NEBRASKA MEDICAID MEDICAL NECESSITY GUIDELINES:

Pursuant to LB1063 (2012) notice of changes to treating guidelines and criteria shall be given to providers and time for public comment provided at least sixty days prior to implementation of such change.

Comments regarding these guidelines can be sent to: dhhs.medicaidmhsu@nebraska.gov

Proposed Changes: 

Magellan Behavioral Health Medical Necessity guidelines for Abilify Maintena.  Changes effective 2/3/14

Medical Necessity Guidelines

Behavioral Health Managed Care

Physical Health Managed Care

Additional Contractors
Guidelines found in the Nebraska Administrative Code
 

471 NAC 1-002.02A Medical Necessity:

NMAP applies the following definition of medical necessity:

Health care services and supplies which are medically appropriate and -

  1. Necessary to meet the basic health needs of the client;
  2. Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;
  3. Consistent in type, frequency, duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;
  4. Consistent with the diagnosis of the condition;
  5. Required for means other than convenience of the client or his or her physician;
  6. No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
  7. Of demonstrated value; and
  8. No more intense level of service than can be safely provided.

The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Medicaid. Services and supplies which do not meet the definition of medical necessity set out above are not covered.

Approval by the federal Food and Drug Administration (FDA) or similar approval does not guarantee coverage by NMAP. Licensure/certification of a particular provider type does not guarantee NMAP coverage.

471 NAC 3-002.02B Coverage Exception:

 Certain medical services, while being medically necessary, may exceed the NMAP coverage guidelines which have been established by the Department. Under these circumstances, the determination of medical necessity for payment purposes is based upon the professional judgment of the Department's consultants and other appropriate staff.

471 NAC 4-002 (Ambulance) Covered Services:

NMAP covers medically necessary and reasonable ambulance services required to transport a client to obtain or after receiving Medicaid-coverable medical care.

4-002.01 Medical Necessity of the Service: To be covered by NMAP, ambulance services must be medically necessary and reasonable.  Medical necessity is established when the client's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of  transportation other than an ambulance could be used without endangering the client's health, whether or not such other transportation is actually available, NMAP shall not make payment for ambulance service. Claims for ambulance services must include adequate documentation for determination of medical necessary.

471 NAC 6-005 (Dental) Covered Services, Coverage Limitations, Prior Authorization Requirements (including the 14 page specific procedure criteria):
NMAP does not cover all American Dental Association (ADA) procedure codes. Covered codes are listed in the Nebraska Medicaid Dental Fee Schedule in 471-000-506.
 
6-005.01 Services for Individuals Age 21 and Older: Dental coverage is limited to $1000 per fiscal year. The $1000 limit is calculated at the Medicaid dental fee schedule rate for the treatment provided or on the all inclusive encounter rate paid to Indian Health Service (IHS) or Federally Qualified Health Centers (FQHC) facilities.
 
6-005.01A Providers Responsibility and Client Responsibility Regarding the Yearly Dental Limit: Providers must inform a client before treatment is provided of the client’s obligation to pay for a service if the client’s annual limit has already been reached or if the amount of treatment proposed will cause the client’s annual limit to be exceeded.
 
A client must inform a provider in advance of receiving treatment if a portion of his/her annual dental benefit amount has already been expended.

471 NAC 7-007 (Durable Medical Equipment) Documentation of Medical Necessity:

The provider shall obtain written documentation from the prescribing physician which justifies the medical necessity for durable medical equipment, medical supplies, orthotics and prosthetics and related services provided. The original documentation of medical necessity must be kept on file by the provider. The documentation must - 

  1. Be signed by the physician's own hand (stamps or other substitutes may not be used) and dated, using the date the documentation is signed;
  2. Specify the start date of the order if the item is provided before the date the documentation is signed;
  3. Include the physician's name, address and telephone number;
  4. Include the diagnosis and/or condition necessitating the item(s) and an estimate of the total length of time the item will be needed (in months or years). The estimated total length of time the item will be needed must be completed by the physician or physician's office staff;
  5. Be sufficiently detailed, including all options or additional features which will be separately billed or will require an upgraded procedure code;
  6. Describe the ordered item(s) using either a narrative description or a brand name/model number, including all options or additional features (this may be completed by someone other than the physician, but the physician must review the order and sign and date it to indicate agreement);
  7. For supplies provided on a periodic basis, include appropriate information on the quantity used, frequency of change and duration of need (PRN or "as needed" may not be used); and
  8. Include information substantiating that all NMAP coverage criteria for the item(s) are met.

471 NAC 7-007.01 Medicaid Certification of Medical Necessity Forms:

Use of the following Medicaid Certification of Medical Necessity (CMN) forms is required. Form examples and completion instructions are included in the Medicaid Provider Handbook - Form MS-78, "Augmentative Communication Device Selection Report" Form MS-79, "Wheelchair and Wheelchair Seating System Selection Report" Form MS-80, "Air Fluidized and Low Air Loss Bed Certification of Medical Necessity"

471 NAC 7-007.02 Medicare Certification of Medical Necessity Forms:

Use of Medicare CMN forms, when a specific Medicaid CMN form does not exist, is strongly encouraged. When using Medicare CNM forms, Medicare completion instructions apply. Use of the following Medicare CMN form is required -

471 NAC 7-010.01 Coverage Criteria:

Criteria for NMAP coverage of durable medical equipment, medical supplies, orthotics and prosthetics is outlined in this Chapter's coverage index (see 471 NAC 7-013). Items not specifically listed may not be covered by NMAP. In order to be covered by NMAP, the client's condition must meet the coverage criteria for the specific item. Documentation which substantiates that the client's condition meets the coverage criteria must be on file with the provider (see 471 NAC 7-007 for documentation of medical necessity requirements).

471 NAC 8-007.03 (Hearing Aids) Prior Authorization Procedures:

NMAP requires that the following information be submitted when requesting prior authorization for a hearing aid or assistive listening device.

  1. A complete audiogram (pure tone, air bone, masking, speech);
  2. The name of the examiner or dispenser performing the audiogram;
  3. The type of hearing aid or assistive listening device being recommended and any accessories;
  4. The estimated cost of the hearing aid or assistive listening device;
  5. The estimated cost of each accessory;
  6. The hearing aid dispenser's provider number; and
  7. The hearing aid dispenser's name, address and phone number.

Form DM-5H "Physician's Report on Hearing Loss," (see 471-000-3 must be used when submitting a request for prior authorization. The examining physician must complete the front portion of Form DM-5H. The back portion of Form DM-5H must be completed by either the examiner or the hearing aid dispenser.

The provider must submit requests for prior authorization using the standard electronic Health Care Services Review – Request for Review and Response transaction (ASC X12N 278) (see Standard Electronic Transaction Instructions at 471-000-50) or by completing and submitting Form MC-9S, "Prior Authorization Document for Hearing Aids" (see 471-000-205 for completion instructions).

Prior authorization is obtained from the Medicaid Division.

471 NAC 9-002.02 (Home Health) Medical Necessity: 

All home health services must be -

  1. Necessary to a continuing medical treatment plan;
  2. Prescribed by a licensed physician; and
  3. Recertified by the licensed physician at least every 60 days.

Therapies must be recertified every 30 days by the licensed physician.

471 NAC 10-001.05 (Hospital) Definition of Medical Necessity:

NMAP defines medical necessity as follows:

Medical Necessity: Health care services and supplies which are medically appropriate and -

  1. Necessary to meet the basic health needs of the client;
  2. Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;
  3. Consistent in type, frequency, duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;
  4. Consistent with the diagnosis of the condition;
  5. Required for means other than convenience of the client or his or her physician;
  6. No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
  7. Of demonstrated value; and
  8. No more intense level of service than can be safely provided. 

The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Medicaid. Services and supplies that do not meet the definition of medical necessity set out above are not covered.

471 NAC 13-002.02 (Private-duty nursing) Medical Necessity:

All skilled nursing services must be -

  1. Necessary to a continuing medical treatment plan;
  2. Prescribed by a licensed physician; and
  3. Recertified by the licensed physician at least every 60 days.
471 NAC 18-004.30 (Radiology Services)
Radiology services are medically necessary services in which x-rays or rays from radioactive substances are used for diagnostic or therapeutic services and associated medical services necessary for the diagnosis and treatment of a patient. These services may be provided in -
  1. A physician's or group of physicians' private office; or
  2. A hospital whose certification covers the radiological services provided.
Claims for radiology procedures must have at least a provisional diagnosis or statement of symptoms. NMAP will not accept claims with a diagnosis of "routine radiology."
471 NAC 18-004.40 (Medical Transplants):
NMAP covers transplants including donor services that are medically necessary and defined as non-experimental by Medicare. If no Medicare policy exists for a specific type of transplant, the Medical Director of the Medicaid Division shall determine whether the transplant is medically necessary or non-experimental.
 
Notwithstanding any Medicare policy on liver or heart transplants, the Nebraska Medical Assistance program covers liver or heart transplantation when the written opinions of two physicians specializing in the specific transplantation state that a transplant is medically necessary as the only clinical, practical, and viable alternative to prolong the patient's life in a meaningful, qualitative way and at a reasonable level of functioning.
 
NMAP is the payor of last resort.
 
NMAP requires prior authorization of all transplant services before the services are provided (see 471 NAC 18-004.40D). An exception may be made for emergency situations, in which case verbal approval is obtained and the notification of authorization is sent.
471 NAC 18-004.44A (Apnea Monitors) cross reference 10-005.22A
Medical Guidelines for the Placement of Home Infant Apnea Monitors:
 
NMAP covers home infant apnea monitoring services for infants who meet one of the following criteria. NMAP defines infancy as birth through completion of one year of age.
  1. Infants with one or more apparent life-threatening events (ALTE's) requiring mouth-to-mouth resuscitation or vigorous stimulation. ALTE is defined as an episode that is frightening to the observer and characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually limpness), choking, or gagging. In some cases, the observer fears the infant has died;
  2. Symptomatic preterm infants;
  3. Siblings of one or more SIDS victims; or
  4. Infants with certain diseases or conditions, such as central hypoventilation, bronchopulmonary dysplasia, infants with tracheostomies, infants of substance-abusing mothers, or infants with less severe ALTE's.
471 NAC 18-004.45A (Phototherapy Equipment) cross reference 10-005.23A
Medical Guidelines for the Placement of Home Phototherapy Equipment: NMAP recognizes the Nebraska Chapter of the American Academy of Pediatric's Standard of Care for home phototherapy. Home phototherapy services will be covered when the following conditions are met:
  1. Infant evaluation by the physician and parent/caregiver training occurs before placement of equipment;
  2. Documentation must be available with the supplier to show that -
    1. The physician certifies that the infant's condition meets the medical criteria outlined below and that the parent/caregiver is capable of administering home phototherapy; and
    2. The provider certifies that the parent/caregiver has been adequately trained and consent forms used by the provider have been signed; and
  3. The infant's medical condition meets the following criteria:
    1. Greater than or equal to 37 weeks gestational age and birth weight greater than 2,270 gms (5 lbs);
    2. Greater than 48 hours of age;
    3. Bilirubin levels at initiation of phototherapy (greater than 48 hours of age) are 14-18 mgs per deciliter;
    4. Direct bilirubin level less than 2 mgs per deciliter;
    5. History and physical assessment (if the service begins immediately upon discharge from the hospital, the newborn discharge exam will suffice); and
    6. Required laboratory studies to include CBC, blood type on mother and infant, direct Coombs, direct and indirect bilirubin (additional laboratory data may be requested at physician's discretion). At a minimum, one bilirubin level must be obtained daily while the infant is receiving home phototherapy.
471 NAC 18-004.46A (Ambulatory Uterine Monitors)

Medical Guidelines for the Placement of Ambulatory Uterine Monitors: Ambulatory uterine monitors will be covered when the following conditions are met:

  1. Evaluation by the physician and training on use of the monitor occurs prior to placement of the monitor;
  2. Documentation must be available with the supplier to show that -
    1. The physician certifies that the client meets the medical criteria outlined below; and
    2. The provider certifies that the client has been adequately trained; and
  3. The client must be at high risk for preterm labor and delivery and must be a candidate for tocolytic therapy. The pregnancy must be greater than 20 weeks gestation and the client must meet one of the medical conditions listed below:
    1. Recent preterm labor with hospitalization and discharge on tocolytic therapy;
    2. Multiple gestation;
    3. History of preterm delivery; 
    4. Anomalies of the uterus;
    5. Incompetent cervix;
    6. Previous cone biopsy;
    7. Polyhydramnios; or
    8. Diethylstilbestrol exposure.

Others at high risk for preterm labor and delivery may be covered for this service upon approval by the Department's Medical Director through written communication from the client's physician (preferably in consultation with a perinatologist).

471 NAC 20-001.15 (Adult MH/SA services) Medical Necessity:

Medically necessary services are services provided at an appropriate level of care which are based on documented clinical evaluations including a comprehensive diagnostic workup and supervising practitioner-ordered treatment.

Biopsychosocially necessary treatment interventions and supplies are those which are:

  1. Consistent with the behavioral health condition and conducted with the treatment of the client as the primary concern;
  2. Supported by sufficient evidence to draw conclusions about the treatment intervention's effects of behavioral health outcomes;
  3. Supported by evidence demonstrating the treatment intervention can be expected to produce its intended effects on behavioral health outcomes;
  4. Supported by evidence demonstrating the intervention's intended beneficial effects on behavioral health outcomes outweigh its expected harmful effects;
  5. Cost effective in addressing the behavioral health outcome;
  6. Determined by the presentation of behavioral health conditions, not necessarily by the credentials of the service provider;
  7. Not primarily for the convenience of the client or the provider;
  8. Delivered in the least restrictive setting that will produce the desired results in accordance with the needs of the client.

Behavioral health conditions are the diagnoses listed in the current version of the Diagnostic and Statistic Manual as published by the American Psychiatric Association. (The NMAP does not reimburse for services for diagnoses of developmental disabilities, mental retardation, or V codes as part of this chapter.) Behavioral health outcomes mean improving adaptive ability, preventing relapse or decompensation, stabilization in an emergency situation, or resolving symptoms.

471 NAC 32-001.02 Medical Necessity:

Medical necessity is defined as the need for treatment services which are necessary to diagnose, treat, cure or prevent regression of significant functional impairments resulting from symptoms of a mental health or substance use disorder diagnosis.  Treatment services shall:

  1. Be provided in the least restrictive level of care that is appropriate to meet the needs of the client; and
  2. Be supported by evidence that the treatment improves symptoms and functioning for the individual client’s mental health or substance use disorder diagnosis; and
  3. Be reasonably expected to improve the individual’s condition or prevent further regression so that the services will no longer be necessary; and
  4. Be required for reasons other than primarily for the convenience of the client or the provider

471 NAC 35-001.02 (Psychiatric Rehabilitation) Definition of Medical Necessity:

The NMAP uses the following definition of medical necessity:

"Health care services and supplies which are medically appropriate and -

  1. Necessary to meet the basic health needs of the client;
  2. Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;
  3. Consistent in type, frequency, duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;
  4. Consistent with the diagnosis of the condition;
  5. Required for means other than convenience of the client or his or her physician;
  6. No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
  7. Of demonstrated value; and
  8. No more intense level of service than can be safely provided.

 The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Medicaid. Services and supplies which do not meet the definition of medical necessity set out above are not covered."

For purposes of covering rehabilitative psychiatric services under this Chapter, the following interpretative notes apply. Medical necessity for rehabilitative psychiatric services includes:

Health care services which are medically appropriate and -

  1. Necessary to meet the psychiatric rehabilitation needs of the client;\
  2. Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;
  3. Consistent in type, frequency, duration of service with accepted principles of psychiatric rehabilitation;
  4. Consistent with the diagnosis of the condition;
  5. Required for means other than convenience of the client or his or her service provider(s);
  6. No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
  7. Of demonstrated value; and
  8. A no more intense level of service than can be safely provided.

For the purpose of this Chapter, rehabilitative psychiatric services are medically necessary when those services can reasonably be expected to increase or maintain the level of functioning in the community of clients with severe and persistent mental illness.

Additional Criteria

Provider Bulletins


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