Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1141 - PHYSICIANS' SERVICES › PAYMENT FOR PHYSICIANS' SERVICES › Section 1141.59 - Noncompensable services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for the following physicians'
					 services:
(1) Procedures not listed in
				  the Medical Assistance program fee schedule.
(2) Medical services or surgical procedures
				  performed on an inpatient basis that could have been performed in the
				  physician's office, the clinic, the emergency room, or a short procedure unit
				  without endangering the life or health of the patient.
(3) Medical or surgical procedures designated
				  in the Medical Assistance program fee schedule as outpatient procedures,
				  signified by the letters OP which are performed on an inpatient basis unless
				  the requirements specified in Chapter 1150 (relating to noncompensable
				  services) are met.
(4) Dental
				  rehabilitation and restorative services provided on an inpatient basis.
Exception
-Oral restorative services are
					 compensable on an inpatient basis for persons requiring extensive oral
					 rehabilitation or restoration who are unmanageable in a doctor's office because
					 of a severe physical or mental condition and require general anesthesia.
					 Documentation of a secondary diagnosis or the specific physical or mental
					 condition that made the hospitalization necessary shall be included in the
					 record of the patient and on the invoice submitted for payment.
(5) Diagnostic tests, for which a
				  patient was admitted, that may be performed on an outpatient basis; tests not
				  related to the diagnosis and treatment of the illness for which the patient was
				  admitted; tests for which there is no medical justification.
(6) Methadone maintenance.
(7) Hysterectomy performed solely for the
				  purpose of rendering an individual incapable of reproducing or if there was
				  more than one purpose to the procedure, it would not have been performed but
				  for the purpose of rendering the individual incapable of reproducing.
(8) Acupuncture, medically unnecessary
				  surgery, insertion of penile prosthesis, gastroplasty for morbid obesity,
				  gastric stapling or ileo-jejunal shunt-except when all other types of treatment
				  of morbid obesity have failed-and other procedures which are experimental or
				  are not in accordance with customary standards of medical practice.
(9) Services and procedures that are
				  available through other public agencies or private insurance plans.
(10) Services to inpatients who no longer
				  require acute inpatient care. However, the Department will make payment to the
				  hospital for skilled nursing or intermediate care provided for a patient in a
				  certified bed in a certified and approved hospital based skilled nursing or
				  intermediate care unit.
(11)
				  Surgical procedures and medical care provided in connection with sex
				  reassignment. This includes but is not limited to hormone therapy, penile
				  construction, revision of labia, vaginoplasty, vaginal dilation, vaginal
				  reconstruction, penectomy, orchiectomy, mamoplasty, mastectomy, hysterectomy,
				  and release of vaginal adhesions.
(12) Experimental procedures as defined in
				  §
										1141.2 (relating to
				  definitions).
(13) Cosmetic surgery
				  as defined in § 1141.2.
Exception:
Cosmetic surgery is a covered
					 service when performed in order to improve the functioning of a malformed body
					 member, to correct a visible disfigurement which would affect the ability of
					 the person to obtain or hold employment, or as postmastectomy breast
					 reconstruction.
(14)
				  Diagnostic pathological examinations of body fluids or tissues, procedure codes
				  80001 through 89360 and 89900 and 99901. Except for professional components for
				  anatomical pathology, payment for these procedures is made only to hospital and
				  independent laboratories that are approved to participate in the Medical
				  Assistance Program.
(15) Services
				  and procedures related to the delivery within the antepartum period and
				  postpartum period when performed and billed by a midwife.
(16) Medical services or surgical procedures
				  performed in a short procedure unit that could have been appropriately and
				  safely performed in the physician's office, the clinic, or the emergency room
				  without endangering the life or health of the patient.
The provisions of this §
												1141.59 issued under the Public
						Welfare Code, §§ 403(a) and (b), 443.2(1) and (2), 443.3(1),
						443.3(2)(i)-(v), 443.4 and 509 (62 P. S. §§
													403(a) and
						(b),
						443.2(1) and (2), 443.3(1),
						443.3(2)(i)-(v), 443.4 and 509).
This section cited in 55 Pa. Code §
												1141.51 (relating to general
						payment policy).