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 51303 - General Provisions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Health care services set forth in this article and in Chapter 5, Article 4
					 (commencing with Section
					 54301 of this title), which are
					 reasonable and necessary to protect life, to prevent significant illness or
					 significant disability, or to alleviate severe pain through the diagnosis or
					 treatment of disease, illness or injury are covered by the Medi-Cal program,
					 subject to utilization controls, to the extent specified in this Chapter,
					 Chapter 5, and Chapter 11. Such utilization controls shall take into account
					 those diseases, illnesses, or injuries which require preventive health services
					 or treatment to prevent serious deterioration of health. Nothing in this
					 section shall preclude payment for family planning services, or for early,
					 periodic screening, diagnosis and treatment services (EPSDT), provided under
					 the Child Health and Disability Prevention (CHDP) Program. Authorization may
					 only be granted 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.
(b) Limitations specified
					 in this article do not apply to Medicare/Medi-Cal program covered services
					 (crossover services).
(c) Except as
					 set forth in (b) above, if the Medi-Cal Program is to pay any portion of a
					 charge for services for which other coverage is available, the limitations and
					 controls specified in this article apply.
(d) Inpatient services in hospitals are
					 covered only when provided on the signed order of the physician, dentist or
					 podiatrist responsible for the care of the patient.
(e) Inpatient services in skilled nursing
					 facilities and intermediate care facilities are covered only when provided on
					 the signed order of the physician responsible for the care of the
					 patient.
(f) Outpatient services
					 are covered subject to the limitations and controls set forth in this
					 chapter.
(g) Experimental services
					 are not covered.
(h)
					 Investigational services are not covered except when it is clearly documented
					 that all of the following apply:
(1)
					 Conventional therapy will not adequately treat the intended patient's
					 condition;
(2) Conventional therapy
					 will not prevent progressive disability or premature death;
(3) The provider of the proposed service has
					 a record of safety and success with it equivalent or superior to that of other
					 providers of the investigational service;
(4) The investigational service is the lowest
					 cost item or service that meets the patient's medical needs and is less costly
					 than all conventional alternatives;
(5) The service is not being performed as a
					 part of a research study protocol;
(6) There is a reasonable expectation that
					 the investigational service will significantly prolong the intended patient's
					 life or will maintain or restore a range of physical and social function suited
					 to activities of daily living.
All investigational services require prior authorization.
						Payment will not be authorized for investigational services that do not meet
						the above criteria, or for associated inpatient care when a beneficiary needs
						to be in the hospital primarily because she/he is receiving such nonapproved
						investigational services.