471 NAC 18-005. SERVICE-SPECIFIC REQUIREMENTS

005. SERVICE-SPECIFIC REQUIREMENTS. 005.01 FACILITY-BASED PHYSICIAN CLINICS. Physician clinic services provided in a hospital location or a facility under the hospital’s licensure are considered to be a physician service, not an outpatient hospital service. (A) Facility or hospital-based non-emergency physician clinics are not recognized for billing, reimbursement, or cost reporting purposes except for itinerant physicians as defined in this chapter . (B) Services and supplies incident to a physician’s professional service provided during a specific encounter are covered and reimbursed as physician clinic services if the service or supply is: (i) Of the type commonly furnished in a physician’s office; (ii) Furnished as an incidental, although integral, part of the physician professional service; and (iii) Furnished under the direct personal supervision of the physician. 005.02 HOSPITAL ADMISSION DIAGNOSTIC PROCEDURES. In addition to the previously defined medical necessity requirements, the following will be considered to determine whether a diagnostic procedure performed as part of the admitting procedure to a hospital is reasonable and medically necessary: (A) The test is specifically ordered by the attending physician, or a hospital staff physician responsible for the beneficiary when there is no attending physician; (B) The test is medically necessary for the diagnosis or treatment of the beneficiary’s condition; and (C) The test does not unnecessarily duplicate: (i) The same test performed on an outpatient basis before admission; or (ii) The same test performed in connection with a separate, but recent, hospital admission. 005.03 MINOR SURGICAL PROCEDURES. Reimbursement for excision of lesions of the skin or subcutaneous tissues include all services and supplies necessary to provide the service. Additional reimbursement is not made for suture removal to the physician who performed the initial services, or to a hospital. If the sutures are removed by a non-hospital-based physician who is not the physician who provided the initial service, separate payment may be approved for the suture removal. 005.04 TREATMENT FOR OBESITY. There will be no payment made for services provided when the sole diagnosis is obesity. While obesity is not itself considered an illness, there are conditions which can be caused by or aggravated by obesity. Treatment for obesity may be covered when the services are an integral and necessary part of a course of treatment or treatment for covered co-morbidities. 005.04(A) INTESTINAL BYPASS SURGERY. Intestinal bypass surgery for treatment of obesity is not covered. 005.04(B) BARIATRIC SURGERY FOR OBESITY. Bariatric surgery for beneficiaries with obesity may be covered when the surgery is medically appropriate for the beneficiary, and is performed to correct an illness which either causes obesity or was aggravated by obesity. Proof of accreditation must be submitted with each prior approval request. This procedure must be performed at a facility that is one of the following: (1) Accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP); or (2) A children’s hospital that has a comprehensive multidisciplinary bariatric surgery program and provides access to an experienced surgeon who employs a team that is capable of long-term follow-up of the metabolic and psychosocial needs of the client and family. 005.05 COSMETIC AND RECONSTRUCTIVE SURGERY. Cosmetic and reconstructive surgical procedures and medical services, are covered when medically necessary, for the purpose of correcting the following conditions: (1) Limitations in movement of a body part caused by trauma or congenital conditions; (2) Disfiguring or painful scars in areas which are visible; (3) Congenital birth anomalies that result in functional impairment or are severely disfiguring; (4) Post-mastectomy breast reconstruction; and (5) Other procedures determined to be restorative or necessary to correct a medical condition. 005.05(A) EXCEPTIONS. To determine the medical necessity of the condition, prior authorization is required for cosmetic and reconstructive surgical procedures except for the following conditions: (i) Cleft lip and cleft palate; (ii) Post-mastectomy breast reconstruction; (iii) Congenital hemangiomas of the face; and (iv) Nevus removals. 005.06 STERILIZATIONS. 005.06(A) COVERAGE RESTRICTIONS. Sterilization of beneficiaries is not covered when the beneficiary is: (i) Under the age of 21 on the date the beneficiary signs the appropriate Nebraska Medicaid approved consent form ; or (ii) Legally incapable of consenting to sterilization. 005.06(B) COVERAGE CONDITIONS. Sterilizations are only covered when: (i) The sterilization is performed because the beneficiary receiving the service made a voluntary request for services; (ii) The beneficiary is advised at the outset and before the request or receipt of their consent to the sterilization that benefits provided by programs or projects will not be withdrawn or withheld because of a decision not to be sterilized; (iii) Beneficiaries whose primary language is other than English are provided with the required elements for informed consent in their primary language; and (iv) Suitable arrangements are made to communicate the required elements of informed consent to a beneficiary who is blind, deaf, hard of hearing, or is otherwise disabled . 005.06(C) PROCEDURE FOR OBTAINING SERVICES. Non-therapeutic sterilizations are covered by Nebraska Medicaid only when: (i) Legally effective informed consent is obtained on the appropriate Nebraska Medicaid approved consent form from the beneficiary on whom the sterilization is to be performed. The surgeon must submit a completed form to Nebraska Medicaid before payment of claims can be considered; and (ii) The sterilization is performed at least 30 days following the date informed consent was given. To calculate this time period, day one is the first day following the date on which the form is signed by the beneficiary. Day 31 in this period is the first day on which the procedure may be covered. The consent is effective for 180 days from the beneficiary’s signature. 005.06(D) EXCEPTION. A beneficiary may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery if at least 72 hours have passed since the beneficiary signed the informed consent for the sterilization. For a premature delivery, the beneficiary must have signed the informed consent at least 72 hours before the surgery is performed and at least 30 days before the expected date of delivery. The expected delivery date must be entered on the appropriate Nebraska Medicaid approved consent form . 005.06(E) INFORMED CONSENT. Informed consent means the voluntary, knowing assent of the beneficiary who is to be sterilized after they have been given the following information and completed the appropriate Nebraska Medicaid consent form : (i) A clear explanation of the procedures to be followed; (ii) A full description of the discomforts and risks which may follow the procedure, including an explanation of the type and possible effects of any anesthetic to be used; (iii) A description of the benefits to be expected; (iv) Counseling concerning appropriate alternative methods, and the effect and impact of the proposed sterilization including the fact that it must be considered an irreversible procedure; (v) An offer to answer any questions concerning the procedures; (vi) An instruction that the beneficiary is free to withhold or withdraw consent to the sterilization at any time before the sterilization without prejudicing future care and without loss of other project or program benefits to which the beneficiary might otherwise be entitled; (vii) Advice that the sterilization will not be performed for at least 30 days, except under the circumstances previously specified; and (viii) The beneficiary to be sterilized must be permitted to have a witness of his or her choice present when informed consent was obtained. 005.06(F) STERILIZATION CONSENT FORMS. The surgeon will submit a completed Nebraska Medicaid approved consent form to Nebraska Medicaid before payment of claims can be considered. The consent form must be signed and dated by the beneficiary to be sterilized, the person obtaining consent, the physician who will perform the procedure, and the interpreter if one was provided. 005.07 HYSTERECTOMIES. Medically necessary hysterectomies are covered if the following conditions have been met, and a completed form is submitted to Nebraska Medicaid by the surgeon before claims for the hysterectomy can be considered for payment: (1) The provider who secured authorization to perform the hysterectomy has informed the woman and her representative, if any, orally and in writing, that the hysterectomy will make the woman permanently incapable of reproducing; and (2) The woman or her representative, if any, has signed the appropriate Nebraska Medicaid approved consent form , acknowledging receipt of the above information. 005.07(A) EXCEPTION. Informed consent is not required in the following situations and a copy of the surgeon’s certification of the following exceptions must be submitted to Nebraska Medicaid prior to consideration of payment for claims associated with the hysterectomy: (i) The woman was sterile before the hysterectomy, and the physician performing the hysterectomy certifies in writing that the woman was sterile before the hysterectomy and states the cause of the sterility; (ii) Post-menopausal women are considered to be sterile. All claims related to the procedure must indicate the woman is post-menopausal; or (iii) The woman requires a hysterectomy due to a life-threatening emergency situation and the physician determines informed consent is not possible. The physician performing the hysterectomy must certify, in writing, that the hysterectomy was performed under a life-threatening emergency situation in which informed consent was not possible. The physician must also include a certification of the emergency. 005.07(B) NON-COVERED HYSTERECTOMIES. Hysterectomies are not covered if they are performed solely to make the woman sterile or, if there was more than one purpose for the procedure, it would not have been performed except to make the woman sterile. 005.08 INFERTILITY. Coverage for infertility is limited to diagnosis and treatment of medical conditions when infertility is a symptom of a suspected medical condition. Reimbursement or coverage is not available when the sole purpose of the service is achieving a pregnancy. 005.09 ALCOHOL AND CHEMICAL DETOXIFICATION. Alcohol and chemical detoxification is limited to medically necessary treatment, subject to Nebraska Medicaid utilization review. 005.10 OSTEOGENIC STIMULATION. Electrical stimulation to augment bone repair, also known as osteogenic stimulation, can be performed either invasively or noninvasively. 005.10(A) INVASIVE OSTEOGENIC STIMULATION. The use of the invasive device is covered only for non-union of long bone fractures. Non-union is considered to exist only after six months or more have elapsed without the fracture healing. 005.10(B) NON-INVASIVE OSTEOGENIC STIMULATION. The use of the non-invasive device is covered only for non-union of long bone fractures, failed fusion, or congenital pseudoarthroses. 005.11 BIOFEEDBACK THERAPY. Biofeedback therapy is covered only when it is reasonable and necessary for the beneficiary for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments have not been successful. This therapy is not covered for treatment of ordinary muscle tension states, for psychosomatic conditions, or for psychiatric conditions. 005.12 SLEEP DISORDER CLINICS. Sleep disorder clinics are facilities in which certain conditions are diagnosed through the study of sleep. Diagnostic and therapeutic services of a sleep disorder clinic are covered under the following conditions. 005.12(A) DIAGNOSTIC SERVICES. Diagnostic testing which is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered. Beneficiaries who undergo diagnostic testing are not considered inpatients; however, if required as part of the diagnostic testing, the overnight stay is considered an integral part of these tests. All reasonable and necessary diagnostic tests given for narcolepsy and sleep apnea are covered when the following criteria are met: (i) The clinic is affiliated with a hospital; (ii) The beneficiary is referred to the sleep disorder clinic by a physician. The clinic must maintain a record of the attending physician’s orders with the physician’s signature; and (iii) The need for diagnostic testing is confirmed by medical evidence, such as physician examinations and laboratory tests. 005.12(B) THERAPEUTIC SERVICES. Therapeutic services may be covered provided they are standard and accepted services and are reasonable and medically necessary for the beneficiary . Sleep disorder clinics must provide therapeutic services in the hospital outpatient setting. Therapeutic services may be provided for: (i) Insomnia which is not associated with psychiatric disorders; (ii) Nocturnal myoclonus, also known as muscle jerks; (iii) Sleep apnea; (iv) Drug dependency; (v) Shift work and schedule disturbances; (vi) Restless leg syndrome; (vii) Hypersomnia, also known as excessive daytime sleepiness; (viii) Somnambulism; (ix) Night terrors or dream anxiety attacks; (x) Enuresis; and (xi) Bruxism. 005.13 SURGERY. Surgical procedures are covered, including 14 days of post-operative care. When multiple procedures are performed at the same time, the primary procedure and any secondary procedures are covered and reimbursed in accordance with this chapter. Incidental procedures through the same incision are not considered separate secondary procedures for reimbursement. 005.13(A) ASSISTANT SURGEON. The services of an assistant surgeon are covered when reasonable and medically necessary. 005.13(B) SECOND SURGICAL OPINION. Beneficiaries who desire a second physician's opinion concerning proposed surgery have coverage to receive a second physician’s opinion. 005.13(C) SERVICES PERFORMED IN AN AMBULATORY SURGICAL CENTER (ASC). In addition to the federally identified ambulatory surgical center (ASC) services, the certain state-defined services provided in an ambulatory surgical center (ASC) are covered. 005.14 HOSPITAL VISITS. Only one visit per day by the same physician, or physicians of the same specialty from the same group practice is covered, unless the primary physician states on the appropriate Nebraska Medicaid approved claim form , or electronically, more than one visit was necessary because of serious illness or change in condition, and approval is given by Nebraska Medicaid . 005.14(A) SURVEILLANCE AND UTILIZATION REVIEW CRITERIA. A medical review organization may be utilized to review inpatient hospital services. The physician must comply with all medical review requirements. For hospitalizations not subject to medical review, Nebraska Medicaid’s in-house utilization review will prevail. If a hospitalization is denied or reduced based on utilization review, the physician's claim may also be denied or reduced accordingly. 005.15 EMERGENCY ROOM SERVICES. At least one of the following conditions must be met before payment is approved for use of an emergency room: (1) The beneficiary is evaluated or treated for an emergency medical condition. The facility must review emergency room services and determine whether services provided in the emergency room constitute an emergency and bill accordingly; (2) If the beneficiary’s evaluation or treatment in the emergency room results in an approved inpatient hospital admission, the emergency room charges must be displayed on the inpatient claim as ancillary charges and included in the inpatient per diem; or (3) The beneficiary is referred by his or her physician for treatment in an emergency room. 005.15(A) NON-EMERGENT SERVICES. When the facility or Nebraska Medicaid determines services are non-emergent, the room fee for non-emergent services provided in an emergency room will be disallowed to 50 percent of what would otherwise be allowed. When these conditions are met, the physician's fee will be disallowed to the rate of a comparable office service. 005.16 PRENATAL, DELIVERY, AND POSTPARTUM CARE. Physicians' services related to pregnancy are covered. Routine prenatal care, delivery, six weeks' postpartum care, and routine urinalysis are reimbursed as a package service. The physician may claim, as independent procedures, those laboratory and medical services which are not related to the pregnancy, or which are not included as part of the global fee package service. Postpartum services are covered through the applicable postpartum period for beneficiaries who were eligible for, applied for, and received medical assistance on the day the pregnancy ends. After the infant is delivered, the infant is treated as a separate patient for reimbursement purposes. 005.16(A) CERTIFIED NURSE MIDWIFE (CNM) SERVICES. Certified nurse midwife (CNM) services which are medically necessary and provided in accordance with the practice as defined by law are covered. Routine office visits to a physician are not covered when a certified nurse midwife (CNM) is providing complete obstetrical care, unless documentation of medical necessity for the physician's office visit is submitted. Prenatal care, delivery, and postpartum care is covered as a global service. Auxiliary services, such as prenatal classes and home visits, are not paid separately. 005.17 PRENATAL PLUS PROGRAM (PPP). Prenatal Plus Program (PPP) services are covered when a Nebraska Medicaid-eligible pregnant mother has been determined by their prenatal health care provider to be at risk of having a negative maternal or infant health outcome. 005.17(A) NUTRITION COUNSELING. Nutrition counseling is provided by the prenatal clinician as part of routine prenatal care and is not reimbursed separately. If the beneficiary is referred to a licensed medical nutrition therapist (LMNT), the Prenatal Plus Program (PPP) covers up to six sessions of nutrition counseling. These sessions can be provided in-person or via audiovisual telehealth. 005.17(B) PSYCHOSOCIAL COUNSELING AND SUPPORT. If the beneficiary has mental health or substance use disorder needs, the beneficiary can be referred to a Nebraska Medicaid enrolled licensed independent practitioner to receive psychosocial counseling and support services. 005.17(C) BREASTFEEDING SUPPORT. Breastfeeding education is provided by the prenatal clinician as part of routine prenatal care and is not reimbursed separately. If the beneficiary is referred for a breastfeeding instruction session, it must be provided by a licensed medical nutrition therapist (LMNT) or an international board-certified lactation consultant (IBCLC). The session can be provided in-person or via audiovisual telehealth and in an individual or group setting. Beneficiaries are limited to one session per pregnancy. 005.17(D) GENERAL PATIENT EDUCATION AND HEALTH PROMOTION. The prenatal clinician provides beneficiary education as part of routine care and is not reimbursed separately. The beneficiary can be referred to an appropriate resource to receive the education. 005.17(E) TARGETED CASE MANAGEMENT (TCM). Targeted case management (TCM) services are provided to assist beneficiaries in gaining access to needed services. This includes a comprehensive assessment, periodic reassessment of the beneficiary’s needs, development and revision of a specific care plan that specifies goals and actions, referral to help the beneficiary obtain needed services, and monitoring and follow-up activities to ensure the care plan is implemented. Targeted case management (TCM) can be provided in-person, via audiovisual telehealth, or by telephone. A minimum of one targeted case management (TCM) interaction per month is required for reimbursement. 005.17(F) PRENATAL PLUS PROGRAM (PPP) DOCUMENTATION. All documentation for the Prenatal Plus Program (PPP) must be completed and maintained in the beneficiary’s medical records. All activities performed must be documented on the appropriate Nebraska Medicaid approved checklist form or directly in the beneficiary’s medical record. The documents must be made available to Nebraska Medicaid upon request. 005.18 ANTIGEN THERAPY. Payment for a reasonable supply of antigens which have been prepared for and administered to a particular beneficiary even though the antigens have not been administered to the beneficiary by the same physician who prepared them may be made if: (A) The antigens are prepared by a physician who is a doctor of medicine or osteopathy; and (B) The physician who prepared the antigens has examined the beneficiary and determined a plan of treatment and a dosage regimen. 005.19 DIALYSIS. Nebraska Medicaid follows Medicare’s requirements for coverage of dialysis are followed. 005.20 FAMILY PLANNING SERVICES. Family planning services, including consultation and procedures, provided upon the request of the beneficiary are covered. The beneficiary must be allowed to exercise freedom of choice in choosing a method of family planning. Family planning services performed in family planning clinics must be prescribed by a physician, and must be and furnished, directed, or supervised by a physician or registered nurse (RN). Family planning services must: (A) Be provided without regard to age, sex, or marital status. There can be no discrimination in the provision of services and information; and (B) Include available services and information relating to medical, social, and educational services and information, including initial physical examination and health history, annual and follow-up visits, laboratory services, prescribing and supplying contraceptive supplies and devices, counseling services, and prescribing medication for specific treatment. 005.21 FRACTURE CARE. Coverage of initial fracture care includes the application and removal of the first cast or traction device. 005.22 COVERED DRUGS. Outpatient prescription drugs are covered in accordance with federal law including legend drugs, compounded prescriptions, and over the counter (OTC) drugs indicated as covered on the Nebraska point of sale system or listed on Nebraska Medicaid’s website. 005.22(A) PREFERRED DRUG LIST (PDL). Prescribed drugs which are found to be therapeutically equivalent to or superior to other drugs within a therapeutic class and whose net cost is equal to or less than other drugs within a therapeutic class after consideration of applicable rebates or discounts negotiated by the Department or its designated contractor will be included on the preferred drug list (PDL) . Medications designated as non-preferred on the preferred drug list (PDL) will be subject to prior authorization. 005.22(B) COMPOUNDED PRESCRIPTIONS. Any mixture of drugs which results in a commercially available over the counter (OTC) preparation is not considered a compounded prescription. 005.22(C) OVER THE COUNTER (OTC) DRUGS. Only over the counter (OTC) drugs indicated as covered on the Nebraska point of sale system or listed on Nebraska Medicaid’s website are covered. Over the counter (OTC) drugs must be prescribed by a licensed practitioner. 005.22(D) BRAND NECESSARY CERTIFICATION OF DRUGS. The Federal Upper Limit (FUL) or State Maximum Allowable Cost (SMAC) limitations will not apply in any case where the prescribing physician certifies a specific brand is medically necessary. In these cases, the usual and customary charge, or National Average Drug Acquisition Cost (NADAC) will be the maximum allowable cost. The prescriber must certify on the appropriate Nebraska Medicaid approved physician’s certification form that a brand name is medically necessary. 005.22(E) INJECTIONS. Injections administered by the physician in the clinical setting are not reimbursable through the outpatient drug program. Medications used in this manner are considered medical services and are to be purchased, used, and billed to Nebraska Medicaid by the physician or clinic. 005.23 PRACTITIONER-ADMINISTERED MEDICATIONS. Practitioner administered injectable medications will be reimbursed at average sales prices (ASP) plus 6%, consistent with the Medicare Drug Fee Schedule. Injectable medications not available on the Medicare Drug Fee Schedule will be reimbursed at whole acquisition cost (WAC) plus 6.8%, or manual pricing based on the provider’s actual acquisition cost. Practitioner administered injectable medications, including specialty drugs, purchased through the Federal Public Health Service’s 340B Drug Pricing Program will be reimbursed at the 340B actual acquisition cost and no more than the 340B ceiling price. When billing for medications administered during the course of a clinic visit, the physician must use the appropriate Health Care Common Procedure Coding System (HCPCS) procedure code for the medication, the correct number of units per the Health Care Common Procedure Coding System (HCPCS) description, the National Drug Code (NDC) of the drug administered, the National Drug Code (NDC) unit of measure, and the number of National Drug Code (NDC) units. A Current Procedural Terminology (CPT) code for the administration must also be submitted. When billing for medication which does not have a specific level I or II code, the physician must use a miscellaneous Health Care Common Procedure Coding System (HCPCS) code with the name and National Drug Code (NDC) number identifying the drug and include the dosage given. If this information is not with the claim, the claim may be returned to the physician for completion or the claim may be paid at the lowest dosage manufactured for the specific drug. Payment for service is as described in this chapter. 005.23(A) ALLERGY INJECTIONS. Allergy injections must be administered under the supervision of a physician who can recognize early symptoms and signs of anaphylaxis and administer emergency medications where necessary. Allergy injections should be administered only in facilities equipped to treat anaphylaxis. 005.23(B) VITAMIN B-12 INJECTIONS. Vitamin B-12 injections are covered as specific or effective treatment for: (i) Gastrectomy; (ii) Idiopathic steatorrhea; (iii) Ileostomy; (iv) Internal cancers; (v) Macrocytic anemia; (vi) Megaloblastic anemia; (vii) During or after radiation therapy; (viii) Certain neuropathies; (ix) Pernicious anemia; and (x) Post-surgical and mechanical disorders. 005.24 CHEMOTHERAPY. Chemotherapy agents may be covered if all of the following criteria are met: (i) The agents are reasonable and medically necessary; (ii) The drug is approved by the Federal Drug Administration (FDA); and (iii) Nationally accepted oncology clinical guidelines have listings with the specific International Classifications of Diseases (ICD-10) diagnosis that is being treated for the drug or agent. 005.25 IMMUNIZATIONS. Routine immunizations are covered for children, adolescents, and adults that are medically necessary according to the Advisory Committee on Immunization Practices’ requirements that are effective the date the service is provided. Immunizations are available to children and adolescents from birth through age 20 under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. Vaccines for those beneficiaries age 18 and younger are available through the Vaccine for Children (VFC) program. When the vaccine is available through the Vaccine for Children (VFC) program and is a physician’s private stock vaccine, it will not be reimbursed. 005.26 LABORATORY SERVICES. Laboratory services may be provided in a physician’s or group of physicians’ private office, in a licensed and certified independent clinical laboratory, or in a hospital whose certification covers services performed in the laboratory. 005.26(A) PHYSICIAN’S OFFICE LABORATORY. A laboratory which a physician or a group of physicians maintains for performing diagnostic tests in connection with their own or the group practice is not considered an independent clinical laboratory. 005.26(B) LICENSED AND CERTIFIED INDEPENDENT CLINICAL LABORATORIES. A laboratory which is operated by or under the supervision of a hospital or the organized medical staff of the hospital which does not meet the definition of a hospital is considered to be an independent laboratory. A laboratory serving hospital inpatients and outpatients and operated on the premises of a hospital which meets the definition of a hospital is presumed to be subject to the supervision of the hospital or its organized medical staff and is not classified as an independent clinical laboratory. The hospital's certification covers the services performed in this laboratory. Laboratory tests which have been referred by one independent laboratory to another may be covered. Handling services for tests referred to a second laboratory are not covered. A specimen collection fee is not covered for samples where the cost of collecting the specimen is minimal, such as a throat culture, a routine capillary puncture, or a pap smear. 005.27 RADIOLOGY SERVICES. Claims for radiology procedures must have at least a provisional diagnosis or statement of symptoms. Claims with a diagnosis of routine radiology are not accepted. These services may be provided in a physician’s or group of physicians’ private office or a hospital whose certification covers the radiological services provided. 005.27(A) PHYSICIAN’S PRIVATE OFFICE. The total radiology procedure is covered when both the technical and professional components of medically necessary radiological procedures are performed in a physician's private office. 005.27(B) HOSPITAL RADIOLOGY SERVICES. Medically necessary radiological services that are referenced in this title are covered when ordered by a physician and performed in a hospital. The ordering physician is not reimbursed for interpreting radiology procedures performed outside their office. 005.27(C) MAMMOGRAMS. Mammograms are covered when provided based on a medically necessary diagnosis. In the absence of a diagnosis, mammograms provided according to the American Cancer Society's periodicity schedule are also covered. 005.27(D) ULTRASOUND DIAGNOSTIC PROCEDURES. Ultrasound diagnostic procedures listed by Medicare under Category I are covered. Claims for these procedures may be reviewed to ensure the techniques are medically appropriate and the general indications of Medicare's categories are met. Claims for uses other than those listed under Medicare's Category I will be reviewed before payment. Ultrasound procedures listed by Medicare under Category II are not covered. 005.27(E) COMPUTERIZED TOMOGRAPHY (CT) SCANS. Diagnostic examinations of the head and of certain other parts of the body performed by computerized tomography (CT) scanners are covered when medical and scientific literature and opinion support the use of a scan for the condition, the scan is reasonable and necessary for the beneficiary , and the scan is performed on a model of computerized tomography (CT) equipment which meets Medicare’s criteria for coverage. 005.27(E)(i) REASONABLE AND NECESSARY. To be determined reasonable and necessary for the beneficiary , the use of the computerized tomography (CT) scan must be medically appropriate considering the beneficiary’s symptoms and preliminary diagnosis. It may be determined the use of a computerized tomography (CT) scan as the initial diagnostic test was not reasonable and necessary because it was not supported by the beneficiary’s symptoms and complaints stated on the claim form or electronic format. Claims for computerized tomography (CT) scans are reviewed for evidence of abuse, such as the absence of reasonable indications for the scans, an excessive number of scans, or unnecessarily expensive types of scans. 005.27(F) PORTABLE X-RAY SERVICES. Diagnostic x-ray services provided by a certified portable x-ray provider are covered when provided in a place of residence used as the beneficiary’s home and in nonparticipating institutions. These services must be performed under the prescription of a physician and conditions relating to health and safety must be met. Diagnostic portable x-ray services are also covered when provided in participating nursing facilities (NF) under circumstances in which they cannot be covered as nursing facility (NF) services, such as those services not provided by the participating institution either directly or under arrangements which allow the institution to bill for the services. If portable x-ray services are provided in a participating hospital under arrangement, the hospital will bill for the service. 005.27(F)(i) COVERED PORTABLE X-RAY SERVICES. The following portable x-ray services are covered: (1) Skeletal films involving arms, legs, pelvis, vertebral column, and skull; (2) Chest films which do not involve the use of contrast media and are not used for routine screening or physical examinations; and (3) Abdominal films which do not involve the use of contrast media. 005.27(F)(ii) ELECTROCARDIOGRAMS. The taking of an electrocardiogram tracing by an approved provider of portable x-ray services may be covered as an other diagnostic test. 005.28 HOSPITAL DIAGNOSTIC AND THERAPEUTIC SERVICES. Hospital diagnostic and therapeutic services are procedures performed to determine the nature and severity of an illness or injury, or procedures used to treat disease or disorders. Hospital diagnostic and therapeutic services include both inpatient and outpatient hospital services. Hospital diagnostic and therapeutic services are comprised of two distinct elements: the professional component and the technical component. Other services may be designated as having professional and technical components when the services are identified. 005.28(A) PROFESSIONAL COMPONENT. The professional component of hospital diagnostic and therapeutic services includes those physician's services directly related to the medical care of the beneficiary . A physician includes not only a specialist but also a physician who normally performs or supervises these services for all inpatients and outpatients of a hospital, even though the physician does not otherwise specialize in this field. 005.28(A)(i) COVERAGE CONDITIONS. To be covered as a professional component, the physician’s services must: (1) Be personally provided to a beneficiary by a physician; (2) Contribute directly to the diagnosis or treatment of a beneficiary; (3) Ordinarily require performance by a physician; (4) Be medically necessary; and (5) For anesthesiology, laboratory, or radiology services, meet the requirements previously set forth in this chapter. 005.28(B) TECHNICAL COMPONENT. The technical component of hospital diagnostic and therapeutic services is comprised of two distinct elements: (i) Physicians’ professional services not directly related to the medical care of the beneficiary; and (ii) Hospital services. 005.28(C) PRE-ADMISSION TESTING. Pre-admission testing performed in a physician’s office which is performed solely to satisfy hospital pre-admission requirements is not covered. 005.287(D) RADIOLOGY AND PATHOLOGY. Medically necessary radiological and pathological services provided to inpatients and outpatients are covered. Only those services which are directly related to the beneficiary’s diagnosis are covered. 005.287(D)(i) OUTPATIENT DIAGNOSTIC SERVICES PROVIDED BY ARRANGEMENT. Medically necessary diagnostic services provided to an outpatient by arrangement are covered. 005.287(D)(ii) LABORATORY AND PATHOLOGY. 005.287(D)(ii)(1) PROFESSIONAL COMPONENT. The professional component of laboratory services provided by a physician to a beneficiary is covered as a physician’s service only if the services meet the conditions of coverage previously outlined and are: (a) Anatomical pathology services; or (b) Consultative pathology services, which must: (i) Be requested by the beneficiary’s attending physician; (ii) Relate to a test result which lies outside the clinically significant normal or expected range in view of the beneficiary’s condition; (iii) Result in a written narrative report included in the beneficiary’s medical record; and (iv) Require the exercise of medical judgment by the consulting physician; or (v) Be performed by a physician in personal administration of test devices, isotopes, or other materials to a beneficiary. 005.287(D)(ii)(2) TECHNICAL COMPONENT. Clinical laboratory services do not require performance by a physician and are considered the technical component. There is no professional component for these services. 005.28(D)(ii)(3) ANATOMICAL PATHOLOGY SERVICES. Anatomical pathology services are services which ordinarily require a physician's interpretation. If these services are provided to hospital inpatients or outpatients, the professional and technical components must be separately identified for billing and payment. 005.28(D)(ii)(4) CLINICAL LABORATORY CONSULTATION. A physician clinical laboratory consultation is covered if the consultation: (a) Is requested by the beneficiary’s attending physician; (b) Relates to a test result which lies outside the clinically significant normal or expected range for the beneficiary’s condition; (c) Results in a written narrative report which is included in the beneficiary’s record; and (d) Requires the exercise of medical judgement by the consulting physician. 005.28(D)(iii) RADIOLOGY. All radiology services have a technical component and a professional component. The professional and technical component of hospital services must be separately identified for billing and payment. 005.28(D)(iii)(1) PROFESSIONAL COMPONENT. The professional component of radiology services provided by a physician to a beneficiary is covered as a physician's service when the services meet the previously outlined conditions of coverage and the services are identifiable, direct, and discrete diagnostic or therapeutic services to a beneficiary. 005.28(D)(iii)(2) TECHNICAL COMPONENT. The technical component of hospital diagnostic and therapeutic services are services needed to produce the x-ray films or other items that are interpreted by the radiologist . 005.29 NON-PHYSICIAN CARE PROVIDERS. Services provided by non-physician care providers who have fulfilled all state and federal licensing, certification, and training requirements are covered, under the following conditions: (A) The non-physician care provider must meet the following definition: An individual trained to assist or act in the place of a physician; (B) The service provided by the non-physician care provider must be within the scope of practice as defined by state law; and (C) The non-physician care provider must provide the services under a practice agreement between the non-physician care provider and their supervising physician and must be approved by the Nebraska Board of Medicine and Surgery or the appropriate licensing agency in the state in which they provide the services. 005.30 PHYSICIAN SERVICES IN NURSING FACILITIES (NF), INTERMEDIATE CARE FACILITIES (ICF) AND INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). Initial certifications for admission into nursing facilities (NF), intermediate care facilities (ICF), or intermediate care facilities for individuals with developmental disabilities (ICF/DD) are required. The physician must examine the beneficiary before completing the certification, within the following time frames: (1) NURSING FACILITIES (NF). The beneficiary must have a physical examination no later than two business days after admission unless an examination was performed within five days before admission; and (2) INTERMEDIATE CARE FACILITIES (ICF). The beneficiary must have a recent physical examination within 30 days before admission or the date eligibility was determined, or no later than two business days after admission or the date eligibility was determined. 005.30(A) ANNUAL PHYSICAL EXAMINATION. All long-term care (LTC) facility residents are required to have an annual physical examination. The physician, based on their authority to prescribe continued treatment, determines the extent of the examination for beneficiaries based on medical necessity. Routine laboratory and radiology services which are not directly related to the beneficiary’s diagnosis and treatment are not covered; however, for the annual physical exam, a complete blood count (CBC), and urinalysis are not considered routine and are reimbursed based on the physician's orders when noted on the claim that these services were performed for an annual physical exam for a long-term care facility (LTC) resident. The results of the examination must be recorded in the beneficiary’s medical record. 005.30(B) PHYSICIANS’ SERVICES FOR NURSING FACILITY (NF) RESIDENTS. 005.30(B)(i) PHYSICIANS’ VISITS. The physician must see the nursing facility (NF) resident whenever necessary, but at least once every 30 days for the first 90 days following admission. After the 90th day following admission, an alternate schedule for physician's visits not to exceed 60 days may be adopted if the attending physician determines, and justifies in the beneficiary’s medical record, the beneficiary’s condition does not require visits at 30-day intervals. The facility's Utilization Review Committee will approve the alternate schedule. At the time of each visit, the physician must document the visit in the beneficiary’s medical record and write and sign a progress note on the beneficiary’s condition. 005.30(B)(ii) REVIEW OF PLAN OF CARE. The physician and facility staff involved in the nursing facility (NF) resident’s care will review each plan of care every 60 days. This should be done in conjunction with a physician's visit or recertification. 005.30(B)(iii) RECERTIFICATION. For nursing facility (NF) residents, the physician, the physician's assistant (PA), or nurse practitioner (NP) will recertify in writing the beneficiary’s continued need for the current level of care (LOC) every 30 days for the first 90 days, every 60 days thereafter, and at any time the beneficiary requires a different level of care (LOC). The nurse practitioner (NP) or physician’s assistant (PA), under the general supervision of a physician, may recertify the individual’s beneficiary’s need . The physician, the physician's assistant (PA), or nurse practitioner (NP) must sign, or stamp and initial, the recertification clearly identifying themselves. The recertification must also be dated at the time it is signed. Facility staff must maintain the recertification in the beneficiary’s medical record in the facility or building where the beneficiary resides. 005.30(B)(iii)(1) ON-SITE RECERTIFICATION. The recertifying practitioner must record recertification accomplished by on-site visits to the facility in the beneficiary’s record. 005.30(C) PHYSICIANS’ SERVICES FOR RESIDENTS OF INTERMEDIATE CARE FACILITIES (ICF’S) AND INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED (ICF/DD’S). 005.30(C)(i) PHYSICIAN’S VISITS. The physician must actually see the beneficiary to claim the service. At the time of each visit, the physician must document the visit in the beneficiary’s medical record and write and sign a progress note on the beneficiary’s condition. 005.30(C)(ii) REVIEW PLAN OF CARE. The interdisciplinary team, which includes the physician, must review each intermediate care facility (ICF) plan of care every 90 days. This should be done in conjunction with recertification and is not reimbursed separately. 005.30(C)(iii) RECERTIFICATION. The physician, physician’s assistant (PA), or nurse practitioner (NP) must recertify in writing the beneficiary’s continued need for the intermediate care facility for the developmentally disabled (ICF/DD) level of care (LOC) at least once every 365 days, and at any time the beneficiary requires a different level of care. The extended recertification period in no way indicates one year is the appropriate length of stay for a beneficiary in an intermediate care facility (ICF) for the developmentally disabled (ICF/DD). The interagency team responsible for the beneficiary’s care determines the beneficiary’s length of stay. The physician's assistant (PA) or nurse practitioner (NP) may recertify the beneficiary’s need under the general supervision of a physician when the physician formally delegates this function to the physician's assistant (PA) or nurse practitioner (NP). The physician, the physician's assistant (PA), or nurse practitioner (NP) must sign, or stamp and initial, the recertification clearly identifying themselves. The physician, physician's assistant (PA), or nurse practitioner (NP) must date the recertification at the same time it is signed. Facility staff must maintain the recertification in the beneficiary’s medical record in the facility or building where the beneficiary resides. 005.30(C)(iii)(1) ON-SITE RECERTIFICATION. The recertifying practitioner must record recertification accomplished by on-site visits to the facility in the beneficiary’s record. 005.31 TELEPHONE CONSULTATIONS. Telephone calls to or from a beneficiary, pharmacy, nursing facility (NF) , or hospital are not covered. Telephone consultations with another physician may be covered if the name of the consulting physician is indicated on or in the claim. 005.32 MEDICAL TRANSPLANTS. Transplants are covered, including donor services which are medically necessary and defined as non-experimental by Medicare. Transplantation services may be covered when performed in a facility approved by Centers for Medicaid & Medicare (CMS) as meeting coverage criteria. Nebraska Medicaid is the payor of last resort.. Prior authorization of all transplant services is required before the services are provided. An exception may be made for emergency situations, in which case verbal approval is obtained and the notification of authorization is sent later. 005.32(A) SERVICES FOR A NEBRASKA MEDICAID-ELIGIBLE DONOR. Medically necessary services are covered, including laboratory tests directly related to the transplant, for the Nebraska Medicaid-eligible donor to a Nebraska Medicaid-eligible beneficiary. The services must be directly related to the transplant. 005.32(B) SERVICES FOR A NEBRASKA MEDICAID-INELIGIBLE DONOR. Medically necessary services are covered, including laboratory tests directly related to the transplant, for a Nebraska Medicaid-ineligible donor to a Nebraska Medicaid-eligible beneficiary. The services must be directly related to the transplant and must directly benefit the Nebraska Medicaid transplant beneficiary . Coverage of treatment for complications related to the donor is limited to those which are reasonably medically foreseeable. 005.32(C) AMBULATORY ROOM AND BOARD. Ambulatory room and board services may be covered for transplant patients for the beneficiary and an attendant, if necessary. 005.33 ITINERANT PHYSICIAN VISITS. Non-emergency physician visits provided in a hospital outpatient setting are covered if the services are: (A) Provided by an out-of-town specialist who has a contractual agreement with the hospital. General practitioners or family practitioners are not considered to be specialists; and (B) Determined to have been provided in the most appropriate place of service . 005.34 NURSE PRACTITIONER SERVICES (NP). Nurse practitioner (NP) services are covered in accordance with the scope of practice applicable to their specific licensure designation. 005.35 DURABLE MEDICAL EQUIPMENT AND SUPPLIES. With certain exceptions, hospitals, hospital pharmacies, long-term care (LTC) facilities, rehabilitation services or centers, or physicians are not enrolled as providers of durable medical equipment and medical supplies. 005.36 ANESTHESIOLOGY. 005.36(A) PROFESSIONAL COMPONENT. The professional component of anesthesiology services provided by a physician to a beneficiary is covered as a physician’s service if the conditions in this chapter are met. 005.36(B) MEDICAL DIRECTION OF FOUR OR FEWER CONCURRENT PROCEDURES. The professional component for the physician's medical direction of concurrent anesthesiology services provided by qualified anesthetists is covered as a physician's service when the services meet the requirements previously designated as conditions of coverage and the following additional requirements: (1) For each beneficiary, the physician: (a) Performs and documents a pre-anesthetic examination and evaluation; (b) Prescribes the anesthesia plan; (c) Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence; (d) Ensures any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual; (e) Monitors the course of anesthesia administration at frequent intervals; (f) Remains physically present and available for immediate diagnosis and treatment of emergencies; and (g) Provides indicated post-anesthesia care; and (2) The physician directs no more than four anesthesia procedures concurrently and does not provide any other services while directing the concurrent procedures. 005.36(B)(i) OTHER SERVICES PROVIDED WHILE DIRECTING CONCURRENT PROCEDURES. A physician who is directing concurrent anesthesia services for four or fewer surgical patients must not ordinarily be involved in providing additional services to other patients. 005.36(B)(i)(1) SERVICES CONSIDERED A TECHNICAL COMPONENT. If the physician leaves the immediate area of the operating suite for longer than short durations, devotes extensive time to an emergency case, or is otherwise not available to respond to the immediate needs of surgical beneficiaries , the physician's services to the surgical beneficiary are supervisory in nature and are considered a technical component; therefore, these services must be billed as the technical component by the hospital. 005.36(C) MEDICAL DIRECTION OF MORE THAN FOUR CONCURRENT PROCEDURES. If the physician is involved in providing supervision for more than four concurrent procedures or is performing other services while directing concurrent procedures, the concurrent anesthesia services are covered as the technical component of the hospital services. The physician must ensure that a qualified individual performs any procedure in which the physician does not personally participate. The physician's personal services up to and including induction are considered the professional component. 005.36(D) STANDBY ANESTHESIA SERVICES. A physician's standby anesthesia services are covered when the physician is physically present in the operating suite, monitoring the beneficiary’s condition, making medical judgments regarding the beneficiary’s anesthesia needs, and is ready to furnish anesthesia services to a specific beneficiary who is known to be in potential need of services. 005.36(E) SERVICES OF CERTIFIED REGISTERED NURSE ANESTHETISTS (CRNA). When anesthesia services are provided by an anesthesiologist and a certified registered nurse anesthetist (CRNA) at the same time, only those services provided by the anesthesiologist are covered. In the event multiple surgical procedures are performed at the same time, only services provided by the certified registered nurse anesthetist (CRNA) for the major procedure are covered. Certified registered nurse anesthetist (CRNA) services for secondary procedures are not covered. 005.37 FEEDING AND SWALLOWING CLINIC SERVICES. This service is covered for those beneficiaries with dysphagia. The service is covered when the beneficiary is referred by a physician for a medical evaluation. The purpose of the evaluation is to assess the beneficiary’s current status and potential for improvement and to develop a plan of care for the beneficiary. 005.37(A) DEFINITIONS. For the purposes of feeding and swallowing clinic services, the following definitions will apply: 005.37(A)(i) SWALLOWING DISORDERS ASSESSMENT, COMPREHENSIVE. This includes, at a minimum, comprehensive evaluation by the occupational therapist (OT), speech-language pathologist, nurse, and nutritionist. The need for a psychological evaluation is determined by intake information; if necessary, the psychological evaluation is billed separately. 005.37(A)(ii) SWALLOWING DISORDER ASSESSMENT, EXTENDED. This includes, at a minimum, a comprehensive evaluation by the occupational therapist (OT) and extended evaluations by the speech-language pathologist, nurse, and nutritionist. The need for a psychological evaluation is determined by intake information; if necessary, the psychological evaluation is billed separately. 005.37(A)(iii) SWALLOWING DISORDER ASSESSMENT, BRIEF. The brief assessment includes approximately two hours of time for the occupational therapist (OT), speech-language pathologist, and nutritionist. 005.37(A)(iv) FOLLOW-UP VISIT, BRIEF. This includes a visit with two or more team members. 005.37(A)(v) FOLLOW-UP VISIT, EXTENDED. This includes a visit which involves four or more team members. 005.37(B) INITIAL EVALUATION. An initial evaluation must be performed by an interdisciplinary team, which, at a minimum, must include a nurse, occupational therapist (OT), speech-language pathologist, nutritionist, psychologist, and radiologist. The interdisciplinary team must be under the direction of a physician. After the initial visit, the interdisciplinary team formulates a formal written report and sends copies to the individual or family, the referring physician, and others designated by the beneficiary or family and by Nebraska Medicaid. The team contacts the referring physician and, if appropriate, other medical professionals, to provide immediate feedback to the team on primary findings and recommendations. 005.37(C) FOLLOW-UP VISITS. Follow-up visits must be available in a frequency adequate to meet beneficiary needs and program objectives. 005.37(D) FOLLOW-UP CALLS. Follow-up telephone calls are made after the initial evaluation and are included in the cost of the evaluation, as follows: (i) Within 48 hours after the evaluation, a team member calls the beneficiary or family to answer questions and provide clarification, if needed, for any information presented during the initial visit; (ii) Two to four weeks after the initial visit, a follow-up call is made to ask about progress and problems in following the plan of care; and (iii) Ongoing telephone communication is maintained with the beneficiary or family and referring physician to facilitate implementation of the plan of care. 005.38 COMPREHENSIVE INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER. Comprehensive interdisciplinary treatment for an infant or child with a severe feeding disorder is covered when it impacts the infant’s or child’s ability to consume sufficient oral nutrition to maintain adequate growth or weight. 005.38(A) DEFINITIONS. For the purposes of comprehensive interdisciplinary treatment for a severe feeding disorder service, the following definitions will apply: 005.38(A)(i) DAY TREATMENT. Daily therapy, which occurs Monday through Friday, from approximately 8:30 am to 5:00 pm. 005.38(A)(ii) OUTPATIENT. Therapy one to two times per week for one to three hours per day. 005.39 TOBACCO CESSATION. Tobacco cessation services are covered as practitioner and pharmacy services, for beneficiaries 18 years of age or older, under the following conditions: (A) Tobacco cessation services must be ordered by a physician or mid-level practitioner; (B) Up to two tobacco cessation sessions may be covered in a 12-month period. A session is defined as medical encounters and drug products as listed below. Beneficiary access to the Nebraska Tobacco Free Quitline will be unlimited; (C) Practitioner office visits: (i) Beneficiaries must see their medical care provider for evaluation particularly for any contraindications for drug products and to obtain prescriptions if tobacco cessation products are needed; and (ii) In addition to the evaluation, a total of four tobacco cessation counseling visits with a medical care provider or tobacco cessation counselor are covered for each tobacco cessation session. This may be a combination of intermediate or intensive tobacco cessation counseling visits; (D) Tobacco cessation products are covered as a pharmacy service for those 18 years of age or older who require this particular assistance; (i) Coverage of products used for tobacco cessation is limited to a maximum 90 days' supply in one tobacco cessation session. Up to two 90-day supplies may be covered in a 12-month period, beginning with the date the first prescription for the products is dispensed; and (ii) Tobacco cessation products will only be covered when beneficiaries are currently enrolled with, and actively participating in, the Nebraska Tobacco Free Quitline. Disenrollment or lack of active participation in the Nebraska Tobacco Free Quitline will result in discontinuation of Nebraska Medicaid coverage of tobacco cessation drug products; and (E) Referral to the Nebraska Tobacco Free Quitline may be made by a medical professional or a self-referral. 005.40 ENDOMETRIAL ASPIRATION. Vacutage type or other endometrial aspiration or curettage is covered. The provider must submit the pathologist's report on the tissue with all claims for this service. For diagnoses of absent, delayed, or late menstruation, the physician must administer a pregnancy test to verify the beneficiary is not pregnant. When requested, the provider must submit copies of beneficiaries’ medical records to Nebraska Medicaid . 005.41 MEDICAL NUTRITION THERAPY FOR BENEFICIARIES AGE 21 AND OLDER. Medical nutrition therapy is available to beneficiaries with medical needs which require nutritional assessment, intervention, and continued monitoring. One-on-one medical nutrition therapy provided by a licensed medical nutritional therapist (LMNT) is covered for beneficiaries age 21 and older under the following requirements: (A) The service is covered when the beneficiary is referred by a physician or nurse practitioner (NP). A nutritional assessment is done by the beneficiary’s primary care provider. The diagnostic finding from the exam must indicate a nutritional problem or condition of such severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted; (B) Beneficiaries must meet at least one of the following medical conditions: (i) Type I or Type II diabetes; (ii) Current kidney disease; or (iii) A kidney transplant in the last 36 months; (C) For beneficiaries who receive medical nutrition therapy as part of their overall dialysis care in a dialysis facility, medical nutrition therapy is not separately billable; and (D) Medical nutrition therapy includes the assessment, intervention, and counseling provided to prevent, improve, or resolve identified nutritional problems. Coverage of medical nutrition therapy allows for: (i) Three hours in the first year; (ii) Two hours in subsequent years; and (iii) Additional hours are considered to be medically necessary and covered if the treating physician determines there is a change in medical condition, diagnosis, or treatment regimen which requires a change in medical nutrition therapy and orders additional hours during that episode of care. Nebraska Medicaid may request periodic review of the services.