(a) Covered services. Medically necessary professional services furnished by or under the supervision of a licensed Physician, except as otherwise specified by this Chapter.
(b) Excluded or limited services. - (i) Anesthesia services shall be limited as follows:
- (A) An anesthesiologist shall not receive Medicaid reimbursement for a consultation in addition to any other anesthesia services for the same surgery.
- (B) Anesthesia services shall not be covered when performed in conjunction with:
- (I) A non-covered surgical procedure; or
- (II) A procedure requiring client consent if proper consent was not obtained.
- (ii) The following allergy and clinical immunotherapy services are excluded:
- (A) Sublingual, intracutaneous and subcutaneous provocative and neutralization testing; and
- (B) Neutralization therapy for food allergies.
- (iii) Cosmetic surgery:
- (A) Services intended solely to improve an individual's physical appearance and which do not restore bodily function or correct a physical deformity are excluded.
- (B) Reconstructive surgery procedures which are intended to improve bodily functions and the appearance of a body area which has been altered by disease, trauma, congenital or developmental anomalies, or previous surgical procedures shall be covered only if authorized prior to the procedure.
- (iv) Dermatology. The following shall be excluded:
- (A) Removal of lesions not suspected to be precancerous, unless medically necessary to restore a bodily function; and
- (B) Services performed primarily for cosmetic reasons.
- (v) Medical supplies. Expendable medical supplies normally used in a physician's office shall be included in the Medicaid payment for the office visit or test performed. The actual cost of special expendable supplies prescribed for home use by a client may be separately billed to Medicaid.
- (vi) Prolonged care shall be limited to a total of three (3) hours per day unless there is documentation in the medical records that additional prolonged care was medically necessary.
- (vii) Sterilizations shall not be covered unless the requirements of 42 C.F.R. § 441 Subpart F are satisfied.
- (viii) Therapeutic injections shall not be covered unless:
- (A) The drug cannot be administered orally;
- (B) The drug cannot be self-administered; and
- (C) The drug is reasonable and medically necessary.
(c) Service Limitations. Unless pre-approved, Medicaid reimbursement for client visits to a Physician, Ophthalmologist, Physician Assistant, Nurse Practitioner, or Optometrist and to the outpatient department of a hospital shall be limited to a total of twelve (12) visits per calendar year. The limitations of this subsection shall not apply to: - (i) A client seeking emergency services who is diagnosed with an emergent condition;
- (ii) A client seeking family planning clinic services;
- (iii) A client who is under age twenty-one (21);
- (v) Items and services furnished directly by the Indian Health Services, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through a referral under a purchase order contract health services (as described in 42 C.F.R., Ch. I, Subch. M, Pt. 136, Subpart C) to an American Indian or Alaskan Native who is enrolled as a member of a Federally-Recognized Tribe or otherwise meets the definition of a "Indian" as Section 4 of the Indian Healthcare Improvement Act ( 25 U.S.C. § 1608 );
- (vi) A resident of a nursing facility; or
- (vii) A client who is also eligible for Medicare and where Medicare has reimbursed the provider for the claim.
048-26 Wyo. Code R. § 26-25
Amended, Eff. 12/17/2015.