reglab/statecodes huggingface dataset:
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-7 - Copayment for legend and nonlegend drugs

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15-6
Sec. 7.
(a) Under IC
				12-15-6, a copayment is required for legend and nonlegend drugs in accordance
				with the following:
(1) The copayment shall be
				paid by the member and collected by the provider at the time the service is
				rendered. Medicaid reimbursement to the provider shall be adjusted to reflect
				the copayment amount for which the member is liable.
(2) In accordance with
				42 CFR
				447.15, the provider may not deny services to
				any eligible individual on account of the individual's inability to pay the
				copayment amount. Under 42
				CFR 447.15, this service guarantee does not
				apply to an individual who is able to pay, nor does an individual's inability
				to pay eliminate his or her liability for the copayment.
(3) The amount of the copayment will be three
				dollars ($3) for each covered drug dispensed. The pharmacy provider shall
				collect a copayment for each drug dispensed by the provider and covered by
				Medicaid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-8 - Prior authorization; brand name drugs

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15; IC 26-2-8-106
Sec. 8.
(a) Prior
				authorization is required for a brand name drug that:
(1) is subject to generic substitution under
				Indiana law; and
(2) the prescriber
				has indicated is "brand medically necessary", either orally or in handwriting
				on the prescription or drug order, or typed in the comments of an electronic
				prescription.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-9 - Food supplements, nutritional supplements, and infant formulas

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 9.
(a) Food
				supplements, nutritional supplements, and infant formulas are covered only when
				no other means of nutrition is feasible or reasonable. Prior authorization for
				these items is required. Approval is subject to the following criteria:
(1) The feasibility or reasonableness of
				other means of nutrition, as documented by the requesting practitioner, and as
				determined by the office's contractor on a case-by-case basis.
(2) Authorization will not be granted when
				convenience of the member or the member's caretaker is the primary reason for
				the request for the service.
(3)
				Coverage is not available in cases of routine or ordinary nutritional
				needs.
(4) Coverage is not
				available in cases in which the item is to be used for other than nutritional
				purposes.
(5) In a long term care
				facility setting, costs for these products, when utilized either for
				nutritional supplementation or as the sole source of nutrition for the
				resident, are included in the facility's established per diem rate. When these
				products are furnished to a long term care facility resident, they are not
				separately reimbursable by Medicaid and are not to be billed separately to
				Medicaid by either the long term care facility or another provider furnishing
				the products.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-10 - Medical and nonmedical supply items for long term care facility residents

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 10.
The cost of both medical and nonmedical supply items is
				  included in the per diem rate for long term care facilities. Under no
				  circumstances shall medical or nonmedical supplies and equipment be billed
				  through a pharmacy or other provider.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-12 - Risk-based managed care

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC
				  12-15-13-6; IC
				  12-15-35-46; IC
				  12-15-35-47
Sec. 12.
The use of prior authorization programs or formularies in
				  risk-based managed care shall be subject to IC
				  12-15-35-46 and IC
				  12-15-35-47 and are not governed
				  by this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-13 - Legend and nonlegend solutions for nursing facility residents

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 13.
The cost of legend and nonlegend water products used for
				  irrigation or humidification are included in the per diem rate for nursing
				  facilities. When water products used for irrigation or humidification are
				  furnished to a nursing facility resident, they are not separately reimbursable
				  by Medicaid and are not to be billed separately to Medicaid by either the
				  nursing facility or another provider furnishing the products, as set forth in
				  405 IAC
				  5-31-4(7). Water agents used (or to
				  be used) as a vehicle to deliver a drug therapy into the body must be
				  reimbursed through the pharmacy benefit and not included in the nursing
				  facility per diem reimbursement.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-14 - Skin protectants, sealants, moisturizers, and ointments for nursing facility residents

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 14.
(a) The cost
				of skin protectants, sealants, moisturizers, and ointments for nursing facility
				residents are to be reimbursed as follows:
(1)
				Skin protectants, sealants, moisturizers, and ointments that are applied on an
				as needed basis, by the member, nursing facility care staff, or by prescriber's
				order, as a part of routine care, as defined in
				405 IAC
				1-14.6-2(ff), must be included in the
				per diem reimbursement and must not be reimbursed through the pharmacy
				benefit.
(2) If all of the
				following conditions are met, skin protectants, sealants, moisturizers, and
				ointments must be reimbursed through the pharmacy benefit:
(A) Legend or nonlegend (listed on the OTC
				drug formulary only).
(B)
				Prescribed for regular application or applications, or both, as a single agent
				or compounded with other drug agents.
(C) Used to treat or ameliorate a defect or
				physical or mental illness or condition.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 25 - Physician Services › Section 25-1 - Applicability

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
Medicaid reimbursement is available for medically necessary
				  services provided by a doctor of medicine or doctor of osteopathy for
				  diagnostic, preventive, therapeutic, rehabilitative, or palliative services
				  provided within the scope of the practice of medicine, as defined by Indiana
				  law, when provided to members, except as provided in this rule. Medical
				  services provided directly to a member by a doctor of medicine or doctor of
				  osteopathy do not require prior authorization, except as specified in this
				  article.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 25 - Physician Services › Section 25-2 - Reimbursement exclusions and limitations

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3
Sec. 2.
(a) Medicaid
				will not reimburse a physician for the following:
(1) Preparation of reports.
(2) Missed appointments.
(3) Writing or telephoning prescriptions to
				pharmacies.
(4) Telephone calls to
				laboratories.
(5) Any extra charge
				for after-hours services.
(6)
				Mileage.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 25 - Physician Services › Section 25-3 - Physician's written order, plan of treatment; when required

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
(a) All
				Medicaid covered services other than transportation and those services provided
				by chiropractors, dentists, optometrists, podiatrists, and psychologists
				certified for private practice require a physician's written order or
				prescription.
(b) A plan of
				treatment developed by a physician, which must be renewed every sixty (60)
				days, is required in addition to a written order for the following services:
(1) Home health services.
(2) All therapy services, including:
(A) physical;
(B) speech pathology;
(C) audiology; and
(D) occupational, respiratory, and
				psychiatric or psychological.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 25 - Physician Services › Section 25-4 - Injections administered by physicians

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 4.
Medicaid reimbursement is not available to a physician for
				  injecting medications that can be self-administered unless justified by the
				  patient's condition. Possible noncompliance by a member to oral medication is
				  insufficient justification to administer injections.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 25 - Physician Services › Section 25-5 - Inpatient services; reimbursement limitations

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 5.
(a) Any
				physician services rendered during inpatient days that require prior
				authorization and paid under the level of care methodology defined in
				405 IAC 1-10.5 that were not
				prior authorized will not be reimbursed.
(b) Reimbursement for any inpatient physician
				service rendered during a hospital stay that is subsequently found not to be
				medically necessary is subject to recoupment.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 26 - Podiatric Services › Section 26-1 - Scope

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
Subject to the limitations set out in this rule, Medicaid
				  reimbursement is available for podiatric services performed within the scope of
				  the practice of the podiatric profession as defined by Indiana law. Services
				  covered shall include diagnosis of foot disorders and mechanical, medical, or
				  surgical treatment of these disorders, subject to the restrictions and
				  limitations set out in this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 26 - Podiatric Services › Section 26-2 - General restrictions

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 2.
Podiatric services are subject to the following
				  restrictions:
(1) Except as set forth
				in 405 IAC
				5-3-12(1), in an emergency situation,
				for services requiring prior authorization, the authorization must be obtained
				within forty-eight (48) hours, not including Saturdays, Sundays, and legal
				holidays.
(2) Any podiatrist
				services rendered during inpatient days that were not appropriately prior
				authorized or were subsequently found to be not medically necessary will not be
				reimbursed. Prior authorization is required for hospitals stays as outlined in
				405 IAC 5-17.
(3) Any podiatrist services rendered during
				an outpatient visit that were not appropriately prior authorized or were
				subsequently found to be not medically necessary will not be
				reimbursed.
(4) Consultation
				services rendered by a podiatrist in a nursing facility are not covered when
				performed on patients on a routine basis for screening purposes, except in
				those cases where a specific foot ailment is involved.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 26 - Podiatric Services › Section 26-3 - Routine foot care; restrictions

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
(a) Routine
				foot care includes the following:
(1) Cutting
				or removal of corns, calluses, or warts (including plantar warts).
(2) Trimming of nails, including mycotic
				nails.
(3) Treatment of a fungal
				(mycotic) infection of the toenail is routine foot care only when:
(A) clinical evidence of infection of the
				toenail is present; and
(B)
				compelling medical evidence exists documenting that the patient either has a
				marked limitation of ambulation requiring active treatment of the foot or, in
				the case of a nonambulatory patient, has a condition that is likely to result
				in significant medical complications in the absence of such
				treatment.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 26 - Podiatric Services › Section 26-4 - Laboratory or x-ray services

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 4.
(a) Medicaid
				will reimburse a podiatrist for laboratory or x-ray services only if the
				services are rendered by or under the personal supervision of the podiatrist.
				Services ordered by a podiatrist, but performed by a laboratory or x-ray
				facility, shall be billed directly to Medicaid by the laboratory or x-ray
				facility. The podiatrist may be reimbursed for handling or conveyance of a
				specimen sent to an outside laboratory in accordance with
				405 IAC 5-18.
(b) Medicaid reimbursement is not available
				for comparative foot x-rays, unless prior authorized.
(c) Medicaid reimbursement is available for
				the following lab and x-ray services billed by a podiatrist:
(1) Cultures for foot infections and mycotic
				(fungal) nails for diagnostic purposes.
(2) Sensitivity studies for treatment of
				infection processes.
(3) Medically
				necessary presurgical testing.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 26 - Podiatric Services › Section 26-5 - Prior authorization

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 5.
(a) Prior
				authorization by the office is required for the following:
(1) Hospital stays as outlined in
				405 IAC 5-17.
(2) When a podiatrist prescribes or supplies
				corrective features built into shoes, such as heels, lifts, and
				wedges.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 26 - Podiatric Services › Section 26-6 - Orthotic services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 6.
Medicaid reimbursement is available for orthotic services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 26 - Podiatric Services › Section 26-7 - Podiatric office visits

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 7.
(a) Medicaid
				reimbursement is available for podiatric office visits, subject to the
				following restrictions:
(1) Reimbursement is
				limited to one (1) office visit per twelve (12) months, per member.
(2) New patient office visits are limited to
				one (1) per member, per provider, within the last three (3) years. As used in
				this subdivision, "new patient" is one who has not received professional
				services from the provider or another provider of the same specialty who
				belongs to the same group practice within the past three (3) years.
(3) A visit may be billed separately only on
				the initial visit. For subsequent visits, a visit may be billed only if a
				significant additional problem is addressed.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 26 - Podiatric Services › Section 26-8 - Doppler evaluations

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 8.
Medicaid reimbursement is available for ultrasonic
				  measurement of blood flow (Doppler) provided that prior authorization has been
				  obtained for the proposed medical procedure and subject to the following
				  limitations:
(1) A preoperative
				diagnosis of diabetes mellitus peripheral vascular disease or peripheral
				neuropathy.
(2) The ultrasonic
				measurement is for preoperative podiatric evaluation.
(3) The ultrasonic measurement cannot be used
				for routine screening purposes.
(4)
				The ultrasonic measurement cannot be used as an evaluation of routine foot care
				procedures, including such services as removal or trimming of corns, calluses,
				and nails.
(5) The preoperative
				Doppler evaluation is limited to one (1) per year.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 26 - Podiatric Services › Section 26-9 - Surgical procedures; reimbursement

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 9.
(a) All
				surgical procedures on one (1) foot or both feet performed on the same date
				will be paid at one hundred percent (100%) of the Medicaid allowance for the
				major procedure and fifty percent (50%) of the Medicaid allowance for
				subsequent procedures.
(b) If the
				surgery is performed on both feet, and if the surgery on the second foot is
				performed at least five (5) days following surgery on the first foot, one
				hundred percent (100%) allowance is payable for the second surgery.
(c) If the major surgical procedure is
				performed on one (1) foot, a time period of five (5) days must elapse before
				subsequent surgery on the same foot would again be paid at one hundred percent
				(100%) of Medicaid allowable reimbursement. Surgery performed sooner than five
				(5) days will be paid at fifty percent (50%) of Medicaid allowable
				reimbursement.
(d) If the major
				surgical procedure is performed on one (1) toe, a time period of thirty (30)
				days must elapse before subsequent surgery on the same toe would again be paid
				at one hundred percent (100%) of Medicaid allowable reimbursement. Surgery
				performed sooner than thirty (30) days will be reimbursed at fifty percent
				(50%) of Medicaid allowable reimbursement.
(e) Podiatric surgical procedures, including
				diagnostic surgical procedures, cannot be fragmented and billed separately.
				Such procedures generally are included in the major procedure. Such procedures
				may include, but are not limited to, the following:
(1) Scope procedures used for the surgical
				procedure approach.
(2) Arthroscopy
				or arthrotomy procedures in the same area as a major joint procedure unless
				claim documents a second incision was made.
(3) Local anesthesia administered to perform
				the surgical or diagnostic procedure.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 26 - Podiatric Services › Section 26-10 - Surgical procedures; confirmatory consultations

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 10.
(a)
				Providers may be required, based upon the facts of the case, to obtain a
				confirmatory consultation in accordance with
				405 IAC 5-8 substantiating the
				medically necessary service or approach for the following surgical procedures:
(1) Bunionectomy procedures.
(2) All surgical procedures involving the
				foot.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 27 - Radiology Services › Section 27-1 - Reimbursement limitations

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
(a) Medicaid
				reimbursement is available to radiology inpatient and outpatient facilities,
				freestanding clinics, and surgical centers for services provided to recipients
				subject to the following limitations:
(1)
				Prior authorization is required for any radiological services that exceed the
				utilization parameters set out in this article.
(2) To be eligible for reimbursement, a
				radiological service must be ordered in writing by a physician or other
				practitioner authorized to do so under state law.
(3) Radiological service facilities must bill
				Medicaid directly for components provided by the facility. When two (2)
				practitioners separately provide a portion of the radiology service, each
				practitioner shall bill Medicaid directly for the component he or she provides.
				Medicaid will reimburse a physician or other practitioner for radiological
				services only when such services are performed under the physician's or
				practitioner's direct supervision.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 27 - Radiology Services › Section 27-2 - Utilization criteria

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
Criteria for utilization of radiological services shall
				  include consideration of the following:
(1) Evidence that this radiologic procedure
				is necessary for the appropriate treatment of illness or injury.
(2) X-rays of the spinal column are limited
				to cases of acute documented injury or a medical condition where interpretation
				of x-ray films would make a direct impact on the medical/surgical
				treatment.
(3) Medicaid
				reimbursement is available for x-rays of the extremities and spine for the
				study of neuromusculoskeletal conditions.
(4) Radiologic procedures must be limited to
				the minimum number of views or films in order to appropriately diagnose or
				assess a patient condition. Procedures must also be limited to the most
				appropriate body part or area to provide or rule out a diagnosis for the
				suspected condition.
(5) Medicaid
				reimbursement is not available for radiology examinations of any body part
				taken as a routine study not necessary for the diagnosis or treatment of a
				medical condition.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 27 - Radiology Services › Section 27-3 - Computerized tomography; general

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
(a) Medicaid
				reimbursement may be available for diagnostic examination of the head (head
				scan) and of other parts of the body (body scans) performed by computerized
				tomography (CT) scanners, subject to the following restrictions:
(1) The scan should be reasonable and
				necessary for the individual patient.
(2) The use of a CT scan must be found to be
				medically necessary considering the patient's symptoms and preliminary
				diagnosis.
(3) Reimbursement will
				be made only for CT scans that have been performed on equipment that has been
				certified by the Food and Drug Administration.
(4) Whole abdomen, or whole pelvis on greater
				than twenty (20) cuts will not be reimbursed except in staging cancer for
				treatment evaluation.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 27 - Radiology Services › Section 27-4 - Nuclear medicine

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 4.
Medicaid reimbursement is available for radionuclide bone
				  scans when performed for the detection and evaluation of suspected or
				  documented bone disease.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 27 - Radiology Services › Section 27-5 - Upper gastrointestinal studies

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 5.
(a) Medicaid
				reimbursement is available for upper gastrointestinal (GI) studies when
				performed for the detection and evaluation of diseases of the esophagus,
				stomach, and duodenum.
(b) An upper
				GI study is not a covered service for a patient with a history of duodenal or
				gastric ulcer disease unless recently symptomatic.
(c) An upper GI study is not a covered
				service in the preoperative cholecystectomy patient unless symptoms indicate an
				upper GI abnormality in addition to the cholelithiasism or if the etiology of
				the abdominal pain is uncertain.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 27 - Radiology Services › Section 27-6 - Sonography

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 6.
(a) Medicaid
				reimbursement is available for the following sonography procedures:
(1) Sonography exams performed during
				pregnancy when warranted by one (1) or more of the following conditions:
(A) Early diagnosis of ectopic or molar
				pregnancy.
(B) Placental
				localization associated with abnormal bleeding.
(C) Fetal postmaturity syndrome.
(D) Suspected multiple births.
(E) Suspected congenital anomaly.
(F) Polyhydramnios or
				oligohydramnios.
(G) Fetal age
				determination if necessitated by:
(i)
				discrepancy in size versus fetal age; or
(ii) lack of fetal growth or suspected fetal
				death.
(H) Guide for
				amniocentesis.
(I) Suspected uterine
				and pelvic abnormality.
(J)
				Determination of fetal position.
(K) Evaluation of cervix for risk of preterm
				loss or birth.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 27 - Radiology Services › Section 27-7 - Positron emission tomography

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 7.
(a) As used
				in this section, "positron emission tomography" or "PET" scan means any
				diagnostic test that utilizes a radioactive substance to look for disease in
				the body or staging of a disease. This also includes any combined radiologic
				exam, such as a computerized tomography (PET-CT) exam or magnetic resonance
				(PET-MR) exam.
(b) Prior
				authorization shall be required for all PET scans.
(c) Medicaid reimbursement may be available
				for PET scans performed for medically necessary conditions as determined by the
				office.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 27 - Radiology Services › Section 27-8 - Interventional radiology

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 8.
(a) Medicaid
				reimbursement may be available for interventional radiology procedures as
				determined medically necessary by the office.
(b) Prior authorization shall be required for
				interventional radiologic procedures as determined by the office.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 27 - Radiology Services › Section 27-9 - Magnetic resonance exams

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 9.
Medicaid reimbursement shall be available for medically
				  necessary magnetic resonance imaging and magnetic resonance angiography exams.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-1 - Reimbursement limitations

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 1.
(a) All
				levels of medical care, prior to surgical procedures, will be reimbursed on an
				individual basis based on documentation of the member's medical condition. All
				levels of preoperative and postoperative care will be based on criteria set out
				in this rule.
(b) If the surgeon is
				doing the surgery only, and not the routine preoperative and postoperative
				care, this information must be indicated on the surgeon's claim form.
(c) If the primary care physician is
				rendering the preoperative or postoperative care only, this information must be
				indicated on the claim form and the name and address of the operating
				surgeon.
(d) If the member's
				condition requires additional medical or surgical care outside the scope of the
				operating surgeon, then reimbursement for medical components will be considered
				on an individual basis.
(e) Medical
				visits made for surgical complications may be reimbursed only if medically
				indicated and no other physician has billed for the same or related diagnosis.
				The claim must indicate the specific complications. These medical visits are
				billed separately from the surgical fee.
(f) If visits are made for treatment of a
				condition other than the surgery related diagnosis and no other physician has
				billed for the same or related diagnosis, then these visits are billed
				separately from the surgical fee. Associated medical care for denied surgical
				procedures will also be denied.
(g)
				When two (2) or more covered surgical procedures are done during the same
				operative session, multiple surgery reductions shall apply to the procedures
				based on the following adjustments:
(1) One
				hundred percent (100%) of the global fee for the most expensive
				procedure.
(2) Fifty percent (50%)
				of the global fee for the second most expensive procedure.
(3) Twenty-five percent (25%) of the global
				fee for the remaining procedures.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-2 - Medical diagnostic procedures

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
Medical diagnostic services may not be fragmented and billed
				  separately. Such procedures include, but are not limited to, electromyography,
				  electrocardiography, and muscle testing procedures.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-3 - Cardiac pacemaker

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
(a) Medicaid
				reimbursement is available for single-chamber cardiac pacemaker implantations.
				Medicaid reimbursement is subject to the restrictions in this
				section.
(b) Reimbursement is
				available for implantation of a single-chamber cardiac pacemaker provided that
				the conditions are:
(1) chronic or recurrent;
				and
(2) not due to transient
				causes, such as acute myocardial infarction, drug toxicity, or electrolyte
				imbalance.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-4 - Single-chamber cardiac pacemaker implantation

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 4.
(a)
				Reimbursement for single-chamber pacemaker implantation, in the absence of
				special medical circumstances documented in the medical record that the
				procedure is medically beneficial, is not available for the following:
(1) Syncope of undetermined cause.
(2) Sinus bradycardia without significant
				symptoms.
(3) Sinoatrial block or
				sinus arrest without significant symptoms.
(4) Prolonged PR intervals (slow ventricular
				response) with atrial fibrillation without third degree atrial ventricular (AV)
				block.
(5) Bradycardia during
				sleep.
(6) Right bundle branch
				block with left axis deviation and other forms of fascicular or bundle branch
				blocks without significant signs or symptoms.
(7) Asymptomatic second degree AV block of
				Mobitz Type I (Wenckebach).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-5 - Dual-chamber cardiac pacemaker implantation

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 5.
(a) Medicaid
				reimbursement is available for dual-chamber cardiac pacemaker implantations.
				Medicaid reimbursement is subject to the restrictions set forth in this
				rule.
(b) Reimbursement is
				available for implantation of a dual-chamber cardiac pacemaker provided that
				the conditions are as follows:
(1) Chronic or
				recurrent.
(2) Not due to transient
				causes such as acute myocardial infarction, drug toxicity, or electrolyte
				imbalance.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-6 - Monitoring of pacemakers

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 6.
(a) Medicaid
				reimbursement is available for clinic and telephone monitoring of cardiac
				pacemakers based upon the restrictions in this section.
(b) Frequency of monitoring, unless
				sufficiently documented by the physician on the Medicaid medical claim form,
				shall not exceed the following:
(1) For clinic
				monitoring of lithium battery pacemakers with single-chamber pacemakers, twice
				in the first six (6) months following implant, then once every twelve (12)
				months.
(2) For clinic monitoring
				of lithium battery pacemakers with dual-chamber pacemakers, twice in the first
				six (6) months following implant, then once every six (6) months.
(3) For telephone monitoring with
				single-chamber pacemaker following the first month of the implant, once every
				two (2) weeks.
(4) For telephone
				monitoring with single-chamber pacemaker following the second month of the
				implant through the thirty-sixth month, once every eight (8) weeks.
(5) For telephone monitoring with
				single-chamber pacemaker following the thirty-seventh month of the implant
				through failure, once every four (4) weeks.
(6) For telephone monitoring with
				dual-chamber pacemaker following the first month of the implant, once every two
				(2) weeks.
(7) For telephone
				monitoring with dual-chamber pacemaker following the second through the sixth
				month of the implant, once every four (4) weeks.
(8) For telephone monitoring with
				dual-chamber pacemaker following the seventh through the thirty-sixth month of
				the implant, once every eight (8) weeks.
(9) For telephone monitoring with
				dual-chamber pacemaker following the seventh through the thirty-seventh month
				through failure of the implant, once every four (4) weeks.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-7 - Abortion

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 7.
Medicaid reimbursement is available for abortions only if
				  performed to preserve the life of the pregnant woman or in other circumstances
				  if the abortion is required to be covered by Medicaid under federal law.
				  Termination of an ectopic pregnancy is not considered an abortion. All
				  appropriate documentation must be attached to the claim and to claims for
				  directly related services before reimbursement shall be made.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-8 - Sterilization

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 8.
Medicaid reimbursement is available for sterilization with
				  the following restrictions:
(1)
				Sterilization procedures must comply with the mandates of federal
				rules.
(2) The member must be
				twenty-one (21) years of age or older at the time the informed consent form is
				signed.
(3) The member must be
				neither mentally incompetent nor institutionalized.
(4) The member must have voluntarily given
				informed consent on forms prescribed for such purposes by the federal
				Department of Health and Human Services.
(5) All appropriate documentation must be
				attached to the claim and to claims for directly related services before
				reimbursement shall be made.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-9 - Hysterectomy

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 9.
Medicaid reimbursement is available for the performance of
				  hysterectomies with the following restrictions:
(1) Hysterectomy procedures must comply with
				federal regulations.
(2) A
				hysterectomy performed solely for the purpose of rendering a woman permanently
				incapable of reproducing, whether performed as a primary or secondary
				procedure, is not reimbursable by Medicaid.
(3) The acknowledgement of the hysterectomy
				information statement must be signed by the member, or member's representative,
				but is not required where the member is already sterile or where a
				life-threatening emergency situation exists. Where the hysterectomy is
				performed on an already sterile member, the physician who performs the
				hysterectomy must certify in writing that the member was already sterile at the
				time the hysterectomy was performed and state the cause of the
				sterility.
(4) Where the
				hysterectomy is performed under a life-threatening emergency situation, the
				physician who performed the hysterectomy must certify in writing that the
				hysterectomy was performed under a life-threatening emergency situation and
				that prior acknowledgement was not possible. The physician must include a
				description of the nature of the life-threatening emergency.
(5) The individual must be informed orally
				and in writing that this procedure will render her permanently incapable of
				reproducing, and she must sign a written acknowledgement of receipt of this
				information.
(6) Hysterectomy is
				subject to prior authorization. Where the hysterectomy is performed under a
				life-threatening emergency situation, the physician shall notify the office
				within forty-eight (48) hours of the procedure, not including Saturday, Sunday,
				and legal holidays, to obtain prior authorization.
(7) All appropriate documentation must be
				attached to the claim and to claims for directly related services before
				reimbursement may be made.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-10 - Chemotherapy

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 10.
(a)
				Outpatient administration of chemotherapy and costs related to this therapy,
				including catheterization, physician's visit, cost of drug and solutions, pump
				regulators, and servicing, will be covered and do not require prior
				authorization.
(b) Chemotherapy
				services provided by a home health agency are subject to the prior
				authorization criteria at
				405
				IAC 5-16-3.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 28 - Medical and Surgical Services › Section 28-11 - Hyperbaric oxygen therapy

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 11.
(a) Medicaid
				reimbursement is available for hyperbaric oxygen (HBO) therapy for the
				following conditions:
(1) Acute carbon
				monoxide intoxication.
(2)
				Decompression illness.
(3) Gas
				embolism.
(4) Gas
				gangrene.
(5) Acute traumatic
				peripheral ischemia.
(6) Crush
				injuries and suturing of severed limbs; as in the previous conditions, HBO
				therapy would be an adjunctive treatment when loss of function, limb, or life
				is threatened.
(7) Meleney ulcers;
				the use of hyperbaric oxygen in any other type of cutaneous ulcer is not
				covered.
(8) Acute peripheral
				arterial insufficiency.
(9)
				Preparation and preservation of compromised skin grafts.
(10) Chronic refractory osteomyelitis,
				unresponsive to conventional medical and surgical management.
(11) Osteoradionecrosis as an adjunct to
				conventional treatment.
(12) Soft
				tissue radionecrosis as an adjunct to conventional treatment.
(13) Cyanide poisoning.
(14) Actinomycosis, only as an adjunct to
				conventional therapy when the disease process is refractory to antibiotics and
				surgical treatment.
(15) Acute
				cerebral edema.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 29 - Services Not Covered by Medicaid › Section 29-1 - Noncovered services

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3
Sec. 1.
The following services are not covered by Medicaid:
(1) Services that are not medically
				necessary.
(2) Services provided
				outside the scope of a provider's license, registration, certification, or
				other authority to practice under state or federal law.
(3) Experimental drugs, treatments, or
				procedures, and all related services.
(4) Any new product, service, or technology
				not specifically covered in this article. The product, service, or technology
				will remain a noncovered product, service, or technology until such time as the
				office authorizes the coverage of the product, service, or technology. This
				subdivision does not apply to legend drugs.
(5) Personal comfort or convenience items,
				including, but not limited to, television, radio, or telephone
				rental.
(6) Services for the
				remediation of learning disabilities.
(7) Treatments or therapies of an educational
				nature.
(8) Experimental
				radiological or surgical or other modalities and procedures, including, but not
				limited to, the following:
(A)
				Acupuncture.
(B) Biofeedback
				therapy.
(C) Carbon dioxide five
				percent (5%) inhalator therapy for inner ear disease.
(D) Hyperthermia.
(E) Hypnotherapy.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-1 - Reimbursement restrictions

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-6-5; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC
				  12-15-6
Sec. 1.
Medicaid reimbursement is available for emergency and
				  nonemergency transportation, subject to the following restrictions:
(1) Except when additional trips are
				medically necessary and the same is demonstrated and documented through the
				prior authorization process, reimbursement is available for a maximum of twenty
				(20) one-way trips per member, per rolling twelve (12) month period of time.
				The following services are exempt from the numeric cap and do not require prior
				authorization, except as specified in subdivision (2):
(A) Emergency ambulance services.
(B) Transportation to or from a hospital for
				the purpose of an inpatient admission or discharge. This includes interhospital
				transfers when the member has been discharged from one (1) hospital for the
				purpose of admission to another hospital.
(C) Transportation for members on renal
				dialysis or those residing in nursing homes.
(D) Accompanying parent or member attendant,
				or both.
(E) Return trip from the
				emergency room in an ambulance, if use of ambulance is medically necessary for
				the transport.