Medical Services: Coverage And Limitations

01. Adult Physicals. Adult preventive physical examinations are limited to one (1) per year. (7-1-26) 02. Injectable Vitamins. Payment for allowable injectable vitamins will be allowed when supported by the diagnosis. Injectable vitamin therapy is limited to Vitamin B12 (and analogues), Vitamin K (and analogues), folic acid, and mixtures consisting of Vitamin B12, folic acid, and iron salts in any combination. (7-1-26) 03. Reconstructive Surgery. Reconstruction or restorative procedures include procedures that restore function of the affected or related body part(s). Covered procedures include breast reconstruction after mastectomy, or the repair of other injuries resulting from physical trauma. (7-1-26) 04. Screening Mammograms. Screening mammograms are covered when aligned with the “A” or “B” recommendations of the United States Preventative Services Task Force. (7-1-26) 05. Tonometry. Payment for tonometry is limited to one (1) examination or, when the examination to determine visual acuity is not done, two (2) tonometry examinations per twelve (12) month period are allowed for participants over the age of forty (40). This limitation does not apply to participants receiving continuing treatment for glaucoma. (7-1-26) 06. Weight Loss Surgical Procedures. Abdominoplasty or panniculectomy is covered when the surgery is prior authorized by the Department. The request for PA must include the following documentation: (7-1-26) a. Photographs of the front, side and underside of the abdomen; (7-1-26) b. Treatment of any ulceration and skin infections involving the panniculus; (7-1-26) c. Failure of conservative treatment, including weight loss; (7-1-26) d. That the panniculus severely inhibits the participant's walking; (7-1-26) e. That the participant is unable to wear a garment to hold the panniculus up; and (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 113 Page 51 f. Other detrimental effects of the panniculus on the participant's health such as severe arthritis in the lower body. (7-1-26)