Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 18 - PHYSICIANS' SERVICES › Section 471-18-006 - NON-COVERED SERVICES

Current through June 17, 2024
The services outlined in this section are specifically excluded from
	 coverage by the Department. This is not intended to be an all-inclusive, or
	 exhaustive, list of non-covered services
006.01
SURGICAL
  PROCEDURES.
Nebraska Medicaid 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) Ballistocardiogram;
(G) Basal metabolic rate (BMR);
(H) Bronchoscopy, with injection of contrast
  medium for bronchography or with injection of radioactive substance;
(I) Circumcision, female;
(J) Excision of carotid body tumor, with or
  without excision of carotid artery, when used as a treatment for
  asthma;
(K) Extra-intra cranial
  arterial bypass for stroke;
(L)
  Fabric wrapping of abdominal aneurysm;
(M) Fascia lata by incision and area
  exposure, with removal of sheet, when used as treatment for lower back
  pain;
(N) Fascia lata by stripper
  when used as a treatment for lower back pain;
(O) Hypogastric or presacral neurectomy as an
  independent procedure;
(P)
  Hysterotomy, non-obstetrical, vaginal;
(Q) Icterus index;
(R) Ileal bypass or any other intestinal
  surgery for the treatment of obesity;
(S) Kidney decapsulation, unilateral and
  bilateral;
(T) Ligation of femoral
  vein, unilateral and bilateral, when used as treatment for post-phlebotic
  syndrome;
(S) Ligation of internal
  mammary arteries, unilateral or bilateral;
(U) Ligation of thyroid arteriesas an
  independent procedure;
(V)
  Nephropexy: fixation or suspension of kidney as an independent procedure,
  unilateral;
(W) Omentopexy for
  establishing collateral circulation in portal obstruction;
(X) Perirenal insufflation;
(Y) Phonocardiogram with interpretation and
  report, and with indirect carotid artery tracings or similar study;
(Z) Protein bound iodine (PBI);
(AA) Radical hemorrhoidectomy, whitehead
  type, including removal of entire pile bearing area;
(BB) Refractive keratoplasty, includes
  keratomileusis, keratophakia, and radial keratotomy;
(CC) Reversal of tubal ligation or
  vasectomy;
(DD) Sex change
  procedures;
(FF) Solid organ
  transplants performed in a facility which is not included on the list of
  Medicare-approved transplant programs;
(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;
  or
(JJ) Uterine suspension, with or
  without presacral sympathectomy.