Section He-W 531.05 - Covered Services(a) The following physician services, subject to the prior authorization requirements in He-W 531.07, as applicable, shall be covered services: (1) Anesthesia not administered by the operating surgeon;(2) Care provided by 2 or more physicians on the same day for unrelated diagnoses regardless of the setting, for example, inpatient or outpatient;(3) Consultation services, as documented in a written report, provided by a physician whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or health care professional;(5) Eye care provided by ophthalmologists as described in He-W 565;(6) Family planning services as described in He-W 541;(7) Inpatient hospital visits for acute care days of stay approved in accordance with He-W 543.11; (8) Laboratory and radiology services as described in He-W 577 and He-W 569;(9) Obstetrical or gynecological procedures that relate to care and treatment of pregnant women and the female reproductive system, except for those procedures for which the sole purpose is to contribute to, promote, or restore fertility, procreation, or sexual activity;(10) Face-to-face services rendered by a physician in any setting, including walk-in clinics, urgent care centers, emergency departments, outpatient hospital settings, nursing facilities, and recipients' homes;(11) Surgical procedures, subject to the prior authorization requirements in He-W 531.07, as applicable, including:a. Operative procedures for the treatment of illnesses, injuries and congenital anomalies;b. The treatment of fractures and dislocations;c. The treatment of burns; andd. Invasive diagnostic and treatment services;(12) Services in addition to those usually and customarily carried out to treat preoperative or postoperative complications, provided that the physician has followed the procedures described in He-W 531.07;(13) The following tissue transplants: b. Skin transplants with the exception of hairplasty; and(b) The following organ transplants from a human donor to a recipient performed at facilities described in He-W 543.05(f) shall be covered subject to the prior authorization requirements in He-W 531.07 and in accordance with the applicable coverage criteria in Interqual Connect Clinical Guidelines, 2019 Edition, available as noted in Appendix A: (3) Heart and lung transplants;(5) Allogenic bone marrow transplants;(6) Autologous bone marrow transplants;(8) Pancreas transplants; and(9) Pancreas and kidney transplants.(c) Bariatric surgical procedures shall be covered, subject to the prior authorization requirements in He-W 531.07 and in accordance with the coverage criteria in Interqual Connect Clinical Guidelines, 2019 Edition, available as noted in Appendix A, except that the recipient shall also have lost at least 15% of body weight prior to scheduling bariatric surgery as documented in the recipient's medical record.(d) Breast reduction surgery shall be covered, subject to the prior authorization requirements in He-W 531.07 and in accordance with the coverage criteria in Interqual Connect Clinical Guidelines, 2019 Edition, available as noted in Appendix A.(e) Blepharoplasty shall be covered, subject to the prior authorization requirements in He-W 531.07 and in accordance with the coverage criteria in Interqual Connect Clinical Guidelines, 2019 Edition, available as noted in Appendix A.(f) Panniculectomy shall be covered, subject to the prior authorization requirements in He-W 531.07 and in accordance with the coverage criteria in Interqual Connect Clinical Guidelines, 2019 Edition, available as noted in Appendix A.(g) Septoplasty and rhinoplasty shall be covered, subject to the prior authorization requirements in He-W 531.07 and in accordance with the coverage criteria in Interqual Connect Clinical Guidelines, 2019 Edition, available as noted in Appendix A.(h) Coverage of routine visits to nursing facilities for non-acute services shall be limited to one visit per calendar month.N.H. Admin. Code § He-W 531.05
Amended by Volume XXXIV Number 16, Filed April 17, 2014, Proposed by #10531, Effective 3/29/2014, Expires3/29/2024.Amended by Volume XL Number 11, Filed March 12, 2020, Proposed by #12999, Effective 3/5/2020, Expires 3/5/2030.