Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.59 - Noncompensable services, items and outlier days

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department does not pay hospitals for
					 an inpatient hospital stay if the admission is directly or indirectly related
					 to the hospital's provision of:
(1)
					 Transsexual surgical procedures for gender change or reassignment-for example,
					 penile construction, revision of labia, vaginoplasty, vaginal dilation, vaginal
					 reconstruction, penectomy, orchiectomy, mammoplasty, mastectomy, hysterectomy
					 and release of vaginal adhesions.
(2) Medical or dental services or surgical
					 procedures performed on an inpatient basis which could have been performed in
					 an outpatient department, or practitioner's office-for example, unilateral or
					 bilateral myringotomy, vasectomy, blood transfusions, chronic maintenance
					 hemodialysis, treatment for chronic pain and dental procedures which may be
					 provided in an outpatient setting without undue risk to the patient.
(3) Inpatient hospital services provided in
					 conjunction with physicians' services which are identified as outpatient
					 procedures in Chapter 1150 (relating to the MA Program payment policies),
					 unless performing the procedure on an outpatient basis could result in undue
					 risk to the life or health of the patient and detailed documentation of the
					 conditions of risk to the life or health of the patient is included in the
					 patient's medical record.
(4)
					 Acupuncture, unnecessary surgery, insertion of penile prosthesis, gastroplasty
					 for morbid obesity, gastric stapling or ileojejunal shunt, except when all
					 other types of treatment of morbid obesity have failed and other procedures
					 which may be experimental are not in accordance with customary standards of
					 medical practice or are not commonly used.
(5) Plastic or cosmetic surgery for
					 beautification purposes-for example, otoplasty for protruding ears or lop ears,
					 rhinoplasty-except for internal nasal deformity-nasal reconstruction, excision
					 of keloids, reduction mammoplasty, augmentation mammoplasty, silicone or
					 silastic implants, facioplasty, osteoplasty-prognathism and
					 micrognathism-dermabrasion, skin grafts and lipectomy. For accidental injury,
					 plastic surgery is compensable if performed for the purpose of improving the
					 functioning of a deformed body member.
(6) Inpatient dental cases involving oral
					 rehabilitation or restorative services, except for procedures performed for
					 treatment of a secondary diagnosis, unless:
(i) The nature of the surgery or the
					 condition of the patient precludes performing the procedure in the dentist's
					 office or other outpatient setting.
(ii) A physician or dentist has documented in
					 the patient's medical record the medical justification for performing the
					 procedure in a short procedure unit or inpatient setting.
(7) Diagnostic tests and procedures that can
					 be performed on an outpatient basis and diagnostic tests and procedures not
					 related to the diagnoses that require that particular inpatient stay.
(8) Sterilizations performed on individuals
					 20 years of age or younger.
(9)
					 Sterilizations performed on individuals 21 years of age or older who have not
					 signed the consent form for sterilization at least 30 days but not more than
					 180 days prior to the sterilization.
(10) Hysterectomies performed solely for the
					 purpose of sterilization.
(11)
					 Abortion procedures performed on individuals if a "Physician Certification for
					 an Abortion" form has not been completed.
(12) Services and items for which full
					 payment is available through Medicare, other financial resources or other
					 health insurance programs.
(13)
					 Services and items not ordinarily provided to the general public.
(14) Methadone maintenance.
(15) Diagnostic or therapeutic procedures
					 solely for experimental, research or educational purposes.
(16) Unnecessary admissions and conditions
					 which do not require hospital-type care, such as rest cures and room and board
					 for relatives during a patient's hospitalization.