needed to attain those goals.
(F) Drug
					 regimen.