471 NAC 10-005. NON-COVERED SERVICES

005. NON-COVERED SERVICES. Non-covered services will not be covered by Nebraska Medicaid. Services will be reviewed on a case-by-case basis to determine if they are covered or not. 005.01 SERVICES REQUIRED TO TREAT COMPLICATIONS OR CONDITIONS RESULTING FROM NON-COVERED SERVICES. Payment for medically necessary services that are required to treat complications or conditions resulting from non-covered services may be made. 005.02 EXPERIMENTAL AND INVESTIGATIONAL SERVICES. Medical services which are considered investigational or experimental or which are not generally employed by the medical profession are not covered. While the circumstances leading to participation in an experimental or investigational program may meet the definition of medical necessity, payment is prohibited for these services. 005.02(A) RELATED SERVICES. Associated or adjunctive services that are directly related to non-covered experimental or investigational services are not covered. All medically necessary expenses incurred which are not directly related to the non-covered experimental or investigative services will be paid. Complications of non-covered services may be covered once the non-covered service is completed. 005.02(B) COVERAGE REQUESTS FOR NEW SERVICES. Requests for Nebraska Medicaid coverage for new services or those which may be considered experimental or investigational must be submitted to Nebraska Medicaid before providing the services, or in the case of true medical emergencies, before submitting a claim. The request for coverage must include sufficient information to document that the new service is not considered investigational or experimental for Nebraska Medicaid payment purposes. Reliable evidence must be submitted identifying the status with regard to the criteria below, cost-benefit data, short and long-term outcome data, patient selection criteria that is both disease or condition specific and age specific, information outlining under what circumstances the service is considered the accepted standard of care, and any other information that would be helpful to Nebraska Medicaid in deciding coverage issues. Additional information may be requested by Nebraska Medicaid. 005.02(C) INVESTIGATIONAL OR EXPERIMENTAL CRITERIA. Services are deemed investigational or experimental by Nebraska Medicaid , who may convene ad hoc advisory groups of experts to review requests for coverage. A service is deemed investigational or experimental if it meets any one of the following criteria: (i) There is no Food and Drug Administration (FDA) or other governmental or regulatory approval given, when appropriate, for general marketing to the public for the proposed use; (ii) Reliable evidence does not permit a conclusion based on consensus that the service is a generally accepted standard of care employed by the medical profession as a safe and effective service for treating or diagnosing the condition or illness for which its use is proposed. Reliable evidence includes peer reviewed literature with statistically significant data regarding the service for the specific disease, proposed use, and age group. Also, facility specific data, including short and long-term outcomes, must be submitted to the Nebraska Medicaid; (iii) The service is available only through an institutional review board (IRB) research protocol for the proposed use or subject to such an institutional review board (IRB) process; or (iv) The service is the subject of an ongoing clinical trial(s) that meets the definition of a phase I, phase II, or phase III clinical trial, regardless of whether the trial is actually subject to Food and Drug Administration (FDA) oversight and regardless of whether an institutional review board (IRB) process or protocol is required at any one particular institution. 005.03 CUSTODIAL OR RESPITE CARE. Hospital services that are custodial or respite care are not covered. 005.04 PRIVATE-DUTY NURSING. The services of a private-duty nurse or other private-duty attendant are not covered as a hospital service. 005.05 PROSTHETICS. External powered prosthetic devices are not covered. 005.06 FACILITY BASED PHYSICIAN CLINICS. Physician clinic services provided in a hospital, or a facility under the hospital’s licensure, are considered to be a physician's service and are reimbursed accordingly. 005.07 TOBACCO CESSATION SERVICES. Tobacco cessation services are not covered as a hospital service. 005.08 HOSPITAL ACQUIRED CONDITIONS (HAC). No payment will be made for treatment of conditions that are a result of avoidable inpatient hospital complications and medical errors that are identifiable, preventable, and serious in their consequences to beneficiaries . Any diagnosis code(s) which are flagged as hospital acquired will be excluded from the final claim All Patient Refined Diagnosis-Related Group (APR DRG) determination. 005.09 NON-COVERED PORTABLE X-RAY SERVICES. The following portable x-ray services are not covered: (A) Procedures involving fluoroscopy; (B) Procedures involving the use of contrast media; (C) Procedures requiring the administration of a substance to the beneficiary, injection of a substance into the beneficiary, or special manipulation of the beneficiary ; (D) Procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor of osteopathy or which require that medical judgment be exercised; (E) Procedures requiring special technical competency or special equipment or materials; (F) Routine screening procedures; and (G) Procedures which are not of a diagnostic nature.