471 Neb. Admin. Code, ch. 18, § 005

Current through June 17, 2024

Section 471-18-005 - COVERED SERVICES

005.01FACILITY-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) The Department does not recognize facility or hospital-based non-emergency physician clinics for billing, reimbursement, or cost reporting purposes except for itinerant physicians as defined in 471 NAC 18.

(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.

005.02HOSPITAL ADMISSION DIAGNOSTIC PROCEDURES. In addition to the previously defined medical necessity requirements, the Department will consider the following 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 admitting physician, or a hospital staff physician responsible for the individual when there is no admitting physician;

(B) The test is medically necessary for the diagnosis or treatment of the individual'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.

005.03MINOR SURGICAL PROCEDURES. Reimbursement for excision of lesions of the skin or subcutaneous tissues include all services and supplies necessary to provide the service. The Department does not make additional reimbursement 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, the Department may approve separate payment for the suture removal.

005.04TREATMENT FOR OBESITY. The Department will not make payment 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. Nebraska Medicaid does not cover intestinal bypass surgery

005.04(B)BARIATRIC SURGERY FOR OBESITY. This procedure must be performed at a Bariatric Surgery Center of Excellence. Bariatric surgery for individuals with severe obesity may be covered when the surgery is medically appropriate for the individual and is performed to correct an illness which either causes the obesity or was aggravated by obesity.

005.05COSMETIC AND RECONSTRUCTIVE SURGERY. Nebraska Medicaid covers cosmetic and reconstructive surgical procedures and medical services, 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;

(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, the Department requires prior authorization 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.

005.06STERILIZATIONS.

005.06(A)COVERAGE RESTRICTIONS. Nebraska Medicaid does not cover sterilization of individuals:

(i) Under the age of 21 on the date the individual signs Form MMS-100: Sterilization Consent Form; or

(ii) Who are mentally incompetent or institutionalized.

005.06(B)COVERAGE CONDITIONS. Nebraska Medicaid covers sterilizations only when:

(i) The sterilization is performed because the individual receiving the service made a voluntary request for services;

(ii) The individual 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) Individuals 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 an individual who is blind, deaf, or otherwise handicapped.

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 Form MMS-100: Sterilization Consent Form from the individual on whom the sterilization is to be performed. The surgeon must submit a completed form to the Department 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 1 is the first day following the date on which the form is signed by the individual. 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 individual's signature.

005.06(D)EXCEPTION. An individual 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 individual signed the informed consent for the sterilization. For a premature delivery, the individual 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 Form MMS-100: Sterilization Consent Form

005.06(E)INFORMED CONSENT. Informed consent means the voluntary, knowing assent of the individual who is to be sterilized after they have been given the following information and completed Form MMS-100: Sterilization 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 individual 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 individual 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 individual 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 Form MMS-100: Sterilization Consent Form to the Department before payment of claims can be considered. The Sterilization Consent Form must be signed and dated by the individual to be sterilized, the person obtaining consent, the physician who will perform the procedure, and the interpreter if one was provided.

005.07HYSTERECTOMIES. Nebraska Medicaid covers a medically necessary hysterectomy if the following conditions have been met and a completed form is submitted to the Department by the surgeon before claims for the hysterectomy can be considered for payment:

(1) The individual who secured authorization to perform the hysterectomy has informed the individual and her representative, if any, orally and in writing, that the hysterectomy will make the individual permanently incapable of reproducing; and

(2) The individual or her representative, if any, has signed Form MMS-101: Informed Consent for Hysterectomy, acknowledging receipt of the above information.

005.07(A)EXCEPTION. Informed consent is not required in the following situations. A copy of the surgeon's certification of the following exceptions must be submitted to the Department prior to consideration of payment for claims associated with the hysterectomy:

(i) The individual was sterile before the hysterectomy, and the physician performing the hysterectomy certifies in writing that the individual was sterile before the hysterectomy and states the cause of the sterility;

(ii) Nebraska Medicaid considers post-menopausal women to be sterile. All claims related to the procedure must indicate the individual is post-menopausal; or

(iii) The individual 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 HYSTERCTOMIES. Nebraska Medicaid does not cover a hysterectomy if it was 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.

005.08INFERTILITY. Nebraska Medicaid limits coverage for infertility 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.

005.09ALCOHOL AND CHEMICAL DETOXIFICATION. Nebraska Medicaid limits alcohol and chemical detoxification to medically necessary treatment, subject to the Department's utilization review.

005.10OSTEOGENIC 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. Nebraska Medicaid covers use of the invasive device only for non-union of long bone fractures. Nebraska Medicaid considers non-union to exist only after six months or more have elapsed without the fracture healing.

005.10(B)NON-INVASIVE OSTEOGENIC STIMULATION. Nebraska Medicaid covers the use of the non-invasive device only for non-union of long bone fractures, failed fusion, or congenital psuedoathroses.

005.11BIOFEEDBACK THERAPY. Nebraska Medicaid covers biofeedback therapy only when it is reasonable and necessary for the individual 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.

005.12SLEEP DISORDER CLINICS. Sleep disorder clinics are facilities in which certain conditions are diagnosed through the study of sleep. Nebraska Medicaid covers diagnostic and therapeutic services of a sleep disorder clinic 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. Individuals 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 must be affiliated with a hospital;

(ii) The individual must be referred to the sleep disorder clinic by a physician. The clinic must maintain a record of the attending physician's orders; and

(iii) The need for diagnostic testing must be confirmed by medical evidence, such as physician examinations and laboratory tests.

005.12(B)THERAPEUTIC SERVICES. Nebraska Medicaid may cover therapeutic services provided they are standard and accepted services, and are reasonable and medically necessary for the individual. 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.

005.13SURGERY. Nebraska Medicaid covers surgical procedures, 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. Nebraska Medicaid covers the services of an assistant surgeon when reasonable and medically necessary.

005.13(B)NEW OR UNUSUAL SURGICAL PROCEDURES. Nebraska Medicaid may cover new or unusual surgical procedures. In all cases, the Department will determine the necessity or usefulness of the procedure pursuant to a prior authorization request.

005.13(C)SECOND SURGICAL OPINION. Nebraska Medicaid provides coverage for individuals who desire a second physician's opinion concerning proposed surgery.

005.13(D)SERVICES PERFORMED IN AN AMBULATORY SURGICAL CENTER. In addition to the federally-identified ambulatory surgical center services, Nebraska Medicaid covers the certain state-defined services provided in an ambulatory surgical center. Payment for facility services provided in connection with the state-defined procedures will not exceed payment for the corresponding group of Medicare-covered ambulatory surgical center procedures. Federally-identified ambulatory surgical center services are defined in 471 NAC 26.

005.14HOSPITAL VISITS. Nebraska Medicaid covers only one visit per day by the same physician, or physicians of the same specialty from the same group practice, unless the primary physician states on Form CMS-1500: Health Insurance Claim Form, or electronically, more than one visit was necessary because of serious illness or change in condition, and approval is given by the Department.

005.14(A)SURVEILLANCE AND UTILIZATION REVIEW CRITERIA. The Department may contract with a medical review organization to review inpatient hospital services. The physician must comply with all medical review requirements. For hospitalizations not subject to medical review, the Department'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.

005.15EMERGENCY ROOM SERVICES. At least one of the following conditions must be met before the Department approves payment for use of an emergency room:

(1) The individual 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 individual'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 individual is referred by his or her physician for treatment in an emergency room.

005.15(A)NON-EMERGENT SERVICES. When the facility or the Department determines service 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. All other Nebraska Medicaid allowable charges incurred in this type of visit will be paid according to 471 NAC 10.

005.16PRENATAL, DELIVERY, AND POSTPARTUM CARE. Nebraska Medicaid covers physicians' services related to pregnancy. 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 package service. Postpartum services are covered for a 60-day period beginning on the day of delivery, and any remaining days in the month in which the 60th day falls, for women 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)NURSE MIDWIFE SERVICES. Nebraska Medicaid covers nurse midwife services which are medically necessary and provided in accordance with the practice as defined by law. Nebraska Medicaid does not cover routine office visits to a physician when a nurse midwife is providing complete obstetrical care, unless documentation of medical necessity for the physician's office visit is submitted. Nebraska Medicaid covers pre-natal care, delivery, and post-partum care as a package service. Auxiliary services, such as pre-natal classes and home visits, are not paid separately.

005.17ANTIGENS. Nebraska Medicaid may make payment for a reasonable supply of antigens which have been prepared for and administered to a particular individual even though the antigens have not been administered to the individual by the same physician who prepared them 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 individual and determined a plan of treatment and a dosage regimen.

005.18DIALYSIS. Nebraska Medicaid follows Medicare's guidelines for coverage of dialysis.

005.19FAMILY PLANNING SERVICES. Nebraska Medicaid covers family planning services, including consultation and procedures, provided upon the request of the individual. The individual 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. 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) The scope of available services and information must include 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.

005.20FRACTURE CARE. Coverage of initial fracture care includes the application and removal of the first cast or traction device.

005.21DRUGS.

005.21(A)COVERED DRUGS. Nebraska Medicaid covers outpatient prescription drugs in accordance with the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) ( Public Law 101-508 ) including legend drugs, compounded prescriptions, and over-the-counter (OTC) drugs indicated as covered on the Nebraska Point of Sale System or listed on the Department's website.

005.21(A)(i)PREFERRED DRUG LIST (PDL). Nebraska Medicaid will include on the preferred drug list prescribed drugs which are found to be therapeutically equivalent to or superior to other drugs within a therapeutic class, and the net cost of the drugs are equal to or less than other drugs within a therapeutic class after consideration of applicable rebates or discounts negotiated by the Department or it's designated contractor. Medications designated as non-preferred on the preferred drug list will be subject to prior authorization. The Pharmaceutical and Therapeutics Committee will develop criteria for use of medications with non-preferred status. The Department will maintain an updated preferred drug list in electronic format and will make the list available to the public on the Department's internet web site.

005.21(A)(ii)COMPOUNDED PRESCRIPTIONS. Any mixture of drugs which results in a commercially available over-the-counter (OTC) preparation is not considered a compounded prescription.

005.21(A)(iii)OVER-THE-COUNTER (OTC) DRUGS. Nebraska Medicaid covers only over-the-counter (OTC) drugs indicated as covered on the Nebraska Point of Sale System or listed on the Department's website. Over-the-counter (OTC) drugs must be prescribed by a licensed practitioner.

005.21(B)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 Form MC-6: Physician's Certification Form that a brand name is medically necessary.

005.21(C)INJECTIONS. In addition to the limitations in 471 NAC 16, 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 the Department by the physician or clinic.

005.22PRACTITIONER-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 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 Department may return the claim to the physician for completion or pay the claim at the lowest dosage manufactured for the specific drug. Payment for service is as described in this chapter.

005.22(A)ALLERGY INJECTIONS. See payment limitations in this chapter.

005.22(B)VITAMIN 8-12 INJECTIONS. Nebraska Medicaid covers vitamin B-12 injections 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.

005.23CHEMOTHERAPY. Nebraska Medicaid covers chemotherapy which has been provided and billed in accordance with this chapter.

005.24IMMUNIZATIONS. Routine immunizations are available to Nebraska Medicaid covered children and adolescents from birth through age 20 under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. Vaccines for those individuals age 18 and younger are available through the Vaccine for Children (VFC) program. The Department will not reimburse for a physician's private stock vaccine when the vaccine is available through the Vaccine for Children (VFC) program. Immunizations for adults age 21 and older are covered by the Department on a case by case basis when medically necessary.

005.25LABORATORY 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.

005.25(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.

005.25(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. Nebraska Medicaid may cover laboratory tests which have been referred by one independent laboratory to another. Nebraska Medicaid does not cover handling services for tests referred to a second laboratory. 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.

005.26RADIOLOGY SERVICES. Claims for radiology procedures must have at least a provisional diagnosis or statement of symptoms. The Department will not accept claims with a diagnosis of 'routine radiology'. 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.

005.26(A)PHYSICIAN'S PRIVATE OFFICE. Nebraska Medicaid covers the total radiology procedure when both the technical and professional components of medically necessary radiological procedures are performed in a physician's private office.

005.26(B)HOSPITAL RADIOLOGY SERVICES. When a physician orders medically necessary radiological services performed in a hospital, Nebraska Medicaid covers those services under 471 NAC 10. The Department does not reimburse the private physician for interpreting radiology procedures performed outside their office.

005.26(C)MAMMOGRAMS. Nebraska Medicaid covers mammograms when provided based on a medically necessary diagnosis. In the absence of a diagnosis, Nebraska Medicaid covers mammograms provided according to the American Cancer Society's periodicity schedule.

005.26(D)ULTRASOUND DIAGNOSTIC PROCEDURES. Nebraska Medicaid covers ultrasound diagnostic procedures listed by Medicare under Category I. The Department may review claims for these procedures 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. Nebraska Medicaid does not cover ultrasound procedures listed by Medicare under Category II.

005.26(E)COMPUTERIZED TOMOGRAPHY (CT) SCANS. Nebraska Medicaid covers diagnostic examinations of the head and of certain other parts of the body performed by computerized tomograhy (CT) scanners when medical and scientific literature and opinion support the use of a scan for the condition, the scan is reasonable and necessary for the individual, and the scan is performed on a model of computerized tomograhy (CT) equipment which meets Medicare's criteria for coverage.

005.26(E)(i)REASONABLE AND NECESSARY. To be determined reasonable and necessary for the individual, the use of the computerized tomograhy (CT) scan must be medically appropriate considering the individual's symptoms and preliminary diagnosis. The Department may determine the use of a computerized tomograhy (CT) scan as the initial diagnostic test was not reasonable and necessary because it was not supported by the individual's symptoms and complaints stated on the claim form or electronic format. The Department reviews claims for computerized tomograhy (CT) scans 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.

005.26(F)PORTABLE X-RAY SERVICES. Nebraska Medicaid covers diagnostic x-ray services provided by a certified portable x-ray provider when provided in a place of residence used as the individual's home and in nonparticipating institutions. These services must be performed under the general supervision of a physician and certain conditions relating to health and safety must be met. Nebraska Medicaid also covers diagnostic portable x-ray services when provided in participating skilled nursing facilities (SNF) under circumstances in which they cannot be covered as skilled nursing facility (SNF) 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.

005.26(F)(i)COVERED PORTABLE X-RAY SERVICES. Nebraska Medicaid covers the following portable x-ray services:

(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.

005.26(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'.

005.27HOSPITAL 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. Nebraska Medicaid may designate other services as having professional and technical components when the services are identified.

005.27(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 individual. 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.

005.27(A)(i)COVERAGE CONDITIONS. To be covered as a professional component, the physician's services must:

(1) Be personally provided to an individual by a physician;

(2) Contribute directly to the diagnosis or treatment of an individual;

(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.

005.27(B)TECHNICAL COMPONENT. The technical component of hospital diagnostic and therapeutic services is covered in accordance with 471 NAC 10.

005.27(C)PRE-ADMISSION TESTING. Nebraska Medicaid does not cover preadmission testing performed in a physician's office which is performed solely to satisfy hospital pre-admission requirements.

005.27(D)RADIOLOGY AND PATHOLOGY. Nebraska Medicaid covers medically necessary radiological and pathological services provided to inpatients and outpatients. Nebraska Medicaid covers only those services which are directly related to the individual's diagnosis.

005.27(D)(i)OUTPATIENT DIAGNOSTIC SERVICES PROVIDED BY ARRANGEMENT. Nebraska Medicaid covers medically necessary diagnostic services provided to an outpatient by arrangement.

005.27(D)(ii)LABORATORY AND PATHOLOGY.

005.27(D)(ii)(1)PROFESSIONAL COMPONENT. Nebraska Medicaid covers as a physician's service the professional component of laboratory services provided by a physician to an individual 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 individual's attending physician;

(ii) Relate to a test result which lies outside the clinically significant normal or expected range in view of the individual's condition;

(iii) Result in a written narrative report included in the individual's medical record; and

(iv) Require the exercise of medical judgment by the consulting physician; or

(v) Services performed by a physician in personal administration of test devices, isotopes, or other materials to an individual.

005.27(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.

005.27(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.

005.27(D)(ii)(4)CLINICAL LABORATORY CONSULTATION. Nebraska Medicaid covers a physician clinical laboratory consultation if the service:

(a) Is requested by the individual's attending physician;

(b) Relates to a test result which lies outside the clinically significant normal or expected range for the individual's condition;

(c) Results in a written narrative report which is included in the individual's record; and

(d) Requires the exercise of medical judgement by the consulting physician.

005.27(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.

005.27(D)(iii)(1)PROFESSIONAL COMPONENT. The professional component of radiology services provided by a physician to an individual 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 an individual, such as interpretation of x-ray plates, angiograms, myelograms, pyelograms, or ultrasound procedures.

005.27(D)(iii)(2)TECHNICAL COMPONENT. The technical component of hospital diagnostic and therapeutic services is covered in accordance with 471 NAC 10.

005.28NON-PHYSICIAN CARE PROVIDERS. Nebraska Medicaid covers services provided by non-physician care providers who have fulfilled all state and federal licensing, certification and training requirements, 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, such as physician assistant, medical specialty assistant, medical services assistant, clinical associate, surgical assistant, or graduate physician assistant who has completed a committee on allied health education and accreditation (CAHEA) accredited surgical residency program;

(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 Board of Medicine and Surgery in the Nebraska Department of Health and Human Services or the appropriate licensing agency in the state in which they provide the services.

005.29PHYSICIAN SERVICES IN SKILLED NURSING FACILITIES (SNF), INTERMEDIATE CARE FACILITIES (ICF) AND INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). The physician must complete, sign and date Form DM-5: Physician's Confidential Report prior to admission in a skilled nursing facility (SNF), intermediate care facility (ICF) or intermediate care facility for individuals with developmental disabilities (ICF/DD). Form DM-5: Physician's Confidential Report serves as the certification required by federal regulations. If the admission is a facility-to-facility transfer, local office staff will obtain a copy of the individual's annual history and physical, if it is current to the individual's condition within 30 days before the transfer, and attach it to the signed and dated Form DM-5: Physician's Confidential Reports. The physician must examine the individual before completing the certification, within the following time frames:

(1)SKILLED NURSING FACILITIES (SNF). The individual 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 individual 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.

005.29(A)ANNUAL PHYSICAL EXAMINATION. Nebraska Medicaid requires all long term care facility residents have an annual physical examination. The physician, based on their authority to prescribe continued treatment, determines the extent of the examination for individuals based on medical necessity. Nebraska Medicaid does not cover routine laboratory and radiology services which are not directly related to the individual's diagnosis and treatment; 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 nursing home resident. The results of the examination must be recorded in the individual's medical record.

005.29(B)PHYSICIANS' SERVICES FOR SKILLED NURSING FACILITY (SNF) RESIDENTS.

005.29(B)(i)PHYSICIANS' VISITS. The physician must see the skilled nursing facility (SNF) 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 individual's medical record, the individual'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 individual's medical record, and write and sign a progress note on the individual's condition.

005.29(B)(ii)REVIEW OF PLAN OF CARE. The physician and facility staff involved in the (SNF) 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.

005.29(B)(iii)RECERTIFICATION. For skilled nursing facility (SNF) residents, the physician or the physician's assistant will recertify in writing the individual's continued need for the current level of care every 30 days for the first 90 days, every 60 days thereafter, and at any time the individual requires a different level of care. The physician's assistant or nurse practitioner may recertify the individual's need under the general supervision of a physician when the physician formally delegates this function to the physician's assistant. The physician, the physician's assistant, or nurse practitioner 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 individual's medical record in the facility or building where the individual resides.

005.29(B)(iii)(1)ON-SITE RECERTIFICATION. The physician must record recertification accomplished by on-site visits to the facility in the individual's record.

005.29(C)PHYSICIANS' SERVICES FOR RESIDENTS OF INTERMEDIATE CARE FACILITIES (ICF'S) AND INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED (ICF/DD'S).

005.29(C)(i)PHYSICIAN'S VISITS. The physician must see the intermediate care facility (ICF) resident whenever necessary, but at least once every 60 days, unless the physician determines the frequency is not necessary and establishes an alternate schedule not to exceed one year, and records the reason in the medical record. The physician must actually see the individual to claim the service. At the time of each visit, the physician must document the visit in the individual's medical record, and write and sign a progress note on the individual's condition.

005.29(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.

005.29(C)(iii)RECERTIFICATION. The physician must recertify in writing the individual's continued need for the intermediate care facilitites for the developmentally disabled (ICF/DD) level of care at least once every 365 days, and at any time the individual requires a different level of care. The extended recertification period in no way indicates one year is the appropriate length of stay for an individual in an intermediate care facilitites for the developmentally disabled (ICF/DD). The interagency team responsible for the individual's care determines the individual's length of stay. The physician's assistant or nurse practitioner may recertify the individual's need under the general supervision of a physician when the physician formally delegates this function to the physician's assistant or nurse practitioner. The physician, the physician's assistant, or nurse practitioner must sign, or stamp and initial, the recertification clearly identifying themselves. The physician, physician's assistant, or nurse practitioner must date the recertification at the same time it is signed. Facility staff must maintain the recertification in the individual's medical record in the facility or building where the individual resides.

005.29(C)(iii)(1)ON-SITE RECERTIFICATION. The physician must record recertification accomplished by on-site visits to the facility in the individual's record.

005.30TELEPHONE CONSULTATIONS. Nebraska Medicaid does not cover telephone calls to or from an individual, pharmacy, nursing home, or hospital. Nebraska Medicaid may cover telephone consultations with another physician if the name of the consulting physician is indicated on or in the claim.

005.31MEDICAL TRANSPLANTS. Nebraska Medicaid covers transplants, including donor services which are medically necessary and defined as non-experimental by Medicare. Nebraska Medicaid may cover transplantation services when performed in a facility approved by Centers for Medicaid and Medicare (CMS) as meeting coverage criteria. Nebraska Medicaid is the payor of last resort, see 471 NAC 3. Nebraska Medicaid requires prior authorization of all transplant services 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.

005.31(A)SERVICES FOR A MEDICAID-ELIGIBLE DONOR. Nebraska Medicaid covers medically necessary services, including laboratory tests directly related to the transplant, for the Nebraska Medicaid-eligible donor to a Nebraska Medicaid-eligible individual. The services must be directly related to the transplant.

005.31(B)SERVICES FOR A MEDICAID-INELIGIBLE DONOR. Nebraska Medicaid covers medically necessary services, including laboratory tests directly related to the transplant, for a Nebraska Medicaid-ineligible donor to a Nebraska Medicaid-eligible individual. The services must be directly related to the transplant and must directly benefit the Nebraska Medicaid transplant recipient. Coverage of treatment for complications related to the donor is limited to those which are reasonably medically foreseeable.

005.31(C)AMBULATORY ROOM AND BOARD. Nebraska Medicaid may cover ambulatory room and board services for transplant patients for the individual and an attendant, if necessary.

005.32ITINERANT PHYSICIAN VISITS. Nebraska Medicaid covers non-emergency physician visits provided in a hospital outpatient setting if the services are:

(A) Provided by an out-of-town specialist who has a contractual agreement with the hospital. Medicaid does not consider general practitioners or family practitioners to be specialists; and

(B) Determined to have been provided in the most appropriate place of service in accordance with 471 NAC 2.

005.33NURSE PRACTITIONER SERVICES. Nebraska Medicaid covers nurse practitioner services, in accordance with the scope of practice applicable to their specific licensure designation.

005.34DURABLE MEDICAL EQUIPMENT AND SUPPLIES. With certain exceptions, Nebraska Medicaid does not enroll hospitals, hospital pharmacies, long term care facilities, rehabilitation services or centers, or physicians as providers of durable medical equipment and medical supplies.

005.34(A)INFANT APNEA MONITORS. Nebraska Medicaid covers rental of home infant apnea monitors for infants with medical conditions which require monitoring due to a specific medical diagnosis only if prescribed by and used under the supervision of a physician. Proper infant evaluation by the physician and parent or caregiver training must occur before placement of infant apnea monitor. In addition to the regulations outlined herein, apnea monitoring services must be provided in accordance with 471 NAC 7.

005.34(A)(i)DOCUMENTATION REQUIRED AFTER INITIAL RENTAL PERIOD. Monitor rental exceeding the original two-month prescription period requires an updated physician's narrative report of patient progress and a statement of continued need to accompany the claim. A new progress report is required every two months. The report must include:

(1) The number of apnea episodes during the previous prescription period;

(2) The results of any tests performed during the previous prescription period;

(3) Additional length of time needed; and

(4) Any additional information the physician may wish to provide.

005.34(A)(ii)PNEUMOCARDIOGRAMS. Pneumocardiograms are covered only when physician ordered to determine when the infant may be removed from the monitor. Payment for rental of an electrocardiogram (ECG) respirator recorder includes all accessories required to obtain a valid pneumocardiogram. Coverage of durable medical equipment does not include analysis and interpretation of tests, which is covered for the physician performing the service.

005.34(B)HOME PHOTOTHERAPY. Nebraska Medicaid covers rental of home phototherapy (bilirubin) equipment for infants who require phototherapy when neonatal hyperbilirubinemia is the infant's sole clinical problem and only if prescribed by and used under the supervision of a physician. Prior authorization is not required for this service. In addition to the regulations outlined herein, home phototherapy services must be provided in accordance with 471 NAC 7.

005.34(B)(i)LIMITATIONS ON COVERAGE OF HOME PHOTOTHERAPY SERVICES. Coverage of the rental of home phototherapy equipment does not include physician's professional services or laboratory and radiology services related to home phototherapy.

005.34(C)AMBULATORY UTERINE MONITORS. Nebraska Medicaid covers rental of ambulatory uterine monitors. The monitor must be prescribed by and used under the supervision of a physician and provided by a medical supplier. Prior authorization is not required for this service. In addition to the regulations outlined herein, ambulatory uterine monitor services must be provided in accordance with 471 NAC 7.

005.34(C)(i)LIMITATIONS ON COVERAGE OF AMBULATORY UTERINE MONITORS. Nebraska Medicaid covers all equipment, supplies, and services necessary for the effective use of the monitor. This does not include medications or physician's professional services. Rental is allowable only when the individual is at home and appropriately using the monitor.

005.35ANESTHESIOLOGY.

005.35(A)PROFESSIONAL COMPONENT. Nebraska Medicaid covers, as a physician's service, the professional component of anesthesiology services provided by a physician to an individual if the conditions in this chapter are met.

005.35(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, such as certified registered nurse anesthetists (CRNA), 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 individual, 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.

005.35(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. The following situations are examples of services which do not constitute a separate service for determining medical direction:

(a) Addressing an emergency of short duration in the immediate area;

(b) Administering an epidural or caudal anesthetic to ease labor pain;

(c) Periodic, rather than continuous, monitoring of an obstetrical patient;

(d) Receiving patients entering the operating suite for the next surgery;

(e) Checking or discharging patients in the recovery room; and

(f) Handling scheduling matters.

005.35(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 patients, the physician's services to the surgical patient are supervisory in nature and are considered a technical component; therefore, these services must be billed as the technical component by the hospital.

005.35(C)SUPERVISION 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.

005.35(D)STANDBY ANESTHESIA SERVICES. A physician's standby anesthesia services are covered when the physician is physically present in the operating suite, monitoring the individual's condition, making medical judgments regarding the individual's anesthesia needs, and is ready to furnish anesthesia services to a specific individual who is known to be in potential need of services.

005.35(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, Nebraska Medicaid will cover only those services provided by the anesthesiologist. In the event multiple surgical procedures are performed at the same time, Nebraska Medicaid only covers the certified registered nurse anesthetist (CRNA) services for the major procedure. Nebraska Medicaid does not cover certified registered nurse anesthetist (CRNA) services for secondary procedures.

005.36FEEDING AND SWALLOWING CLINIC SERVICES. This service is covered for those individuals with dysphagia, a medical condition which makes feeding and swallowing difficult. The service is covered when the individual is referred by a physician for a medical evaluation. The purpose of the evaluation is to assess the individual's current status and potential for improvement and to develop a plan of care for the individual.

005.36(A)DEFINITIONS. For the purposes of feeding and swallowing clinic services, the following definitions will apply:

005.36(A)(i)SWALLOWING DISORDERS ASSESSMENT, COMPREHENSIVE. This includes, at a minimum, comprehensive evaluation by the occupational therapist, speech pathologist, nurse, and nutritionist. The need for a psychology evaluation is determined by intake information; if necessary, the psychology evaluation is billed separately.

005.36(A)(ii)SWALLOWING DISORDER ASSESSMENT, EXTENDED. This includes, at a minimum, a comprehensive evaluation by the occupational therapist and extended evaluations by the speech pathologist, nurse, and nutritionist. The need for a psychology evaluation is determined by intake information; if necessary, the psychology evaluation is billed separately.

005.36(A)(iii)SWALLOWING DISORDER ASSESSMENT, BRIEF. The brief assessment includes approximately two hours of time for the occupational therapist, speech pathologist, and nutritionist.

005.36(A)(iv)FOLLOW-UP VISIT, BRIEF. This includes a visit with two or more team members.

005.36(A)(v)FOLLOW-UP VISIT, EXTENDED. This includes a visit which involves four or more team members.

005.36(B)INITIAL EVALUATION. An initial evaluation must be performed by an interdisciplinary team (IDT), which, at a minimum, must include a nurse, occupational therapist, speech pathologist, nutritionist, psychologist, and radiologist. The interdisciplinary team (IDT) must be under the direction of a physician. After the initial visit, the interdisciplinary team (IDT) formulates a formal written report and sends copies to the individual or family, the referring physician, and others designated by the individual or family and by the Department. The team contacts the referring physician and, if appropriate, other medical professionals, to provide immediate feedback to the team on primary findings and recommendations.

005.36(C)FOLLOW-UP VISITS. Follow-up visits must be available in a frequency adequate to meet patient needs and program objectives.

005.36(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 individual 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 individual or family and referring physician to facilitate implementation of the plan of care.

005.37COMPREHENSIVE INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER. Nebraska Medicaid covers comprehensive interdisciplinary treatment for an infant or child with a severe feeding disorder when it impacts the infant's or child's ability to consume sufficient oral nutrition to maintain adequate growth or weight.

005.37(A)DEFINITIONS. For the purposes of comprehensive interdisciplinary treatment for a severe feeding disorder services, the following definitions will apply:

005.37(A)(i)DAY TREATMENT. Daily therapy, which occurs Monday through Friday, from approximately 8:30 am to 5 pm.

005.37(A)(ii)OUTPATIENT. Therapy one to two times per week for one to three hours per day.

005.38TOBACCO CESSATION. Nebraska Medicaid covers tobacco cessation services as practitioner and pharmacy services, for individuals 18 years of age or older, under the following conditions:

(A) Tobacco cessation services must be ordered by a physician or mid-level practitioner, and provided in accordance with the provider requirements listed in 471 NAC 16;

(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. Individual access to the Nebraska Tobacco Free Quitline will be unlimited;

(C) Practitioner office visits:

(i) Individuals 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;

(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 by Nebraska Medicaid 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;

(ii) Tobacco cessation products will only be covered when individuals 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) Nebraska Tobacco Free Quitline: Referral to the Quitline may be made by a medical professional or a self-referral.

005.39ENDOMETRIAL ASPIRATION. Nebraska Medicaid covers vacutage type or other endometrial aspiration or curettage. 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 individual is not pregnant. When requested, the provider must submit copies of individuals' medical records to the Department.

005.40MEDICAL NUTRITION THERAPY FOR INDIVIDUALS AGE 21 AND OLDER. Medical nutrition therapy is available to individuals with medical needs which require nutritional assessment, intervention, and continued monitoring. Nebraska Medicaid covers one-on-one medical nutrition therapy provided by a licensed medical nutritional therapist for individuals age 21 and older under the following guidelines:

(A) The service is covered when the individual is referred by a physician or nurse practitioner. A nutritional assessment is done by an individual'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) Individuals 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) Individuals receiving dialysis in a dialysis facility receive medical nutrition therapy as part of their overall dialysis care, medical nutrition therapy is not separately billable.

(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. The Department may request periodic review of the services.

471 Neb. Admin. Code, ch. 18, § 005

Reserved effective 7/2/2017.

Amended effective 7/5/2022

Amended effective 7/10/2022