(a)
Outpatient physician services are covered if they are medically necessary to
protect life, to prevent significant illness or significant disability, or to
alleviate severe pain, subject to the limitations specified below.
(b) Outpatient surgical procedures, other
than those needed for diagnostic purposes or those rendered as emergency
services pursuant to Section
51056; procedures considered to be
elective; and specified outpatient medical procedures, including but not
limited to, Hyperbaric Oxygen Therapy, Pheresis, Psoriasis Day Care and Cardiac
Catheterization, require prior authorization. Authorization may be granted only
when fully documented medical justification is provided that the services are
medically necessary. Services not requiring prior authorization are subject to
other utilization controls, as specified in this chapter. Utilization controls
shall be imposed on medical/surgical procedures in accordance with the
standards set forth in Section
51159. Identification of those
procedures requiring prior authorization shall be transmitted to all affected
providers of service in bulletins authorized by the Department.
(c) Surgical procedures typically performed
on an inpatient basis which can be performed safely on an outpatient or
ambulatory basis will not be reimbursed in an inpatient setting. Exceptions may
be authorized by a field office medical consultant if there is adequate
documentation of the medical need for inpatient care. In selecting procedures
which should normally be performed in an outpatient setting, the Department
shall consider patient safety, quality of medical care, common practice in the
medical community, and cost of the procedure. Lists of surgical procedures
identified by the Department for performance on an outpatient or ambulatory
basis will be transmitted to all interested providers of service in bulletins
authorized by the Department.
(d) A
maximum of eight injections for allergy desensitization, hyposensitization, or
immunotherapy by injection of an antigen to stimulate production of protective
antibodies may be provided in any 120-day period without prior authorization.
Prior authorization shall be required when more than eight of the above allergy
injections are provided in a 120-day period except those provided on an
emergency basis.
(1) Services rendered on an
emergency basis are exempt from authorization. The emergency services shall
meet the definition in Section
51056 and the provider shall
comply with the requirements of that section.
(2) A total treatment plan shall be developed
for allergy services which require prior authorization. The treatment plan may
be authorized for a period up to 120 days and shall include the following:
(A) The principal diagnosis and significant
associated diagnosis.
(B) Clinical
information adequate to describe the physiological and functional limitations,
including the date of onset of the illness(es).
(C) Prognosis.
(D) Specific services to be
rendered.
(E) The therapeutic goals
to be achieved and the anticipated time needed to attain those goals.
(F) Drug
regimen.
(e)
Physician services provided to hospital, skilled nursing facility or
intermediate care facility inpatients are covered only during periods of
hospital, skilled nursing facility or intermediate care facility stays covered
by the program.
(f) Psychiatry,
psychology, physical therapy, occupational therapy, audiology, speech therapy,
optometry and podiatry services are not covered as physicians' services when
performed by persons other than physicians.
(g) Respiratory care is covered as a
physician service. Respiratory care is subject to prior authorization except
when personally rendered by the physician. Authorization requests shall include
clinical justification for the services and the nature, frequency and expected
duration of the respiratory care.
(h) Orthoptics and pleoptics are not
covered.
(i) Procedures for the
treatment of defects for cosmetic purposes only are covered subject to prior
authorization. Authorization may be granted only for the correction of serious
disfigurement eligible for coverage by California Children Services. These
patients shall be referred to that program as provided in Section
51013.
(j) A second eye examination with refraction
within twenty-four months is covered only when a sign or symptom indicates a
need for this service. The provider of services shall make a reasonable effort
to ascertain the date of any prior eye examination with refraction.
(k) Primary care physician services rendered
by nonphysician medical practitioners are covered as physician's services to
the extent permitted by applicable professional licensing statutes and
regulations, and as set forth in the Physician-Practitioner Interface as
described in Section
51240.
(1) Services and entries in the patient's
health record by nonphysician medical practitioners shall be reviewed by the
primary care physician to the extent required by the applicable professional
licensing statutes and regulations.
(2) Patients shall be informed or notified in
writing, prior to being served, that medical services may be rendered by
nonphysician medical practitioners. In cases of emergencies as defined in
Section
51056, the nonphysician medical
practitioner may render emergency services to a patient without such prior
notification.
(3) Reimbursement for
services rendered by nonphysician medical practitioners shall be made in
accordance with Section
51503.1.
(4) Reimbursement shall not be made for
service rendered by a nonphysician medical practitioner to a person eligible
for Medicare benefits unless Medicare makes reimbursement for that service by
that practitioner.
(5) Out-of-State
services of nonphysician medical practitioners are covered in accordance with
each of the following:
(A) The Medicaid law
and program for that location.
(B)
Local laws applicable to such practitioners.
(C) The provisions of Section
51006.
(l) External mammary prostheses made of
silicone or other similar materials, prosthetic mammary implants, and
reconstructive mammoplasty shall be deemed medically necessary incident to
mastectomy and shall be covered. "Mastectomy" means the surgical procedures as
described in the latest edition of the Physicians' Current Procedural
Terminology for the removal of all or part of the breast for medically
necessary reasons, as determined by a licensed physician and surgeon who is a
Department Medi-Cal consultant.
(m)
One early discharge follow up visit is covered without prior authorization when
the requirements of Section
51327(b) are
met.
Notes
Cal. Code Regs. Tit. 22, §
51305
1. New
subsection (l) filed 7-18-85 as an emergency; effective upon filing (Register
85, No. 29). A Certificate of Compliance must be transmitted to OAL within 120
days or emergency language will be repealed on 11-15-85. For prior history, see
Register 83, No. 27.
2. Certificate of Compliance transmitted to OAL
10-30-85 and filed 12-2-85 (Register 85, No. 49).
3. Amendment of
subsection (a) filed 7-7-86 as an emergency; effective upon filing (Register
86, No. 28). A Certificate of Compliance must be transmitted to OAL within 120
days or emergency language will be repealed on 11-4-86.
4.
Certificate of Compliance transmitted to OAL 10-30-86 and filed 11-25-86
(Register 86, No. 48).
5. Amendment of subsection (g) filed 6-22-87;
operative 7-22-87 (Register 87, No. 27).
6. Amendment of subsection
(l) filed 10-1-87; operative 10-31-87 (Register 87, No. 41).
7. New
subsection (m) and amendment of NOTE filed 3-13-2000 as an emergency; operative
3-13-2000 (Register 2000, No. 11). A Certificate of Compliance must be
transmitted to OAL by 7-11-2000 or emergency language will be repealed by
operation of law on the following day.
8. Certificate of Compliance
as to 3-13-2000 order transmitted to OAL 7-5-2000 and filed 8-14-2000 (Register
2000, No. 33).
9. Amendment of subsection (k)(1) and NOTE filed
5-17-2012; operative 6-16-2012 (Register 2012, No. 20).
10. Change
without regulatory effect amending subsections (d) and (d)(2) and amending NOTE
filed 8-18-2014 pursuant to section
100, title 1, California Code of
Regulations (Register 2014, No. 34).
Note: Authority cited: Sections
10725
and
14124.5,
Welfare and Institutions Code; and Section
20,
Health and Safety Code. Reference: Sections
14043.47,
14053,
14059,
14059.5,
14060,
14132,
14132.03,
14132.41,
14132.42,
14133(a),
14133(b),
14132.6,
14133.25
and
14133.3,
Welfare and Institutions Code; and Title 42, Code of Federal Regulations,
Sections 483.40(e) and
485.631(b)(iv).
1. New subsection
(l) filed 7-18-85 as an emergency; effective upon filing (Register 85, No. 29).
A Certificate of Compliance must be transmitted to OAL within 120 days or
emergency language will be repealed on 11-15-85. For prior history, see
Register 83, No. 27.
2. Certificate of Compliance transmitted to
OAL 10-30-85 and filed 12-2-85 (Register 85, No. 49).
3. Amendment
of subsection (a) filed 7-7-86 as an emergency; effective upon filing (Register
86, No. 28). A Certificate of Compliance must be transmitted to OAL within 120
days or emergency language will be repealed on 11-4-86.
4.
Certificate of Compliance transmitted to OAL 10-30-86 and filed 11-25-86
(Register 86, No. 48).
5. Amendment of subsection (g) filed
6-22-87; operative 7-22-87 (Register 87, No. 27).
6. Amendment of
subsection (l) filed 10-1-87; operative 10-31-87 (Register 87, No.
41).
7. New subsection (m) and amendment of Note filed 3-13-2000 as
an emergency; operative 3-13-2000 (Register 2000, No. 11). A Certificate of
Compliance must be transmitted to OAL by 7-11-2000 or emergency language will
be repealed by operation of law on the following day.
8.
Certificate of Compliance as to 3-13-2000 order transmitted to OAL 7-5-2000 and
filed 8-14-2000 (Register 2000, No. 33).
9. Amendment of subsection
(k)(1) and Note filed 5-17-2012; operative 6-16-2012 (Register 2012, No.
20).
1. New subsection (l)
filed 7-18-85 as an emergency; effective upon filing (Register 85, No. 29). A
Certificate of Compliance must be transmitted to OAL within 120 days or
emergency language will be repealed on 11-15-85. For prior history, see
Register 83, No. 27.
2. Certificate of Compliance transmitted to OAL
10-30-85 and filed 12-2-85 (Register 85, No. 49).
3. Amendment of
subsection (a) filed 7-7-86 as an emergency; effective upon filing (Register
86, No. 28). A Certificate of Compliance must be transmitted to OAL within 120
days or emergency language will be repealed on 11-4-86.
4.
Certificate of Compliance transmitted to OAL 10-30-86 and filed 11-25-86
(Register 86, No. 48).
5. Amendment of subsection (g) filed 6-22-87;
operative 7-22-87 (Register 87, No. 27).
6. Amendment of subsection
(l) filed 10-1-87; operative 10-31-87 (Register 87, No. 41).
7. New
subsection (m) and amendment of Note filed 3-13-2000 as an emergency; operative
3-13-2000 (Register 2000, No. 11). A Certificate of Compliance must be
transmitted to OAL by 7-11-2000 or emergency language will be repealed by
operation of law on the following day.
8. Certificate of Compliance
as to 3-13-2000 order transmitted to OAL 7-5-2000 and filed 8-14-2000 (Register
2000, No. 33).
9. Amendment of subsection (k)(1) and Note filed
5-17-2012; operative 6-16-2012 (Register 2012, No. 20).
10. Change
without regulatory effect amending subsections (d) and (d)(2) and amending Note
filed 8-18-2014 pursuant to section 100, title 1, California Code of
Regulations (Register
2014, No. 34).