§ 1141.59. Noncompensable services.

 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.

Authority

   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).

Source

   The provisions of this §  1141.59 adopted August 15, 1980, effective September 1, 1980, 10 Pa.B. 3386; amended October 8, 1982, effective October 9, 1982, 12 Pa.B. 3647; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 7, 1984, effective July 1, 1984, 14 Pa.B. 3252; amended September 30, 1988, effective November 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (99333) to (99335) and (93493).

Cross References

   This section cited in 55 Pa. Code §  1141.51 (relating to general payment policy).



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