1. A. The following medical professional services are covered services if a member receives these services in an inpatient, outpatient, or office:

   1. 1. Dialysis;

   2. 2. The following family planning services if provided to delay or prevent pregnancy:

      1. a. Medications,
      2. b. Supplies,
      3. c. Devices, and
      4. d. Surgical procedures;

   3. 3. Family planning services are limited to:

      1. a. Contraceptive counseling, medications, supplies, and associated medical and laboratory examinations, including HIV blood screening as part of a package of sexually transmitted disease tests provided with a family planning service;
      2. b. Sterilization; and
      3. c. Natural family planning education or referral;
   4. 4. Midwifery services provided by a certified nurse practitioner in midwifery;
   5. 5. Midwifery services for low-risk pregnancies and home deliveries provided by a licensed midwife;
   6. 6. Respiratory therapy;
   7. 7. Ambulatory and outpatient surgery facilities services;
   8. 8. Home health services under A.R.S. § 36-2907(D);
   9. 9. Private or special duty nursing services;
   10. 10. Rehabilitation services including physical therapy, occupational therapy, speech therapy, and audiology within limitations in subsection (C);
   11. 11. Total parenteral nutrition services, which are the provision of total caloric needs by intravenous route for individuals with severe pathology of the alimentary tract; and
   12. 12. Chemotherapy.

2. B. Prior authorization from the Administration for a member is required for services listed in subsections (A)(3)(b), and (A)(4) through (11); except for:

   1. 1. Voluntary sterilization;
   2. 2. Dialysis shunt placement;
   3. 3. Arteriovenous graft placement for dialysis;
   4. 4. Angioplasties or thrombectomies of dialysis shunts;
   5. 5. Angioplasties or thrombectomies of arteriovenous grafts for dialysis;
   6. 6. Eye surgery for the treatment of diabetic retinopathy;
   7. 7. Eye surgery for the treatment of glaucoma;
   8. 8. Eye surgery for the treatment of macular degeneration;
   9. 9. Home health visits following an acute hospitalization (limited up to five visits);
   10. 10. Hysteroscopies (up to two, one before and one after) when associated with a family planning diagnosis code and done within 90 days of hysteroscopic sterilization;
   11. 11. Physical therapy subject to the limitation in subsection (C);
   12. 12. Facility services related to wound debridement,
   13. 13. Apnea management and training for premature babies up to the age of 1; and
   14. 14. Other services identified by the Administration through the Provider Participation Agreement.

3. C. The following are not covered services:

   1. 1. Occupational and speech therapies provided on an outpatient basis for a member age 21 or older;
   2. 2. Abortion counseling;
   3. 3. Services or items furnished solely for cosmetic purposes;
   4. 4. Services provided by a podiatrist; or
   5. 5. More than 15 outpatient physical therapy visits per benefit year for persons age 21 years or older for the purpose of restoring a skill or level of function and maintaining that skill or level of function once restored.
   6. 6. More than 15 outpatient physical therapy visits per benefit year for persons age 21 years or older for the purpose of acquiring a new skill or a new level of function and maintaining that skill or level of function once acquired.

Historical Note

Adopted as an emergency effective May 20, 1982 pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-3). Former Section R9-22-215 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Amended effective October 1, 1985 (Supp. 85-5). Section repealed, new Section adopted effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 6 A.A.R. 179, effective December 13, 1999 (Supp. 99-4). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by exempt rulemaking at 16 A.A.R. 1638, effective October 1, 2010 (Supp. 10-3). Amended by final rulemaking at 17 A.A.R. 1658, effective August 2, 2011 (Supp. 11-3). Amended by final rulemaking at 20 A.A.R. 1949, effective September 6, 2014 (Supp. 14-3).