Title XIX Procedure of Exception to Medical Care Services Limitations

PURPOSE: This rule establishes the basis, procedure, and criteria where the state Medicaid agency may grant an exception to bene fit limitations otherwise imposed by the state’s Medicaid program. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumber some or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Under the requirements of this rule, the MO HealthNet Division (MHD) may approve and authorize payment for the provision to a Medicaid-eligible recipient of an essential med ical service or item that would otherwise exceed the benefit limitations of the medical assistance program. An administra tive exception may be made on a case-by-case basis to limita tions and restrictions. The director of the MHD will have the final authority to approve payment on a request made to the exception process. These decisions will be made with appropri ate medical or pharmaceutical advice and consultation. (2) Requirements for consideration and provision of a service as an exception to the normal limitations of Medicaid coverage are as follows: (A) A physician, resident, intern, extern, nurse clinician, nurse practitioner, or registered nurse (RN) acting on the behalf of the physician must certify that medical treatment or items of service which are covered under the Medicaid Program and which, under accepted standards of medical practice, are indicated as appropriate to the treatment of the illness or con dition, have been used and found to be medically ineffective in the treatment of the recipient for whom the exception is being requested, or inappropriate for that specific recipient; (B) All third-party resource benefits must be exhausted be fore the MO HealthNet program will pay for any treatment or service; (C) Any drug requested has been approved by the Food and Drug Administration (FDA) and is being prescribed for an FDAapproved indication and route of administration or medical literature must exist justifying the effectiveness of the drug or that specific diagnosis or for that specific route of administra tion; (D) Any medical, surgical, or diagnostic service requested which is provided by a physician must be listed in the most recent publication of the CPT Professional Edition code book, which is incorporated by reference and made a part of this rule as published by The American Medical Association (AMA), 330 North Wabash, Chicago, Illinois 60611, October 25, 2024. This rule does not incorporate any subsequent amendments or additions; (E) Any individual for whom an exception request is made must be eligible for MO HealthNet coverage on the date(s) the item or services are provided, or in the case of retroactive eligibility, approval can be granted if requested; (F) The provider of the service must be an enrolled provider in the MO HealthNet program on the date(s) the item or services are provided; (G) The item or services for which an exception is requested must be of a type and nature which falls within the broad scope of a medical discipline included in the MO HealthNet program and which does not represent a departure from the accepted standards and precepts of good medical practice; (H) Requests must be made and approval granted before the requested item or services are provided, or not more than one (1) state working day following the provision of the service. Retroactive approval of coverage may be granted in cases in which the recipient’s eligibility for MO HealthNet coverage is established; (I) All requests for exception consideration must be initiated by the attending physician, the resident, intern, extern, nurse clinician, nurse practitioner, or RN acting in the physician’s behalf for an eligible recipient and must be submitted as pre scribed in policy of the MHD; (J) Requests for exception consideration, by whatever means received, must support and demonstrate that one (1) or more of the following conditions are met: 1. The item or service is required to sustain the recipient’s life; 2. The item or service would substantially improve the quality of life for a terminally ill patient; 3. The item or service is necessary as a replacement due to an act occasioned by violence of nature without human inter ference, such as a tornado or flood; or 4. The item or service is necessary to prevent a higher level of care; (K) All exception requests must represent cost-effective uti lization of MHD funds. When an exception item or service is presented as an alternative, lesser level-of-care than the level otherwise necessary, the exception must be less program costly; and (L) Reimbursement of services and items approved under this exception procedure shall be made in accordance with the MO HealthNet fee schedules or rates for the same or comparable services. For those services for which no MO HealthNet fee schedule or rate is applicable, reimbursement will be determined by the state agency considering costs and charges. (3) Consideration under this rule shall not be applicable to requests for services under the following circumstances such as, but not limited to— (A) Services that would be provided by individuals whose specialty is not covered by the MO HealthNet program; (B) Orthodontics; (C) Inpatient hospital services; (D) Air transportation; (E) Alternative services such as personal care, adult day health care, homemaker/chore, hospice, and respite care, regardless of authorization by the Department of Health and Senior Services; (F) Waiver of MO HealthNet program requirements for doc umentation, applicable to services requiring a second surgical opinion, voluntary sterilization, hysterectomies, or legal abor tions; (G) Failure to obtain prior authorization as required for a service otherwise covered by MO HealthNet; (H) Delivery or placement of custom-made items following the recipient’s death or loss of eligibility for the service; (I) Previous denial by the MHD of a request for exception con sideration where the current request fails to present informa tion of significance in overcoming the deficiency upon which the original request was denied; (J) Requests for additional reimbursement for items or services otherwise covered by the MO HealthNet program; (K) MO HealthNet waiver services; and (L) Transplants. AUTHORITY: sections 207.020, 208.201, and 660.017, RSMo 2016, and section 208.153, RSMo Supp. 2025.* This rule was previously filed as 13 CSR 40-81.195. Original rule filed May 15, 1987, effective Oct. 11, 1987. Amended: Filed June 4, 1990, effective Dec. 31, 1990. Amended: Filed Oct. 2, 2006, effective April 30, 2007. Amended: Filed Aug. 28, 2018, effective April 30, 2019. Amended: Filed Dec. 16, 2025, effective June 30, 2026. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, 2007; and 660.017, RSMo 1993, amended 1995.