471 NAC 18-004. SERVICE REQUIREMENTS

004. SERVICE REQUIREMENTS. 004.01 MEDICAL NECESSITY. Physicians' services may be provided at the physician's office, the beneficiary’s home, a hospital, a long-term care facility (LTC), or elsewhere. Additionally, Nebraska Medicaid covers medically necessary physicians' services are covered within program requirements which are provided: (A) Within the scope of the practice of medicine or osteopathy as defined by Nebraska state law; and (B) By, or under the personal supervision of, an individual licensed under Nebraska state law to practice medicine or osteopathy. 004.02 PRIOR AUTHORIZATION. For services provided to beneficiaries enrolled in a managed care program, physicians must follow the prior authorization requirements of the applicable managed care plan. For all other beneficiaries, physicians must request prior authorization from Nebraska Medicaid before providing: (1) Medical transplants; (2) Abortions; (3) Cosmetic and reconstructive surgery; (4) Bariatric surgery for obesity; (5) Out-of-state services, except emergency services provided out-of-state; (6) Established procedures of questionable clinical efficacy ; (7) Procedures which tend to be redundant when performed in combination with other procedures; (8) New or recently developed procedures of unproven clinical efficacy and health outcomes value; (9) Certain drug products; (10) All attended sleep studies; or (11)Ventricular assist device. 004.02(A) PRIOR AUTHORIZATION PROCEDURES. Prior to providing the service, a request for prior authorization must be submitted by the physician . 004.02(A)(i) REQUEST FOR ADDITIONAL EVALUATIONS. Additional evaluations may be requested, and the provider must submit them, when Nebraska Medicaid determines the medical history for the request is questionable or when there is not sufficient information to support the requirements for authorization. 004.02(A)(ii) NOTIFICATION PROCESS. Upon determination of approval or denial, written notification is provided, as applicable, to the physician submitting the request, the caseworker, and the medical review organization. 004.02(A)(iii) VERBAL AUTHORIZATION PROCEDURES. A verbal authorization may be issued when circumstances are of an emergency nature or urgent to the extent a delay would place the beneficiary at risk of not receiving medical care. When a verbal authorization is granted, the physician must submit the appropriate Nebraska Medicaid approved form must be submitted within 14 calendar days of the verbal authorization. 004.02(A)(iv) BILLING AND PAYMENT REQUIREMENTS. Claims submitted to Nebraska Medicaid for services requiring prior authorization will not be paid without written or electronic approval. A copy of the approval documentation issued by Nebraska Medicaid is not needed for submission with the claim unless instructed to do so as part of the authorization notification. 004.02(B) PRIOR AUTHORIZATION FOR PRESCRIPTION DRUGS. Authorization is required to be granted prior to payment for certain drugs or items. Prior authorization may pertain to either certain drugs prescribed, or certain physician administered drugs. Physicians wishing to prescribe these drugs must obtain prior authorization by submitting the request to either the Nebraska point of sale contractor, Nebraska Medicaid, or its designee. In cases of medical emergency, the Nebraska point of sale contractor or Nebraska Medicaid will authorize dispensing a 72 hour supply of a covered outpatient prescribed medication . 004.02(C) PRODUCTS REQUIRING PRIOR APPROVAL. Identifiable products requiring approval prior to payment are designated as such on the Nebraska point of sale system or on Nebraska Medicaid’s website. The following prescribed products require prior approval: (i) Sunscreen; (ii) Certain modified versions, combinations, double-strength entities, or products considered by Nebraska Medicaid to be equivalent to drug products contained on the state maximum allowable cost or federal upper limit listings in this title ; (iii) Human growth hormone; (iv) Erythropoietin; (v) Drugs or supplies intended for convenience use; (vi) Drugs used for prevention of infection with respiratory syncytial virus; (vii) Certain drugs or classes of drugs used for gastrointestinal disorders; (viii) Certain drugs or classes of drugs used for relief of pain, discomfort associated with musculoskeletal conditions, inflammation, or fever; (ix) Certain drugs or classes of drugs used for relief of cough or symptoms of the common cold, influenza, or allergic conditions; (x) Certain drugs or classes of drugs used for both non-covered services or indications and for covered services or indications; (xi) Certain drugs or classes of drugs on the state maximum allowable cost or federal upper limit listings; (xii) Certain drugs or classes of drugs upon initial availability or marketing or when Nebraska Medicaid coverage begins; (xiii) Certain drugs or classes of drugs used for tobacco cessation; and (xiv) Certain drugs or classes of drugs determined by the Pharmaceutical and Therapeutics Committee to not be placed onto the preferred drug list (PDL). 004.02(D) PRIOR AUTHORIZATION FOR PHYSICIAN ADMINISTERED DRUGS. The following drugs administered in the clinical setting require prior authorization: (i) Any drug used for the prevention of respiratory syncytial virus infections; (ii) Certain drugs used for the treatment of multiple sclerosis; (iii) Enzyme replacement therapy (ERT) or lysomal storage disorders; (iv) Immunoglobulin E (IgE) blocker therapies for asthma; (v) Certain drugs or classes of drugs upon initial availability or marketing or when Nebraska Medicaid coverage begins; and (vi) Drugs not covered under the Nebraska Medicaid Early and Periodic Screening Diagnostic, and Treatment (EPSDT) program. 004.02(E) PRIOR AUTHORIZATION FOR BARIATRIC SURGERY. Prior authorization requests must include documentation of each of the three following subsections: (i) Medical diagnosis; (ii) Body mass index (BMI) 35 or greater with at least one of the following co-morbidities: (1) Type 2 Diabetes Mellitus including recent laboratory results and current medications; (2) Medically refrectory hypertension, including current medications, antihypertensive, and blood pressure readings; (3) Hyperlipidemia, including recent lab results and current medications; (4) Cardiovascular disease; (5)Coronary artery disease (CAD), congestive heart failure (CHF), dyslipidemia, including recent laboratory results and current medications; (6)Obstructive sleep apnea, including sleep study results and treatment; (7) Obesity-hypoventilation syndromes; (8)Gastroesophageal reflux disease (GERD), including test results and current medications being used to manage the symptoms; (9)Osteoarthritis, including information about the beneficiary’s ability to ambulate, assistive devices used, and any medications being ; or (10)Idiopathic intracranial hypertension (Pseudotumor cerebri); and (iii) Preoperative evaluation within six months of the scheduled surgery that includes: (1) Nutritional consultation that includes: (a) Diet and physical activity history and patterns of previous weight loss and regain; (b) Counseling on steps to modify current problem eating behaviors; (c) Counseling on postoperative dietary modifications; and (d) Determination of the beneficiary’s motivation to comply with dietary modifications to reduce the risk of postoperative complications. (2) Psychiatry or psychology consultation that includes: (a) Evaluation of the beneficiary to determine readiness for surgery and lifestyle change; (b) Assessment for major mental health disorders, psychosocial functioning, alcohol and substance use disorder, and maladaptive eating behaviors; and (c) Adequate treatment as needed, to maximize successful postoperative outcomes. (3) Medical clearance that includes: (a) Evaluation of cardiac and pulmonary risk; (b) Nutritional, hormonal, and other lab parameters as indicated; (c) No history of tobacco use, or tobacco cessation has been attempted prior to surgery; and (d) Beneficiary’s understanding of surgical risk, postoperative compliance, and follow-up. 004.02(F) PRIOR AUTHORIZATION FOR TRANSPLANT SERVICES. Prior authorization is required of all transplant services. Physicians must request and receive prior authorization before performing any transplant service or related donor service. The request for authorization must include, at a minimum: (i) The beneficiary’s name, Nebraska Medicaid identification number, and date of birth; (ii) Diagnosis, pertinent past medical history and treatment, prognosis with and without the transplant, and the procedures for which the authorization is requested; (iii) Name of the hospital, city, and state where the services will be performed, including the National Provider Identifier (NPI) of the provider; (1) All providers must be enrolled with Nebraska Medicaid before services are performed; (iv) Name of the physician who will perform the surgery if other than the physician requesting authorization; and (v) A physician specializing in the specific transplantation must also supply the following: (1) The screening criteria used in determining if the beneficiary is an appropriate candidate for a liver, heart, allogenic, intestinal, or multi-visceral transplant; (2) The results of the screening for the beneficiary ; and (3) A written statement by the physician: (a) Recommending the transplant; (b) Certifying and explaining why the transplant is medically necessary as the only clinical, practical, and viable alternative to prolong the beneficiary’s life in a meaningful, qualitative way and at a reasonable level of functioning; (c) Including a psycho-social evaluation for solid organ transplants; and (d)For heart, lung, liver, stem cell, bone marrow, allogeneic, or intestinal or multi-visceral transplants, a second physician specializing in the specified transplant must also supply the above required information. 004.02(G) PRIOR AUTHORIZATION FOR COSMETIC AND RECONSTRUCTIVE SURGERY. In addition to the prior authorization requirements included in this chapter, the surgeon who will be performing the cosmetic or reconstructive surgery must submit a request to Nebraska Medicaid. This request must include the following: (i) An overview of the medical condition and medical history of any conditions caused or aggravated by the condition; (ii) Photographs of the involved area when appropriate to the request; (iii) A description of the procedure being requested, including any plan to perform the procedure when it requires a staged process; and (iv) When appropriate, additional information regarding the medical history may be submitted by the beneficiary’s primary care physician. 004.02(H) PRIOR AUTHORIZATION OF RADIOLOGY PROCEDURES. All non-emergency outpatient computerized tomography (CT) scans, magnetic resonance angiogram (MRA) scans, magnetic resonance imaging (MRI) scans, magnetic resonance spectroscopy (MRS) scans, nuclear medicine cardiology scans, positron emission tomography (PET) scans, and single photon emission computed tomography (SPECT) will require prior authorization. These prior authorization requirements apply for all Nebraska Medicaid beneficiaries enrolled in fee-for-service programs and must be completed prior to the scan being performed. These requirements do not apply to these scans when performed during an inpatient hospitalization or as an emergency through the hospital’s emergency department. 004.02(I) PRIOR AUTHORIZATION FOR COMPREHENSIVE INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER. Prior authorization is required for all services before the services are provided. The requesting physician must submit a request to Nebraska Medicaid including the following information or explanation as appropriate to the case: (i) A referral from the primary care physician which includes current appropriate medical evaluations or treatment plans; (ii) Medical records for the last year which include height and weight measurements; and (iii) Any records from feeding and swallowing clinic evaluations and other therapeutic interventions which have occurred. 004.03 DEFINITIONS AND TERMS OF COMMONALITY. The Current Procedural Terminology (CPT) contains terms and phrases common to the practice of medicine. Claims for physicians' services must be coded according to the definitions in the Current Procedural Terminology (CPT). At the request of Nebraska Medicaid, the provider must submit copies of the beneficiary’s medical records to document the level of care provided. If the requested documentation is not provided or is insufficient in contents, payment may be withheld or recouped.