Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.06 - Physician services

Current through June 24, 2024
(1) COVERED SERVICES. Physician services
				covered by the MA program are, except as otherwise limited in this chapter, any
				medically necessary diagnostic, preventive, therapeutic, rehabilitative or
				palliative services provided in a physician's office, in a hospital, in a
				nursing home, in a recipient's residence or elsewhere, and performed by or
				under the direct supervision of a physician within the scope of the practice of
				medicine and surgery as defined in s.
				448.01 (9),
				Stats. These services shall be in conformity with generally accepted good
				medical practice.
(2) SERVICES
				REQUIRING PRIOR AUTHORIZATION. The following physician services require prior
				authorization in order to be covered under the MA program:
(a) All covered physician services if
				provided out-of-state under non-emergency circumstances by a provider who does
				not have border status. Transportation to and from these services shall also
				require prior authorization, which shall be obtained by the transportation
				provider;
(b) All medical,
				surgical, or psychiatric services aimed specifically at weight control or
				reduction, and procedures to reverse the result of these services;
(c) Surgical or other medical procedures of
				questionable medical necessity but deemed advisable in order to correct
				conditions that may reasonably be assumed to significantly interfere with a
				recipient's personal or social adjustment or employability, an example of which
				is cosmetic surgery;
(d)
				Prescriptions for those drugs listed in s.
				DHS 107.10
				(2);
(e) Ligation of internal mammary arteries,
				unilateral or bilateral;
(f)
				Omentopexy for establishing collateral circulation in portal
				obstruction;
(g)
1. Kidney decapsulation, unilateral and
				bilateral;
2. Perirenal
				insufflation; and
3. Nephropexy:
				fixation or suspension of kidney (independent procedure), unilateral;
(h) Female circumcision;
(i) Hysterotomy, non-obstetrical or
				vaginal;
(j) Supracervical
				hysterectomy, that is, subtotal hysterectomy, with or without removal of tubes
				or ovaries or both tubes and ovaries;
(k) Uterine suspension, with or without
				presacral sympathectomy;
(L)
				Ligation of thyroid arteries as an independent procedure;
(m) Hypogastric or presacral neurectomy as an
				independent procedure;
(n)
1. Fascia lata by stripper when used as
				treatment for lower back pain;
2.
				Fascia lata by incision and area exposure, with removal of sheet, when used as
				treatment for lower back pain;
(o) Ligation of femoral vein, unilateral and
				bilateral, when used as treatment for post-phlebitic syndrome;
(p) Excision of carotid body tumor without
				excision of carotid artery, or with excision of carotid artery, when used as
				treatment for asthma;
(q)
				Sympathectomy, thoracolumbar or lumbar, unilateral or bilateral, when used as
				treatment for hypertension;
(r)
				Splanchnicectomy, unilateral or bilateral, when used as treatment for
				hypertension;
(s) Bronchoscopy with
				injection of contrast medium for bronchography or with injection of radioactive
				substance;
(t) Basal metabolic rate
				(BMR);
(u) Protein bound iodine
				(PBI);
(v)
				Ballistocardiogram;
(w) Icterus
				index;
(x) Phonocardiogram with
				interpretation and report, and with indirect carotid artery tracings or similar
				study;
(y)
1. Angiocardiography, utilizing C02 method,
				supervision and interpretation only;
2. Angiocardiography, either single plane,
				supervision and interpretation in conjunction with cineradiography or
				multi-plane, supervision and interpretation in conjunction with
				cineradiography;
(z)
1. Angiography - coronary: unilateral,
				selective injection, supervision and interpretation only, single view unless
				emergency;
2. Angiography -
				extremity: unilateral, supervision and interpretation only, single view unless
				emergency;
(za) Fabric
				wrapping of abdominal aneurysm;
(zb)
1.
				Mammoplasty, reduction or repositioning, one-stage - bilateral;
2. Mammoplasty, reduction or repositioning,
				two-stage - bilateral;
3.
				Mammoplasty augmentation, unilateral and bilateral;
4. Breast reconstruction and
				reduction.
(zc)
				Rhinoplasty;
(zd)
				Cingulotomy;
(ze)
				Dermabrasion;
(zf)
				Lipectomy;
(zg) Mandibular
				osteotomy;
(zh) Excision or
				surgical planning for rhinophyma;
(zi) Rhytidectomy;
(zj) Constructing an artificial
				vagina;
(zk) Repair blepharoptosis,
				lid retraction;
(zL) Any other
				procedure not identified in the physicians' "current procedural terminology",
				fourth edition, published by the American medical association;
Note:
The referenced publication is on file and
				  may be reviewed in the department's division of health care financing.
				  Interested persons may obtain a copy by writing American Medical Association,
				  535 N. Dearborn Avenue, Chicago, Illinois 60610.
(zm) Transplants;
1. Heart;
2. Pancreas;
3. Bone marrow;
4. Liver;
5. Heart-lung; and
6. Lung.
Note:
For more information about prior
				  authorization, see s.
				  DHS 107.02
				  (3).
(zn) Drugs identified by the department that
				are sometimes used to enhance the prospects of fertility in males or females,
				when proposed to be used for treatment of a non-fertility related
				condition;
(zo) Drugs identified by
				the department that are sometimes used to treat impotence, when proposed to be
				used for treatment of a non-impotence related condition;