Haw. Code R. § 17-1737-84

Current through September, 2024

Section 17-1737-84 - Exclusions and limitations

(a) Medical assistance payments shall not be made for certain health services or items for reasons including, but not limited to the following:

(1) The procedure, service, or material is of generally unproven benefit;

(2) It is of an experimental nature;

(3) It is excluded by federal regulations or state rules;

(4) It is not considered by the department to be medically necessary;

(5) The same or similar results may be obtained by another method at a reduced cost;

(6) The procedure is frequently followed by severe complications which may be in themselves life-threatening or require prolonged medical care or secondary operations; or

(7) Prior authorization is required but has not been obtained.

(b) Based on subsection (a), the following procedures or services are excluded and the medical assistance program shall not pay any services in association with them:

(1) Drugs not approved by the U.S. Food and Drug Administration;

(2) Long term psychiatric institutional treatment;

(3) Treatment of a person confined to a public institution regardless of where the treatment is performed;

(4) The follow-up examination or treatment of Hansen's disease after the diagnosis has been established regardless of whether the patient is contagious except for surgical or rehabilitative procedures to restore useful function;

(5) Treatment for tuberculosis when such treatment is available free to the general public;

(6) Acupuncture;

(7) Naturopathic, chiropractic, or Christian Science or faith healing services;

(8) Private duty nursing;

(9) Circumcision after twelve months of age unless there is documentation of phimosis severe enough to prevent retraction, recurrent balanitis, severe verrucae of or under the prepuce or severe adhesions between glans and prepuce;

(10) Repair of umbilical or ventral herniae unless they are painful or bowel is present in the sac;

(11) Excision or destruction of benign skin or subcutaneous lesions except hemangiomas, plantar warts, molluscum contagiosum, leukiplakia or milia without medical justification;

(12) Hysterectomies and sterilization procedures not complying with the restrictions under sections 17-1737-47 and 17-1737-48;

(13) Reversal of elective sterilization procedures;

(14) Rhinoplasties except following accidental injury resulting in significant obstruction of breathing;

(15) Gastroplasty or other surgical procedures on the stomach or bowel, or both, when performed for morbid obesity unless the operation may logically be expected to improve an established medical condition such as cardiac or respiratory decompensation or severe hypertension. Guidelines issued by the department shall be met;

(16) Orthodontic services except for the provisions of section 17-1737-75(c)(1) and fixed bridgework;

(17) Orthoptic training;

(18) Tinted and contact lenses except as described under section 17-1737-76 (visual services);

(19) Personal comfort items such as radios, televisions, telephones, fans, or air conditioners;

(20) Standard household items such as beds, linens, cooking utensils, or blenders;

(21) Cosmetic, reconstructive, or plastic surgery performed primarily to improve or change physical appearance, performed primarily for psychological purposes, or to restore form but which does not correct or materially improve bodily function. However, consideration may be given when the purpose of the procedure is to:

(A) Correct a congenital anomaly;

(B) Restore body form following an accidental injury; or

(C) Revise disfigurement or extensive scars, or both, resulting from neoplastic surgery;

(22) Specific cosmetic surgery procedures including:

(A) Sex transformation treatments, procedures, hormones, or other medication for the establishment or maintenance of gender reassignment except that medication may be allowed if the sex of the individual has been changed by court order;

(B) Cosmetic, reconstructive, or plastic surgery procedures performed primarily for psychological reasons or as a result of the aging process;

(C) Augmentation mammoplasties except following medically indicated mastectomies for carcinoma, precancerous conditions, or extensive fibrosis or traumatic amputation;

(D) Reduction mammoplasties unless there is medical documentation of intractable pain not amenable to other forms of treatment as a result of increasingly large pendulous breasts;

(E) Paniculectomies and other body sculpturing procedures;

(F) Removal of tattoos;

(G) Hair transplants;

(H) Electrolysis;

(I) Insertion of testicular prostheses, unilateral or bilateral;

(J) Jejuno-ileal by-pass procedures for morbid obesity;

(K) Ear piercing;

(23) In vitro fertilization procedures;

(24) Medications, devices, or agents for the treatment of erectile dysfuction in males;

(25) Swimming lessons, summer camp, gym membership, weight control classes, or smoking cessation classes;

(26) Personal use of physical therapy equipment that is customarily used by a physical therapist in a physical therapy treatment or modality including, but not limited to, tilt tables, whirlpools, mats, play equipment, or exercise equipment;

(27) Modifications to motor vehicles; and

(28) Equipment to access motor vehicles or modifications to access motor vehicles.

(c) The UCC shall apply these exclusions in facilities and for recipients under its review. In other cases authorization of the department shall be obtained before performing any of the above procedures where exclusions are allowed.

(d) A medical service, supply, or durable medical equipment excluded from coverage may be approved on a case by case basis by the deparment if there is sufficient justification to support the medical necessity, as determined by its medical consultant.

(e) All other forms or types of health care services and supplies not specifically mentioned in this chapter shall not be included in the program. Questions regarding a form or type of health care service or supply shall be directed to the medical consultant.

(f) New tests, procedures, equipment, supplies, and other services for which payment has not been claimed previously shall not be considered for inclusion until information satisfactory and acceptable to the program has been received and approval given. This particularly applies to tests and procedures not included in the HCPCS code, where several procedures are being clumped under one heading, or a single procedure is divided into several components.

Haw. Code R. § 17-1737-84

[Eff 08/01/94; am 03/30/96; am 11/25/96; am 02/10/97; am 07/06/99; am 06/19/00; am 10/26/01; 09/17/07 ] (Auth: HRS § 346-14) (Imp: 42 C.F.R. §456.3 )