471 NAC 18-006. NON-COVERED SERVICES

006. NON-COVERED SERVICES. Non-covered services will not be covered by Nebraska Medicaid. Services are reviewed on a case-by-case basis to determine if they are covered. 006.01 SERVICES REQUIRED TO TREAT COMPLICATIONS OR CONDITIONS RESULTING FROM NON-COVERED SERVICES. If medically necessary services which are required to treat complications or conditions resulting from non-covered services are determined to be part of a previous non-covered service, such as an extension or a periodic segment of a non-covered service or follow-up care associated with it, the subsequent services will be denied. 006.02 SERVICES NOT REASONABLE AND NECESSARY. Items and services which are not reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the function of a malformed body member are not covered. 006.03 SURGICAL ASSISTANT FEES. Surgical assistance fees for the following procedures are not covered. Additional assistant fees may be determined to be noncovered during the utilization review process. (A) Laparoscopy, including laparoscopic tubal ligation; (B) Tonsillectomy, adenoidectomy, myringotomy; (C) Conservative or closed fracture care; and (D) Uncomplicated procedures of the integument. 006.04 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 for these services is prohibited. 006.04(A) RELATED SERVICES. Associated or adjunctive services which 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. 006.04(B) INVESTIGATIONAL AND EXPERIMENTAL CRITERIA. Services may be deemed investigational or experimental by Nebraska Medicaid, which 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: (1) The Food and Drug Administration (FDA), or other governmental or regulatory authority, has not approved the service or treatment for general marketing to the public for the proposed use; (2) Reliable evidence does not lead to the conclusion that there is a consensus within the medical community 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 or proposed use and age group. Also, facility specific data, including short and long term outcomes, must be submitted to Nebraska Medicaid; (3) 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 (4) The service is the subject of an ongoing clinical trial which 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. 006.04(C) DEFINITION OF CLINICAL TRIALS. For services not subject to Food and Drug Administration (FDA) approval, the following definitions apply: (i) PHASE I. Initial introduction of an investigational service into humans. (ii) PHASE II. Controlled clinical studies conducted to evaluate the effectiveness of the service for a particular indication or medical condition of the beneficiary; these studies are also designed to determine the short-term side effects and risks associated with the clinical trial. (iii) PHASE III. Clinical studies to further evaluate the effectiveness and safety of a service which is needed to evaluate the overall risk and benefit and to provide an adequate basis for determining patient selection criteria for the service as the recommended standard of care. These studies usually compare the clinical trial to the current recommended standard of care. 006.05 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 or 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 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. 006.06 INFLUENZA INJECTIONS IN LONG-TERM CARE (LTC) FACILITIES. No payment is made to a physician giving influenza injections in long-term care (LTC) facilities. 006.07 INJECTABLE ESTROGENS. Injectable estrogens for depression or osteoporosis associated with menopause are not covered. 006.08 LIVER AND VITAMIN INJECTIONS. Liver and vitamin injections are not covered. 006.09 AUTOPSIES. Autopsies are a non-covered service . 006.10 REQUESTS FOR NEBRASKA MEDICAID COVERAGE. Requests for Nebraska Medicaid coverage for new or currently non-covered services or those which may be considered experimental or investigational must be submitted in writing before providing the services, or in the case of medical emergencies, before submitting a claim. The request for coverage must include sufficient information to document the new service is not considered investigational or experimental for Nebraska Medicaid payment purposes. Reliable evidence must be submitted identifying the status on the new service with regard to cost-benefit data, short- and long-term outcome data, patient selection criteria which is both disease or condition specific and age specific, information outlining the circumstances under which the service is considered the accepted standard of care, and any other information which would be helpful to Nebraska Medicaid in deciding coverage determination. Requests must be submitted to Nebraska Medicaid, and additional information may be requested. Nebraska Medicaid will make the final determination of coverage. The decision is final and is not appealable.